Devastating genital injury leads to degloving and rerouting of the penis: An unusual case report in an 8-year-old child

Abstract

Penetrating penile injuries are rare in children. Thus, the evaluation and management of this type of injury have not been well described. Penile trauma in children varies in severity from trivial to more severe, with devastating functional and psychosocial consequences. Here, we report the case of an 8-year-old boy who suffered a penetrating penile injury as a result of falling from a height onto a sharp object, necessitating rerouting of the penis. After stabilization, the patient was subjected to careful surgical exploration and meticulous reconstructive surgery. The final outcome was excellent with good functional and cosmetic result without any complications.

Introduction

Severe trauma of the external male genitalia is rare because of the location and mobility of the penis and scrotum [1], [2], [3], [4]. In terms of its etiology, pediatric genitourinary trauma has generally been classified into blunt and penetrating types. Blunt injuries include those resulting from falls, road traffic accidents, sporting accidents, physical assault, or sexual abuse, while penetrating injuries can occur as a result of gunshot or knife wounds, or falling onto a sharp object as in the present case [5], [6], [7], [8]. However, in the literature, there are insufficient descriptions of how to evaluate and manage these injuries [1]. Here, we report on an 8-year-old boy with a devastating penile injury as a result of falling from a height onto a sharp object. After stabilization, the patient was subjected to immediate surgical exploration and reconstructive surgery.

Case presentation

An 8-year-old boy was taken to the emergency department by his parents. He had penile trauma resulting from a fall from a height onto a sharp object, resulting in a deep open wound. On general examination upon arrival at the emergency room, he was conscious and oriented, while being hemodynamically stable on local examination. There was a deep open wound in the pubic area, and the penis was tender to the touch. The penis was degloved, rerouted, and retracted through the pubic wound. The scrotum was intact, and the abdomen was non-tender (Fig. 1).

Fig. 1.

Images of the penetrating penile injuries at presentation, with a deep open wound in the pubic area and the penis being tender to the touch.

A broad-spectrum antibiotic and analgesic were given. The results of laboratory investigations were within normal limits. A pan-CT scan with contrast was performed, revealing that there was no penetration to adjacent organs and that the major vessels had been spared. In addition, no extravasation of the contrast agent or significant hematoma was observed. Otherwise, the head of the penis was depressed, along with a small local subcutaneous hematoma and skin abrasion (Fig. 2).

Fig. 2.

A & B: Coronal plane: CT with contrast showed that there was no penetration to adjacent organs and that the major vessels had been spared. In addition, no significant hematoma could be observed. C: Sagittal Plane: The head of the penis was depressed, with a small local subcutaneous hematoma and skin abrasion.

A scrotal Doppler ultrasound was also performed, demonstrating normal scrotal anatomy and normal testicular blood flow bilaterally. The patient was taken to the operating room. Under general anesthesia, he was reassessed and carefully reexamined using a loupe. The wound was also thoroughly irrigated with normal saline and Chlorhexidine. Meticulous exploration revealed penile degloving and retraction through the pubic wound, with a mild hematoma in the proximal Buck's fascia due to bleeding from a dorsal vein. Hemostasis was achieved using bipolar diathermy. No foreign body was found. The wound was debrided and cleaned, and skin loss was reassessed and found to be good enough to be covered by primary repair. The pubic and penile wounds were closed by 4/0 and 5/0 Vicryl sutures, respectively. An intraoperative drain was also inserted.

Postoperatively, the patient remained stable and afebrile. The drain and dressing were removed on day 2, at which point he was voiding freely and had clean, dry wounds (Fig. 3). He was discharged home on day 3 with analgesics and antibiotics. At the 2-month follow-up in the clinic, the patient was doing well, and the wound had completely healed without any complications. The functional and cosmetic outcomes were good, and there were no lower urinary tract–related symptoms (Fig. 4).

Fig. 3.

On day 2 postoperatively, the drain and dressing were removed and the patient voided freely.

Fig. 4.

In the clinic 2 months after the injury, the patient was doing well, and the wound had completely healed.

Discussion

Injuries to the genitourinary system are generally defined as those caused by either blunt or penetrating trauma. Approximately 10% of all injuries encountered in the emergency department are related to the genitourinary system [5]. Apart from the external genital organs, the genitourinary system is well protected from blunt and penetrating trauma in males because of the surrounding internal organs, musculoskeletal structures, and natural mobility. Blunt injuries to the penis are more often seen due to the mobility and localization of the penis, rather than penetrating injuries caused by firearms or cutting instruments [5].

Male genital trauma is a urological emergency because of the high risk of infection and the need to protect sexual, endocrine, and reproductive functions. For such injuries, the primary aim of treatment is to preserve urethral integrity and sexual function [5].

