More cock tales: A brief look at genital drug injection

The idea for this blog was initiated when I read a snippet in The Fortean Times about a 34-year old man from New York who injected cocaine into his penis and ended up with gangrene and further medical complications. It turns out that this report was based on a letter published in a 1988 issue of the Journal of the American Medical Association by Drs. John Mahler, Samuel Perry and Bruce Sutton (and subsequently reported in a June 1988 issue of the New York Times).

The man in question came in for medical treatment following three days of priapism (i.e., prolonged and painful penile erection) and paraphimosis (i.e., foreskin in uncircumcised males can no longer be pulled over the tip of the penis). To enhance his sexual performance, he had administered cocaine directly into his urethra. After three days, both the priapism and the paraphimosis “spontaneously resolved”. However, the blood that had caused the priapism then leaked to other areas of his body over the next 12 hours (including his feet, hands, genitals, chest, and back). To stop the spread of gangrene, the medics had to partially amputate both of his legs (above the knee), and nine of his fingers. Following this, his penis also developed gangrene and fell off by itself while he was taking a bath. The exact reason for the spread of gangrene was unknown but sexologists (such as Professor John Money) speculated that it may have been because of impure cocaine being used.

When I started to search for medical literature on the topic of injecting drugs directly into male genitalia I was surprised to find quite a few papers on the topic (but unsurprisingly all case study reports given the rarity of such behaviour). One of the earliest I located was one from 1986 in the Journal of Urology by Dr. W. Somers and Dr. F. Lowe. They reported the cases of four heroin abusers with localized gangrene of the genitalia, although only one of these had actually injected heroin directly into his genitalia, in this case his scrotum and perineum (the area between the anus and the scrotum). This latter case developed more severe gangrene and was described as a “more lethal entity” than the gangrene in the other three heroin users’ genitalia.

Later, in a 1999 issue of the American Journal of Forensic Medicine and Pathology, Dr. Charles Winek and his colleagues reported the rare case of a fatality due to a male injecting heroin directly into his penis. The cause of death was determined to be due to heroin and ethanol intoxication. More recently, in a 2005 issue of the Medical Journal of the Iranian Red Crescent, Dr. Z. Ahmadinezhad and his colleagues reported a case of heroin-associated priapism. In their paper, they reported the case of a 32-year old man who was admitted to hospital following pain and swelling after injecting heroin into his penis two weeks earlier. Unfortunately, the person left the hospital following initial consultation and never came back so the outcome of the treatment provided is unknown.

In a 2011 issue of the Internet Journal of Surgery, Dr. I. Malek and colleagues reported the case of a 35-year old long-term intra-venous drug user who injected citric acid laced with heroin into the dorsal vein of his penis. This caused worsening pain and his penis developed gangrene. Over the (non-operative) treatment period, the man’s pain became worse and he had trouble urinating (so he was catheterised). Eventually, the treatment with antibiotics led to a good recovery at three-month follow-up.

Another unusual case was reported by Dr. Francois Brecheteau and his colleagues in a 2013 issue of the Journal of Sexual Medicine. They reported the successful treatment of a 26-year old male drug addict who had injected the opiate drug buprenorphine directly into the dorsal vein of his penis. After unsuccessful antibiotic treatment on its own, they then used a number of simultaneous treatments including heparin, anti-platelet drugs, antibiotics, and hyperbaric oxygen therapy, the man made a successful recovery.

Returning to cocaine rather than opiates, a case report by Dr. V. B. Mouraviev and his colleagues in a 2002 issue of the Scandinavian Journal of Urology and Nephrology reported the case of a 31-year-old Canadian man who had injected cocaine directly into his penis. He turned up at the emergency having endured penile pain for 22 hours following the injection. Twelve hours after injecting the cocaine, the man noticed swelling and bruising starting to appear on the right side of his penis where he had made the injection. As a consequence, his penis developed gangrene (“localized death and decomposition of body tissue, resulting from obstructed circulation or bacterial infection”) most probably from bacterial infection via the injection. He had to undergo reconstructive skin graft surgery and was given antibiotics. In this particular case, the treatment was successful. Other similar reports of medical complications (usually gangrene) following the injection of cocaine into the penis have since appeared in a number of papers including a 2013 paper by Dr. Fahd Khan and colleagues in the Journal of Sexual Medicine.

Cocaine and heroin aren’t the only recreational drugs to have been injected into male genitalia. A paper in a 2014 issue of Urology Case Reports by Dr. Cindy Garcia and her colleagues reported the case of a 45-year-old male intravenous drug user who developed an abscess after he injected amphetamine into his penis. The man chose a penile vein after being unable to find any other suitable peripheral vein. He was treated with intravenous antibiotics and had to have his abscess drained via a penile incision. Within a month he had been all but successfully treated. In their paper (which also included a review of the literature on penile abscesses), they concluded that:

“Penile abscesses are an uncommon condition. There are multiple aetiologies of penile abscesses, including penile injection, penile trauma, and disseminated infection. Penile abscesses might also occur in the absence of an underlying cause. The treatment of penile abscesses should depend on the extent of infection and the cause of the abscess. Most cases of penile abscess necessitate surgical debridement [removal of dead or infected tissue]”.

