Erection after Amputation of Penis. Case Description and Review
of the Relevant Literature on Phantoms
Background: Perception of a phantom limb is frequent
after an amputation of an upper or lower extremity. Phantom
penis is reported infrequently. Method: Case description
and literature review. Result: The phenomenon
of phantom penis followed total penectomy. Several aspects were
unusual, particularly the existence with phantom only in the
erect state, and associated recrudescence of a preoperative
painful ulcer. General features of limb phantoms after amputation
are reviewed including a résumé of recent studies
of cortical reorganization. The phantom process is analyzed
looking for clues to the nature of the underlying neural organization.
The puzzle of phantom pain is briefly touched on. Conclusion:
The development of the phantom is attributed to activity
in the deafferented parietal sensory cortex.
Érection fantôme après amputation du pénis.
Présentation de cas et revue de la littérature
pertinente sur les fantômes. Introduction: La
perception d'un membre fantôme est fréquente après
une amputation d'un membre supérieur ou inférieur.
On a rarement rapporté un pénis fantôme.
Méthode: Présentation de cas et
revue de littérature. Résultat: Le
phénomène du pénis fantôme s'est
manifesté à la suite d'une pénicectomie
totale. Plusieurs aspects étaient inusités, particulièrement
l'existence du fantôme seulement en état d'érection
et associé à une recrudescence d'un ulcère
douloureux préopératoire. Nous revoyons les caractéristiques
générales des membres fantômes après
amputation, incluant un résumé des études
récentes sur l'organisation corticale. Le processus du
fantôme est analysé pour chercher des indices sous-jacents
sur la nature de l'organisation neurale. Nous faisons allusion
à l'énigme de la douleur fantôme. Conclusion:
Le développement du fantôme est attribué
à l'activité du cortex pariétal sensitif
J. Neurol. Sci. 1999; 26: 53-56
presence of a phantom limb is experienced by almost all amputees
after amputation of an upper or lower extremity, and can be
considered a normal physiological event.(1-3) A phantom breast
after mastectomy is also well known.(4) Phantom penis is reported
infrequently and only three references were found. A brief review
of the literature at this point will provide the reader with
some perspective on this rather esoteric subject. Afterwards
the present case will be described.
Mitchell in his original monograph &endash; "Injuries of Nerves
and their Consequences" included a foot-note reference to an
unpublished case described to him by Ruschenberger of the U.S.
Navy, of a penile phantom which was subject to erections.(5)
Price Heusner's case 1(6) was a man aged 70 years who began
to have intermittent erections two years after amputation of
his penis. Prior to the amputation he had been impotent and
lacked desire. The erection was not provoked by sexual phantasies.
The phantom was so natural the subject was led to check for
its presence visually. This state was brought to an end four
years later when the subject suffered a gunshot wound of the
spine productive of a paraplegia with loss of sensation for
pain and temperature below the level of the navel. In Heusner's
case 2 there was a painful phantom penis, not subject to erection.
found in a follow-up study of 12 cases of penile amputation
for carcinoma that seven experienced penile phantoms which faithfully
reproduced the original member in size and position. All of
these patients had residual penis stumps, 2 to 3.5 cm in length
and voided via the stump-urethra. The passage of urine and any
accompanying dysuria were felt in the phantom. Six of the seven
retained their customary libido with normal erection and ejaculation.
In two instances the phantom sensation had gradually been lost
and was present only in the erect state. Two of the seven had
transient pain in the phantom. The five cases without a phantom
had lost their libido before operation.
present case is of interest insofar as the amputation was total
and the erect phantom regularly included recrudescence of a
preoperative malignant ulceration with its accompanying pain.
studies of phantom phenomena including pain, are providing new
insights into the functional organization of cerebral cortical
processes(8) and it is conceivable that cases like the present
one could contribute to knowledge of one of nature's most basic
successful businessman, aged 44 years, developed a painful sore
about 8 mm in diameter on the glans penis. Biopsy revealed carcinoma
and he underwent penile amputation along with radical dissection
of the inguinal lymph nodes bilaterally. One node on the left
side showed the presence of carcinoma and maximum roentgen ray
therapy was delivered. The amputation was total, that is there
was no stump projecting anterior to the pubis. The patient voided
via a perineal urethrostomy. The testicles were retained and
bladder control was preserved. There was no recurrence of the
the age of 64 years, 20 years later, while under care for cerebral
transient ischemic attacks the patient casually mentioned that
since the operation and despite the absence of his male organ,
phantom erections regularly occurred especially with erotic
stimulation, for example, "seeing a pretty young woman". The
phantom seemed to be of normal size, configuration and alignment,
and was accompanied by a normal sexual feeling. So real was
the experience that even after 20 years, the subject was still
periodically obliged to check on the situation, tactually and
visually. Particularly surprising to him was the exact reproduction
on each occasion of the original painful sore, at the same site
on the glans, accompanied by the same type and severity of pain
as before the operation. The pain was apparently not severe.