Penetrating scrotal injuries are rarely seen in children. In adults, etiologically, such injuries are typically the result of gunshot wounds, stabbing, road traffic accidents, combat-related wounds, bomb blasts, and self-inflicted wounds [1], [9]. In children, the most common causes of such injuries are falling from a height onto a sharp object, animal bites, and accidental injuries [1]. Penetrating scrotal trauma can affect the testes, spermatic cord, urethra, and penis. The injury can also extend into the anal canal and rectum. Such injuries also pose a risk to the iliac vessels, femoral vessels, and nerves [1]. Penile injuries in children can have various causes, including motor vehicle accidents, iatrogenic trauma, animal bites, electrocution, entrapment in a zipper, and hair strangulation. They vary from trivial to more severe, with devastating functional and psychosocial consequences [3], [10].

El-Bahnasawi and El-Sherbiny published a report on the largest number of penile trauma cases (n = 64) in the pediatric population. The most common cause of such trauma was circumcision (63%), followed by hair strangulation. In such cases, in which the coronal sulcus is lost after replantation, a buccal graft has been used with good results [4], [6]. Severe penile trauma might present with adjacent comorbidity involving the scrotum, pelvis, buttocks, and thighs [4].

Genital injury in children generally occurs by one of two mechanisms. The first is a result of sexual abuse, particularly in developed countries. The second genital trauma is accidental impalement injury resulting from a traffic road accident or fall, particularly in developing countries. Thus, genital trauma is relatively more severe and is associated more frequently with anorectal or other additional organ injuries in these countries [11], [12]. The mechanism of injury was a traffic road accident or fall in most of the patients. It is possible that genital injury in the setting of traffic road accidents and falls cause a greater risk of complications because of tissue destruction, contamination, and additional organ injuries [11], [12].

Pediatric reports on trauma to the external genitalia, in particular, are published only sporadically. The cause and severity of penile trauma vary from entrapment in a zipper to more serious injuries and complete emasculation [6]. Penile trauma as a complication of circumcision has also been reported relatively frequently, with varying degrees of severity ranging from skin or meatal injury and partial glanular amputation to total penile amputation [7]. Total penile ablation by electrocautery during circumcision has also been reported, but the most common circumcision-related complications are hemorrhage and primary infection [2], [6].

Guidelines for the treatment of adult and pediatric genitourinary trauma recommend a comprehensive clinical and radiological evaluation of these patients. After initial resuscitation and control of any active bleeding, a broad-spectrum antibiotic and tetanus booster should be administered. Laboratory investigations should include urine analysis and stool guaiac test, which can reveal potential urethral or anorectal injury [1], [12]. Physical examination should include digital rectal examination to rule out anorectal injury. Both lower limbs should be assessed for peripheral pulse and sensorimotor function, which can reveal findings suggestive of neurovascular injury. Local examination should focus on the presence of any blood at the meatus as an indication of urethral injury. Penile or scrotal hematoma may suggest a corporal or testicular rupture. If there is any bleeding from the rectum, proctosigmoidoscopy should be performed to rule out rectal injury [1]. Careful physical examination should be followed by imaging and radiographic examinations. For example, Doppler ultrasound can be used to evaluate the integrity of the testes and their blood flow. CT scan of the abdomen, pelvis, and external genitalia can also provide anatomical details of the injury. A retrograde urethrogram can be performed if the physical examination suggests urethral injury [1], [12]. Although the literature does not contain any definitive guidelines for the management of pediatric penetrating penoscrotal injuries, surgical exploration is required in almost all of these injuries. The goals of such exploration include complete hemostasis, assessment of the extent of the damage inflicted, debridement of all nonviable tissues, and thorough irrigation of the wound. In addition, in the case of testicular injury, testicular salvage should be attempted [1]. Patients with penile amputation benefit from the development of microsurgery, with which many successful reimplantation have been achieved [10].

Conclusion

Penetrating penile injuries are rare in children but demand careful evaluation by physical examination and radiological investigations, followed by urgent and meticulous surgical exploration. Penile trauma in children varies in severity from trivial to more severe, with devastating functional and psychosocial consequences. The main goal of reconstructive surgery is to ensure normal appearance and functions of the penis.

CRediT authorship contribution statement

Alhareth Baarimah: Writing – review & editing, Writing – original draft, Project administration, Conceptualization. Ziyad Althobaiti: Writing – original draft, Methodology, Funding acquisition, Data curation. Nasser Alshamrani: Writing – original draft, Resources, Funding acquisition. Mohammed Althobaiti: Writing – original draft, Resources, Funding acquisition. Ashraf Soliman: Writing – review & editing, Visualization, Validation, Supervision.

Consent form

A written consent was obtained from the parents for publication of this case report and accompanying images.

Funding

No funding was received for this study.

Declaration of competing interest

The authors declare no competing interests.