ADULT UROLOGY
UROLOGIC COMPLICATIONS OF SEXUAL TRAUMA AMONG
MARIE NORREDAM, SONDRA CROSBY, RICARDO MUNARRIZ, LIN PIWOWARCZYK,
ABSTRACT Objectives. To describe the urologic and sexual complications of male survivors of sexual torture, including prevalence, sequelae, diagnosis, and treatment. Methods. Through chart reviews, we identified all male survivors of torture who had been treated for physical and/or psychological symptoms due to sexual trauma at the Boston Center for Refugee Health and Human Rights at Boston Medical Center between January 1, 2001 and January 1, 2002. Of the 72 men seen, 20 (28%) were survivors of sexual trauma. Our study focused on genital trauma leading to urologic and/or sexual dysfunction. Therefore, all cases of male genital trauma that had been referred to the urology department (3 of 20) were selected for this review. Results. The patients presented with chronic genital and erectile pain, lower urinary tract symptoms, and sexual dysfunction. The diagnostic workup included history, physical examination, and ultrasonography. Treatment included steroid injections for chronic pain and oral erectogenic agents for sexual dysfunction. Conclusions. The apparent prevalence and severity of the physical and mental sequelae to sexual trauma make it an important area for screening when treating survivors of torture. Our study is the first of its kind to document urologic complications of sexual torture in a foreign-born U.S. cohort of tortured men, including prevalence, diagnosis, and treatment. The proposed use of steroid injections in the clinical treatment of these patients has not been previously reported.
UROLOGY 65: 28–32, 2005. 2005 Elsevier Inc. Thousands of asylum seekers and refugees enter hadsufferedfromItisofconcernthathealth
Western countries every year. Between 1991 and
professionals often fail to ask about torture or are not
2000, about 1 million people applied for asylum in
trained to recognize the physical and psychological
the United Among those seeking asylum are
torture survivors. In 1999, 400,000 survivors of tor-
their history of persecution because of shame or out
ture were estimated to reside in the United
of fear because the clinical setting is reminiscent of
Although not necessarily self-proclaimed, survivors
of torture and refugee trauma are consequently
ashamed to discuss sexual trauma because of fear of
bound to appear in the offices of health professionals.
stigmatization and the shame of a perceived loss of
A U.S. study of the prevalence of torture survivors
among a random sample of foreign-born patients in
The United Nations Convention against Torture
primary care in a metropolitan area showed that 25%
and Other Cruel, Inhuman and Degrading Treat-ment or Punishment defines torture as “an act by
From the Department of Health Law, Bioethics, and Human
which severe pain or suffering, whether physical or
Rights, Boston University School of Public Health; Boston Center
mental, is intentionally inflicted on a person for
for Refugee Health and Human Rights, Section of General Internal
such purposes as obtaining from him or a third
Medicine, and Department of Urology, Boston Medical Center,
person information or confession. . . Male sex-
Boston, Massachusetts; and Department of Health Services Re-search, Institute of Public Health, University of Copenhagen,
ual trauma, which is a form of torture, can be char-
Reprint requests: Marie Norredam, M.D., Department ofHealth Services Research, Institute of Public Health, Univer-
1. Direct genital trauma: hitting, kicking, or ap-
sity of Copenhagen, Blegdamsvej 3B, Copenhagen North 2200,
plying electric shocks to genitals and/or anus,
Denmark. E-mail: m.norredam@pubhealth.ku.dkSubmitted: May 20, 2004, accepted (with revisions): August
object inserted into urethral meatus and/or
Most common methods of sexual torture and physical sequelae among 20 survivors of torture treated at Boston Center for Refugee Health and Human Rights at Boston Medical Center between January 1, 2001 and January 1, 2002 Physical Trauma Acute Physical Sequelae Chronic Physical Sequelae
Genital beatings with fists, sticks, or other instruments
Forced fellatioInsertion of toothpicks into the penis
2. Nonconsensual sexual acts: pawing, anal rape,
genitalia tied to the floor for 12 hours. He was
unable to stand upright without painfully stretch-
3. Mental assaults: forced nakedness, sexual hu-
ing his genitalia. He presented with complaints of
erectile dysfunction and chronic incapacitatinggenital pain. On physical examination, he had di-
On the basis of our work with survivors of tor-
minished tunica elasticity and compliance, consis-
ture and refugee trauma, we report 3 cases of gen-
tent with Peyronie’s disease. Penile stretching elic-
ital trauma and their physical sequelae, focusing on
ited exquisite proximal dorsal penile pain radiating
the urologic complications. Our aim was to sensi-
to the pubic bone and suspensory ligament. After
tize medical professionals to the male genital
he provided informed consent, two subcutaneous
trauma that occurs in the context of sexual torture
steroid injections (triamcinolone 50 mg) on the
by discussing the methods of torture and the phys-
dorsal aspect of the penis, fundiform ligament, and
ical sequelae, diagnosis, and treatment strategies.