Restrictive undergarments were not an impediment. The patient
was unaware of a phantom in the non-erect state. He gave no
hint of having consulted the medical literature and he was not
asked if he had discussed the matter with other physicians.
patient died from prostatic carcinoma seven years later, aged
71 years, without further history or follow-up information.
There was no postmortem examination.
The history as recorded is probably reliable since it was proffered
unsolicitedly. In retrospect many further details could have
been sought that would have permitted a better comparison with
what is known about phantoms at other sites, for example, the
duration of the ulceration and pain before surgery, when in
relation to surgery the phantom first appeared, the character
and severity of the pain, changes in the phantom and pain with
the passage of time, the duration of the phantom erection each
time, an account of all the stimuli that were effective in eliciting
a response, an analysis of the genito-pelvic sexual sensation,
Brief Summary of Current Views on a Phantom Limb Phenomena
special features of the present case will be better appreciated
within the context of some knowledge of phantoms in general.(1-3)
Phantom limbs are a normal consequence of amputation of extremities.
Phantoms generally appear in the first few days after surgery
and many patients, upon recovering from the anesthesia, feel
that the amputated part is still present in its usual place.
The surface contour of the three-dimensional limb phantom consists
of a faint tingling feeling. Distal parts of a limb are plainer:
hand and foot, and thumb, index finger and hallux, the regions
with relatively larger cortical sensory representation.(9) The
phantom is a purely somatosensory creation and can occur in
can usually move the fingers or toes but to a limited extent,
and flexion better than extension. With changes of body position
the phantom maintains a natural relationship to the stump. Painless
phantoms especially of the arm undergo gradual telescoping in
which the arm and forearm gradually fade from awareness and
a normal-sized remnant of hand and fingers approaches or even
penetrates the stump.
of variable severity, from bothersome to highly distressing,
may involve the phantom or stump or both. Pain in a phantom
is usually a duplicate of pre-amputation limb pain.(10) A phantom
part may bear an exact replica of an article worn preoperatively,
ring, watch, shoe, bandage, etc.
also occur after brachial plexus avulsion,(11) and after spinal
cord transection with paraplegia.(12,13)
the neural mechanism underlying a phantom limb, the dominant
view is that it is created by activity in the parietal sensory
cortex that normally subserved somatosensation in the amputated
part.(8) A sensation of tingling which reflects a partial deficit
in the touch system at any level from the periphery to the parietal
lobe, takes on the natural form of its amputated source. It
might be expected that a preamputation painful neural pattern
could co-exist. Older theories that attributed phantoms to activity
in the severed nerves in the stump, or to psychological factors,
have been discredited.(3) Surgical procedures which interrupt
nerves peripherally, or tracts in the spinal cord or brain stem,
fail to relieve painful phantoms.(14) Several reports describe
relief from phantom pain, at least temporarily, as a result
of surgical corticectomy, stroke or tumor involving the appropriate
evidence for cortical participation derives from studies of
cortical sensory reorganization in amputees, based on the original
work of Merzenich et al.(20) Pons et al.(21) found extension
of facial responses far into the cortical arm area of primates
with long-term deafferentation of an upper limb. Ramachandran
et al.(22) in studying two subjects with arm-amputations, found
that touch sensations on the face and on the stump, were referred
somatotopically to particular regions of the phantom. The appearance
of the phenomenon four weeks after the amputation was regarded
as evidence against sprouting as the basis of reorganization,
and in favor of the unmasking of preexisting silent connections.
Kew et al.(23) used positron emission tomography to study the
reorganization of cortical patterns in two patients with a deafferented
amputated upper limb. Vibrotactile stimulation of the pectoral
region on the involved side was referred to the phantom. At
the same time blood flow was significantly increased in the
corresponding hand-arm area of the cortex, representing an abnormal
extension of 20 mm and l2 mm respectively, compared with the
further experiments Ramachandran et al.(24) and Ramachandran
and Rogers-Ramachandran(25) using a mirror-box, enabled subjects
to move their immobile phantom fingers when the phantom was
superimposed, visually, on the mirror image of their own normal
moving hand. Also using a mirror-box, sensory stimuli delivered
to the subject's normal hand were felt in the same place in
the phantom. These results suggested that there is a considerable
amount of latent plasticity in the adult human brain with pathways
bridging the two hemispheres, emerging in less than three weeks.
