Amputation of the glans due to sexual abuse in children: case report

Abstract

Introduction

Amputations of the glans in children are rare and have various etiologies. We report a case of glans amputation due to sexual abuse.

Case presentation

This is a case of a 4-year-old child who was admitted to the hospital with a cut glans following sexual abuse. The child presented with total amputation of the tip of the glans. We performed glans regularization and meatoplasty with a Foley probe. Postoperative management was straightforward.

Discussion

Penile amputations are serious but rare urological emergencies. In the study by Diabaté et al. [4], amputations of the penis accounted for 0.6% of urological emergencies. The most common causes were circumcision performed by untrained personnel and animal bites [1, 3, 4, 6]. Amputation of the glans due to sexual abuse is a medico-legal problem. For investigation and prosecution purposes, the doctor or surgeon must inform the judicial authorities.

Conclusion

Glans amputations in children are a tragic reality. They pose psychological, emotional, and, above all, medico-legal challenges.

Highlights

• •Amputations of the glans in children are rare and have various etiologies. Amputation of the glans because of sexual abuse is extremely rare.
• •We report a case of glans amputation due to sexual abuse. This is a case of a 4-year-old child who was admitted to the hospital with a cut glans following sexual abuse.
• •The child presented with total amputation of the tip of the glans. We performed glans regularization and meatoplasty with a Foley probe.
• •Postoperative management was straightforward.

1. Introduction

Amputations of the glans in children are rare and have various etiologies. Amputations can result from circumcision, with animal bites being the most common cause [[1], [2], [3], [4], [5], [6], [7]]. However, no case of glans amputation due to sexual abuse has been reported. These amputations can have significant psychological, functional (urinary and sexual) [5,8], and overall quality-of-life consequences. Immediate management is necessary to preserve the amputated penis. In accordance with the PROCESS guidelines [9], we report a case of complete amputation of the tip of the glans penis due to sexual abuse in a 4-year-old child. This case report has been reported in line with the SCARE checklist [9].

2. Case presentation

A 4-year-old child with no previous history of sexual abuse was admitted to the emergency department with a painful glans penis, presenting six hours after the injury. According to the housekeeper, the child had been electrocuted. However, according to the child, the cleaning lady, whom he referred to as “his wife,” had bitten him. Forensic investigations concluded that the glans had been amputated during fellatio. On admission, the child presented with total amputation of the tip of the glans penis with a clean-cut slice [Fig. 1]. The urethral meatus was central and obstructed by a blood clot. Peno-glandular flanges were present, which were sequelae of neonatal circumcision. The amputated tip was not found, nor were other maltreatment lesions. Under general anaesthesia, we performed an emergency glans tip regularization associated with a meatoplasty using invaginating spongio-cutaneous and carveno-cutaneous stitches with 6/0 PDS sutures on a siliconized Foley probe, combined with resection of the peno-glandular flanges. We performed emergency glans tip regularization combined with Foley catheter meatoplasty and resection of the peno-glandular flange [Fig. 2]. Greasy dressing was applied. Post-operative evolution was straightforward (1st dressing applied on postoperative day 4 and removal of the urinary catheter on postoperative day 8). After 8 months, the cosmetic appearance was satisfactory, the urinary stream was normal, and sexual function will be assessed in adulthood [Fig. 3]. A declaration was made to the judicial authorities, parental custody was revoked, and the patient was entrusted to the child protection department for social and psychological care.

Fig. 1.

Partial glans amputation of the penis A (profile) B (face).

Fig. 2.

Plasty of the tip of the glans on a urethral catheter A (profile) B (face).

Fig. 3.

Appearance of the penis at 8 months postoperative (A: dorsal side, B: ventral side).

3. Discussion

Penile amputations are serious but rare urological emergencies. The incidence of these injuries is poorly known due to lack of reporting. In the study by Diabaté et al. [4], amputations of the penis accounted for 0.6 % of urological emergencies, with children representing more than 60 % of the cases. The most common causes were circumcision performed by untrained personnel and animal bites [1,3,4,6]. In addition to circumcision and animal bites, other rare causes such as crushing of the penis by a pestle [10] or amputation by a sliding door [11] have been reported in the literature. Amputation of the glans due to sexual abuse is a medico-legal problem. For investigation and prosecution purposes, the doctor or surgeon must inform the judicial authorities. The seriousness of these injuries is due not only to the surgical difficulties involved but also to postoperative complications that affect the patient's aesthetic, urinary, and sexual outcomes, with psychosocial repercussions for both the patient and their family [5,8,12].

The penis can be subject to a wide variety of injuries, depending on the trauma's cause. There is no standard classification for external genitalia injuries. Rashid et al. [13] proposed a classification of male genital injuries based on their anatomical location. According to this classification, our case involved a total amputation of the tip of the glans, classified as type I due to sexual abuse.

The patient may be admitted to the emergency department with or without the amputated stump. It is also important to look for associated injuries to address life-threatening conditions as quickly as possible. Emergency surgical exploration is essential. Penile amputations in children are more complex and technically demanding due to the reduced size of the organ and vessels. Microsurgical reimplantation should be performed if the amputation stump is available and viable. However, a case series has suggested that achieving successful penile micro-anastomosis in prepubertal children is extremely difficult, if not impossible [14]. Some authors suggest that depending on the time to amputation and the degree of infection, reimplantation with or without grafting can be performed with good results [10,12,13,15]. In our patient, reimplantation was not considered, as the amputated stump was not recovered. Therefore, we performed regularization combined with meatoplasty, with a simple postoperative course.

Postoperative complications may include infections, vascular (ischemic) issues, urinary complications (stenosis, fistulas), and sensory or sexual dysfunction [4,6]. According to Ince et al. [6], sensory and erectile disorders tend to regress most rapidly in children. However, sexual function will not be assessed until adulthood.

4. Conclusion

Glans amputation due to sexual abuse in children is a tragic reality. It presents essential to preserve the amputated penis.

Consent

Written informed consent was obtained from the patient's mother for publication of this case report and accompanying images.

Ethical approval

Case reports do not require the approval of our institute's ethics committee.

Funding

All authors declare that they have no financial conflicts of interest.

Author contribution

Study concept ou design: Amenan Kan Sophie Kouassi Dria.

Data collection: Rebecca Bonny Obro and Jean Jaures Ouattara.

Data analysis or interpretation: Kokoe Midekor Gonebo and Yapi Landry Aké.

Writing the paper: Amenan Kan Sophie Kouassi Dria and Ello Nicolas Moh.

Guarantor

Dr. Amenan Kan Sophie Kouassi-Dria.

Research registration number

N/A.

Declaration of Generative AI and AI-assisted technologies in the writing process

The authors state that they did not use AI at any stage in the preparation of this case report.

Conflict of interest statement

All authors declare that they have no personal conflicts of interest or other relationships with other people or organizations that could improperly influence this work.