pubic tubercles were performed within a 4-monthperiod. After the first steroid injection, the patient
MATERIAL AND METHODS
experienced immediate and significant improve-
Through chart reviews, we identified all male torture survi-
ment of his incapacitating genital pain. After the
vors who had been treated for physical or psychological symp-
second injection, the pain resolved completely. At
toms due to sexual trauma at the Boston Center for Refugee
last follow-up, his erectile dysfunction was being
Health and Human Rights at the Boston Medical Center. Be-tween January 1, 2001 and January 1, 2002, 20 (28%) of the 72
managed with oral erectogenic agents (sildenafil)
men seen were identified as survivors of sexual trauma. The
patients were all between 31 and 50 years of age and refugeesfrom African countries in conflict. They had all been impris-
CASE 2
oned or captured and had suffered torture, including severe
Patient 2 was a 31-year-old man who had also
genital beatings. lists the most common methods ofsexual torture, as well as the acute and chronic physical se-
been repetitively beaten in the genitals by fists and
quelae, among the 20 survivors of torture. Most patients had
sticks while imprisoned in an East African country
experienced multiple sexual assaults of the same or different
for political activities. He also presented with com-
kinds. We focus on the genital trauma leading to urologic
plaints of erectile dysfunction and severe and
and/or sexual dysfunction. Therefore, all cases of male genital
chronic genital pain. He had no orgasmic or ejac-
trauma that had been referred to the urology department (3 of20) were selected for this review. The cases are presented and
ulatory problems, but his erections were reduced
serve to illustrate the different aspects of the symptoms, diag-
in rigidity compared with previously. The physical
nosis, and treatment of male genital trauma. All patients have
examination revealed exquisite pubic tubercle,
been kept anonymous. The Institutional Review Board at Bos-
cord, and suspensory ligament tenderness. Penile
ton Medical Center approved the study.
duplex Doppler ultrasonography after intracaver-nosal injection of vasoactive agents revealed de-
creased cavernosal systolic velocities and normal
CASE 1
end-diastolic velocities. These findings were con-
Patient 1 was a 50-year-old man who had fled
sistent with pure (no corporeal occlusive dysfunc-
from a country in Central Africa after being perse-
tion) cavernosal artery insufficiency, most likely
cuted by the military for rebel activity and impris-
secondary to blunt perineal trauma. No penile
oned on 7 occasions between 1996 and 2000. Dur-
plaques or tunica thickening were observed. After
ing imprisonment, he was repeatedly beaten with
he provided informed consent, two steroid injec-
fists and sticks all over his body, including the gen-
tions (triamcinolone 50 mg) were given into the
ital area. On one occasion, he was suspended na-
cord, fundiform, and pubic tubercle, with com-
ked from the ceiling by his arms with his legs bent,
plete resolution of his genital pain. At last follow-
his feet secured to the floor wide apart, and his
up, he was taking oral erectogenic agents (silde-
UROLOGY 65 (1), 2005
nafil) for the management of his erectile
refugees, who had been imprisoned, and found a
dysfunction, with excellent results.