Chen et al.(26) using transcranial magnetic stimulation found
that motor reorganization following amputation, occurs predominantly
at supraspinal levels. Two investigators studied the relation
of phantom pain to cortical reorganization. Flor et al.(27)
investigated the relation between the degree of cortical reorganization
and the severity of the phantom pain in 13 amputees using magnetoencephalography.
The amount of phantom limb pain was closely correlated (r =
0.93) with the amount of cortical reorganization. Birbaumer
et al.(28) studied the effect of local anesthetic block of the
brachial plexus on the amount of cortical reorganization. Using
somatosensory evoked potentials they demonstrated, first, that
the linear shift associated with cerebral reorganization was
correlated with the amount of phantom pain, and secondly, relief
of pain by the anesthetic block was accompanied by a substantial
mean reduction or reversal of the amount of linear shift of
reorganization. The rapidity with which the plexus block abolished
cortical reorganization, reflected a surprising impermanence
or plasticity of an apparently long-standing system of reorganization.
Davis et al.(29) concluded from microelectrode recordings in
the thalamus of amputees, that reorganization in the sensory
nucleus offers another mechanism by which stump afferents might
influence phantom sensation including pain.
on the Present Case
special features in the present case of phantom penile erection
include: 1) The penile amputation was complete unlike reported
cases in which a stump remained, through which micturition occurred;
2) the presence of a phantom only in the erect state and not
in the flaccid state; 3) the replica in the phantom of the preoperative
ulcerated lesion with its associated pain; 4) the unusual facility
with which an erotic stimulus precipitated a response; 5) a
rare instance of bihemispheric cortical representation is exemplified;
6) the 20 year duration of the phenomenon.
physiology of male tumescence is only partly understood. It
can be considered an involuntary, reflex or automatic response
to a thought or sensory perception of an erotic nature. The
efferent system is autonomic by way of the lower spinal cord
parasympathetic and sympathetic outflow. Sensory afferents are
carried in the somatosensory system. The erectile mechanism
probably involves relaxation of afferent small penile arteries
with compression or constriction of venous outflow.(30) In our
patient there were probably remnants of the most posterior part
of the corpora cavernosa. Presumably under normal circumstances,
in humans, erotic stimuli involve the parietal sensory cortex
whence the penile vasomotor response is elicited, possibly via
a descending hypothalamic pathway. The resultant genito-pelvic
sexual feeling could participate in a feedback process through
the parietal cortex.
the sensory homunculus of Penfield and Rasmussen(9) the genitalia
are depicted on the medial surface of the hemisphere, in the
most inferior position, just below or posterior to the region
of the toes. In their electrical exploration of the human cortex,
sensory responses referred to the genital region were rare.
In one patient, stimulation at two points in the posterior portion
of the post-central area near the central fissure, produced
a sensation in the contralateral side of the penis. Stimulation
of the cortex never produced erotic sensations of any sort.
Also, of some relevance here, stimulation never elicited a vasomotor
response. An abnormal erotic feeling of cerebral origin is rarely
produced by focal epilepsy;(31) it is better known in the Klüver-Bucy
syndrome(32) in which the temporal lobes are damaged bilaterally.
with the human upper limb with its remarkable sensorimotor dexterity,
the penis is largely a tactile organ whose only response is
passive or automatic. In the non-erect state, sensory awareness
of the penis is almost nil, a circumstance which, it might be
inferred from experience with phantom limbs, would not favor
the ready development of a phantom after amputation. Also judging
from cortical stimulation studies, the cortical area representing
the genitalia is probably small with little scope for cortical
reorganization. The concept that the propensity to develop a
phantom is related to the size of the area of cortical representation,
finds little support here.
on the synopsis of up-to-date information concerning phantom
limb phenomena, already presented, it may be posited that our
patient's phantom erection was also a product of the "deafferented"
parietal sensory cortex. There was no stump to complicate the
interpretation. The presence of a phantom only in the erect
state and not in the flaccid state represents a virtually unique
event. Creating a realistic concept of the neural circuitry
involved, is an impossibility at present. In attempting a verbal
interpretation of the phenomenon, one might say that a thought
or a visual perception first gained an erotic connotation. The
most likely site for this is the genital area of the parietal
sensory cortex. In the absence of the male organ, a cortical
sensory image of the normal erect state was evoked. The usual
duration of this phase was not sought from the patient. Whether
descending autonomic impulses played a part by producing changes
in any residual erectile tissue is a matter for speculation.
