Autopsies on bodies with genital mutilation require a careful approach in order to correctly establish the manner of death [3, 5]. In the case here discussed, several peculiar traits had to be considered.

Death due to hemorrhage as a result of genital mutilations is rare [2, 6, 7]. In the present case, the severity of the injury, the age of the victim and the cirrhosis from which he suffered are likely to have contributed to the fatal outcome, despite the fluid resuscitation, the respiratory support and the lack of complications during the surgical procedure [6, 8, 9].

At autopsy, the aforementioned surgical treatment influenced the analysis of the wound. In such cases, the medical record can provide crucial information, since surgery and hospitalization may result in the alteration or onset of wounds [10].

The vomited material included part of the victim’s genitalia. During the examination of the wound in the operating room, the edges were found to be cut-off in the lower part, while they were irregular, crenated and accompanied by scratch-like abrasions in the upper part.

The margins of the lower part were consistent with a sharp-force injury, whereas, as regards the upper margins and the vomited genitalia, the hypothesis of dog predation had to be considered.

Wounds inflicted by dogs can be classified as non-fatal bite wounds, fatal bite wounds, and post-mortem lacerations [11].

Dogs usually target the head, the neck, the throat and any exposed part of the body, with the genitalia being occasionally consumed [11,12,13]. Dogs immobilize their victims by striking their limbs, and attack the upper half of the victim’s body after he/she has been brought down [14].

The typical injury pattern caused by dog bites, named “hole and tear”, is the consequence of a combination of biting, clawing, and crushing, with a round “hole” made by the canine tooth penetrating into the skin, whereas the other teeth cut into the flesh and cause stretch lacerations due to the shaking of the head (the “tear”) [11, 12, 14].

Considering the lack of bite wounds on the lower limbs and the absence of defense injuries, it was likely that the man was already lying on the ground when the dog attacked him and that he did not attempt to defend himself.

Furthermore, taking into consideration the features of the wound and the presence of parallel scratches close to the injury, the hypothesis of the dog having amputated and then consumed the genitals could be ruled out.

Since the interpretation of dog-inflicted wounds can be misleading, an odontological examination of the bite marks and the DNA analysis of the saliva recovered on the victim’s body can assist the forensic pathologist in identifying the animal [15, 16].

In the present case, such methods might have been affected by the way the wound had been treated during surgery.

The peculiarity of this case consists in the fact that the victim was still alive when his genitals were eaten: cases of dogs eating their dead owners have been frequently reported, whereas dog injuries are extremely rare on unconscious victims [17,18,19].

The literature reports the case of a dog that vomited human parts and dog food, as well as cases of post-mortem genital predation by dogs on a 49-year-male who had died of myocardial infarction and on a young man who had hanged himself [3, 13, 20].

Another key point was the presence of sharp edges in the lower part of the wound, which raised the possibility of an assault.

Given that no signs of struggle were noticed and that blood was only found on the man’s body, the fact may have occurred in the same place where the man was found.

However, the involvement of other people could not be ruled out, as the scene may have been altered by the victim’s relatives in order to cover up the nature of the self-injury [21, 22].

The lack of damage to the undershirt and the presence of the injury on an unclothed part of the body were consistent with a case of self-injury, but could not rule out an aggression. Tentative wounds were not observed [23].

Moreover, defense wounds may also be missing in homicide victims who suffer a single sharp-force injury, if the victim is attacked suddenly or if his/her ability to act is reduced. The latter hypothesis was not supported by the toxicological and autopsy findings [24,25,26].

Homicidal injuries to the genital area are rare and are typically associated with sadistic and sexual homicides [3, 27]. Perpetrators may be affected by anti-social disorders or paraphilias and tend to be men, whereas victims tend to be adult women.

Cases of elderly victims (mostly women) often involve other offenses, such as burglary [28].

A considerable number of non-fatal cases where women cut off the penis of their male partner while the man slept was documented in Thailand in the 1970s [29].

In the present case, since the victim was found in his courtyard and no signs of struggle were found, the abovementioned hypothesis was unlikely.

The other hypothesis concerned male genital self-mutilation (GSM) resulting in complete emasculation [2, 8].

Suicidal attempts through GSM are rare and often unsuccessful, while GSM is more frequent in cases of self-harm [2, 7, 30,31,32].

GSM is often associated with psychiatric conditions. However, GSM is sometimes performed by non-psychotic individuals for aesthetic and social purposes, for distorted religious beliefs or to seek sexual reassignment surgery [1, 33,34,35,36,37,38].

The large majority of individuals performing GSM are males in the third and fourth decades of life [1, 39], with the oldest victims being aged 62, 66, and 72 [35, 40,41,42].

In a recent paper, a 60-year-old man with a history of fronto-temporal dementia inserted a spoon into the urethra during a stay in hospital [43].