prevalence of 21%. In a different study, studied 607 men from 45 countries, of whom
CASE 3
25% had been sexually assaulted. Of these, 21%
Patient 3 was a 39-year-old man who had fled from
had been raped, 47% had had assaults to the
a West African country after being captured by rebels
genitals, 27% had had electric shocks to the gen-
and forced to do hard labor. During captivity, he was
itals, and/or 21% had had an object inserted in
severely beaten in the genital area with fists and sticks
the anus or urethral meatus. These prevalence
on multiple occasions. He presented with complaints
figures may be underestimates because of the ta-
of erectile dysfunction and lower urinary tract symp-
boo and stigmatization to discussing male sexual
toms (International Prostate Symptom Score of 23)
trauma inherent in most cultural norms. A study
characterized by decreased force of stream, incom-
of British male victims of sexual assaults in gen-
plete emptying, and urinary frequency. He achieved
eral showed that 79% of raped men sought no
an approximately 50% erection, which had poor
help for a mean time of 16 years after the as-
spontaneity and sustaining capabilities. His past
medical history was only remarkable for a urethral
The sequelae of sexual torture include both psy-
stricture managed endoscopically several years previ-
ously. His physical examination was unremarkable,
In this report, we focused on the physical sequelae.
but urethroscopy revealed a tight bulbar urethral
When reviewing published reports, we found few
stricture. Penile duplex Doppler ultrasonography af-
studies describing the physical sequelae of sexual
ter intracavernosal injection of vasoactive agents re-
vealed a peak systolic velocity of 31 and 15 cm/s for
causes has, however, been documented. Erectile
the right and left cavernosal artery, respectively, with
dysfunction has resulted from innocent falls or
normal end-diastolic velocities. These findings were
consistent with pure (no corporeal occlusive dys-
erectile dysfunction and groin pain owing to pro-
function) cavernosal artery insufficiency, most likely
secondary to blunt perineal trauma because of tor-
ture. He underwent internal (endoscopic) urethrot-
gested that blunt genital trauma may roughly result
omy of a long bulbar stricture. However, the stricture
in four clinical problems that are not mutually ex-
recurred within 6 months, requiring a second inter-
nal urethrotomy with excellent results. The patient
1. Chronic genital pain, including erectile pain
also began taking sildenafil, with excellent results. A
2. Peyronie’s disease characterized by penile pain,
detailed vascular evaluation was obtained to assess
penile curvature, and erectile dysfunction
the feasibility of penile revascularization from the
dorsal to the cavernosal artery in an attempt to re-
These clinical problems arise from different
pathologic mechanisms. Chronic genital pain may
result from injury to the inguinal cord, suspensory
Little has been written about the sexual trauma
and/or fundiform ligaments, or tunica albuginea,
of men within the published medical reports on
leading to Peyronie’s Peyronie’s disease
torture. Attention has so far mainly been devoted
is characterized by decreased tunica elasticity and
to female survivors of sexual trauma. The myth
compliance secondary to fibrosis and plaque for-
that men are only aggressors and not victims
mation. Lower urinary tract symptoms may be due
to urethral trauma leading to stricture formation.
many countries and in some states in the United
Apart from Peyronie’s disease, erectile dysfunction
may result from compression injuries of the pu-
prevalence of male sexual trauma is uncertain.
dendal arteries as they enter the perineum through
Estimates, however, have shown that 5000 to
Alcock’s canal and/or corporal damage leading to
8000 men were raped in the former Yugoslavia
corporeal veno-occlusive dysfunction (venous
and that thousands of men and boys were raped
leak). Depending on the symptoms, the diagnosis
of male genital trauma is based on the physical
ual trauma mostly takes place during detention
examination and penile duplex Doppler ultra-
and is perpetrated by guards, interrogators, or
sound findings. Not yet described in published re-
ports, we propose that chronic genital pain due to
political prisoners who sought help after torture
Peyronie’s disease, pubitis, or suspensory ligament
had been sexually abused. Peel et specifi-
injury can be successfully treated with steroid in-
cally studied male sexual trauma among Tamil
jections. Penile curvature can be managed medi-
UROLOGY 65 (1), 2005
cally (verapamil, interferon, colchicine, vitamin
torture in a U.S. cohort of tortured men, including
or surgically (Nesbit plication versus tunica
the prevalence, diagnosis, and treatment. The pro-
posed use of steroid injections in the clinical treat-
tures can be generally treated. The treatments for
ment of these patients has not been previously re-
erectile dysfunction include oral erectogenic
agents (sildenafil, vardenafil, penile re-vascularization procedures, intracavernosal ther-apy, and penile
is most common in survivors who have been ex-
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