In Heusner's case 1(6) a traumatic paraparesis apparently ended
the patient's phantom experience.
a phantom to make its appearance only under certain physiological
circumstances is almost unknown in phantoms of other parts.
Phantom limbs may be influenced by mental concentration, emotional
states, surprise, pain, wearing a prosthesis, etc., but show
no change at all comparable to that of the phantom erection.
Breast phantoms may clearly swell premenstrually and slowly
recede again after cessation of the period.(33) Along somewhat
the same line, Jankovic and Glass(34) described tardive dyskinesia
in a phantom arm, as a result of metoclopramide therapy. The
occurrence of a phantom only of the erect state may reflect
a relatively greater sensory experience in that state, resulting
in a more abundant neural connectivity in the parietal cortex.
the sensory cortex is normally subject to analogous changes
under the influence of ideas and perceptions cannot be answered.
Normally penile erection, a stereotyped reaction, would be sensed
in the parietal cortex, where a neural tracery is left. Presumably,
when the peripheral sensory receptors are eliminated as in amputation,
the particular cortical circuitry lies unused, waiting to participate
when the appropriate stimulus arrives. There is the suggestion
here, that we are witnessing evidence for the cortical basis
of a thought, a simple one, linked to a basic biological function.
The thought is tactile, it is vivid, it approaches the form
of a tactile hallucination (the phantom). Where else in the
human nervous system would an accustomed thought or perception
gain an erotic implication, if not in the sensory cortex? This
is tantamount to suggesting that, in humans, innate sexual drive
and appetite are centered in the parietal cortex where other
influences, for example, endocrine can play their part.
much of this speculation seems to imply limited neuronal activity
locally in the sensory cortex, it must always be regarded as
an evanescent focus within a widespread, dynamic, ever-changing,
cerebral electrical activity whose "sweep" encompasses every
new cerebral interval change, thereby constituting the mind
and self-awareness. Regrettably our patient was not asked about
the occurrence of ejaculation, whether his erotic inclination
could have represented heightened activity and whether any particular
pattern was associated with nocturnal dreaming. The effect on
the phantom of castration and estrogen therapy used in the treatment
of prostatic carcinoma, could have been informative.
presence in a phantom limb of a pre-existing pain, that is pain
that predated amputation, is not uncommon and poses a major
therapeutic challenge.(35) In the present case, there is the
unusual situation that the ulcerated lesion and the associated
pain, were transient, reappearing only as part of the erect
phantom, not otherwise. The neural tracery corresponding to
the ulcer and pain, entered awareness only as part of the phantom.
The recurrence of the pain was not just the ordinary recall
of a pain; it was an actual re-creation of the original neural
tracery (engram). The intimate relationship of the pain to the
somatosensory (tactile) phantom, warrants scrutiny for any lessons
it might bear concerning the biology of pain. The literature
contains no record of a cortical pain homunculus. The same is
true of the cortical localization of hotness, without any tactile
component. Penfield and Rasmussen(9) reported no pain responses
on cortical stimulation and assigned pain to the thalamus. It
would seem that pain, being inconstant, does not establish its
own homunculus, and gains its localization signature through
tactile association. Phantom limbs tend to persist when pain
is present. Clinically most pains have a tactile admixture.
Genitalia in Paraplegia
reported that all 150 cases of severe spinal cord injury that
he studied, had a phantom of one paralyzed part or another at
some time after the injury. In Bors' study(12) of 50 patients
with cord injury, 13 reported only non-erect penile phantoms,
8 erect phantoms only and 6 both erect and non-erect phantoms.
Of the non-erect group, 9 specified the tip as represented and
3 the shaft, one was undecided. In the erect group the phantom
occurred with and without erotic stimulation. In addition, reflex,
unfelt actual erections occurred in 43 of the 50 cases. In three
cases, erect phantoms ceased after anterolateral chordotomy,
an effect which would argue against a wholly cerebral mechanism
in paraplegic cases.
during dreaming inform us as much about dreams as they do about
phantoms, for most paraplegics walk normally in their dreams(12)
and male paraplegics may experience penile erections with or
without a sensation of ejaculation.(36)
penis is a very special syndrome even within the field of phantom
phenomenology. With a more complete acquisition of historical
data than pertained in the present case, there is the potential
to gain further insight into the normal and abnormal physiology
of high level behavior and pain.
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the Neurology Service, Massachusetts General Hospital,
Fruit Street, Boston, MA, USA.
April 17, 1998. Accepted in final form August 31, 1998.
requests to: C.M. Fisher, Neurology Service, Massachusetts
General Hospital, Fruit Street, Boston MA USA 02114
J. Neurol. Sci. 1999; 26: 53-56