Similarly, in a 2015 issue of Case Reports in Urology, Dr. Thomas W. Gaither and his colleagues reported two cases of men who had injected metamphetamine into their penis. The first case was a 47-year-old gay man who had a history of “methamphetamine use, prior penile abscesses, urethral foreign body insertions, HIV, hepatitis C, and diabetes mellitus”. He attended the hospital emergency department suffering from severe penile pain and scrotal swelling having injected methamphetamine into the shaft of his penis a few days before. On the same day that he went to the emergency department he was immediately taken into the operating room where an incision was made in his penis, and the abscess was drained of its “purulent foul-smelling fluid” and washed out with saline solution. The second case was a 33-year-old heterosexual male with no previous medical history (apart from a history of depression) turned up at the hospital emergency department with acute penile pain, a day after he had injected methamphetamine directly into his penis. Again, he was immediately taken to the operating room where his penile abscess was drained after an incision. Neither of the cases involved any penile gangrene and both men were also given antibiotics to treat the infected area. In both cases, the authors speculated that the abscesses formed as a result of direct contamination from repeated penile injections.

Finally, Dr. Lucas Prado and his colleagues reported a case study in a 2012 issue of the Journal of Andrology of a 31-year-old man who was admitted to the emergency department after he had injected 10ml of methadone into his penis in an attempt to commit suicide (the first case of penile methadone injection). The man had a 15-year history of drug abuse over the past year and had attempted a drug-related suicide three times. This particular suicide attempt led to acute liver and renal failure as well as erectile dysfunction. Although the man survived, ten months after the suicide attempt, the man still had complete erectile dysfunction.

Although I didn’t do a systematic review of all the literature, it is clear that the injection of recreational drugs directly into male genitalia appears to be relatively rare although all the literature I located was based on those who end up seeking treatment for when things go horribly wrong. There could of course be many hundreds or thousands of people out there that have engaged in such practices but don’t end up in a hospital emergency ward. However, I certainly wouldn’t recommend such a practice to anyone.

Dr. Mark Griffiths, Professor of Behavioural Addiction, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ahmadinezhad, Z., Jabbari, B.H., Saberi, H., Khaledi, F., & Safavi, F. (2005). Heroin associated priapism. Medical Journal of the Iranian Red Crescent, 7(3), 67-68.

Brecheteau, F., Grison, P., Abraham, P., Lebdai, S., Kemgang, S., Souday, V., … & Bigot, P. (2013). Successful medical treatment of glans ischemia after voluntary buprenorphine injection. Journal of Sexual Medicine, 10(11), 2866-2870.

Cunningham, D.L., & Persky, L. (1989). Penile ecthyma gangrenosum: Complication of drug addiction. Urology, 34(2), 109-110.

Gaither, T.W., Osterberg, E.C., Awad, M. A., & Breyer, B.N. (2015). Surgical intervention for penile methamphetamine injections. Case Reports in Urology, 467683, doi.org/10.1155/2015/467683

Garcia, C., Winter, M., Chalasani, V., & Dean, T. (2014). Penile abscess: a case report and review of literature. Urology Case Reports, 2(1), 17-19.

Khan, F., Mukhtar, S., Anjum, F., Tripathi, B., Sriprasad, S., Dickinson, I. K., & Madaan, S. (2013). Fournier’s gangrene associated with intradermal injection of cocaine. Journal of Sexual Medicine, 10(4), 1184-1186.

Malek, I., Parmar, C., McCabe, J., & Irwin, P. (2011). Successful non-operative management of penile wet gangrene following self-injection of heroin in dorsal vein of penis. Internet Journal of Surgery, 11(1), 1-3.

Mireku-Boateng, A.O., & Tasie, B. (2001). Priapism associated with intracavernosal injection of cocaine. Urologia Internationalis, 67(1), 109-110.

Mouraviev, V. B., Pautler, S. E., & Hayman, W. P. (2002). Fournier’s gangrene following penile self-injection with cocaine. Scandinavian Journal of Urology and Nephrology, 36(4), 317-318.

Munarriz, R., Hwang, J., Goldstein, I., Traish, A.M., & Kim, N.N. (2003). Cocaine and ephedrine-induced priapism: case reports and investigation of potential adrenergic mechanisms. Urology, 62(1), 187-192.

Prado, L. G., Huber, J., Huber, C. G., Mogler, C., Ehrenheim, J., Nyarangi‐Dix, J., … & Hohenfellner, M. (2012). Penile methadone injection in suicidal intent: Life‐threatening and fatal for erectile function. Journal of Andrology, 33(5), 801-804.

Singh, V., Sinha, R. J., & Sankhwar, S. N. (2011). Penile gangrene: A devastating and lethal entity. Saudi Journal of Kidney Diseases and Transplantation, 22(2), 359.

Somers, W.J., & Lowe, F.C. (1986). Localized gangrene of the scrotum and penis: A complication of heroin injection into the femoral vessels. Journal of Urology, 136, 111-113.

Winek, C. L., Wahba, W. W., & Rozin, L. (1999). Heroin fatality due to penile injection. American Journal of Forensic Medicine and Pathology, 20(1), 90-92.