Animal bite of penis in a neonate and macroscopic repair.

We are reporting a newborn male who had injury of the penis probably due to rat bite. The baby was brought to the hospital within 3 h of the injury. The urethra was completely transected. Macroscopic repair was performed. The patient had an uneventful recovery and was discharged after 2 weeks. The patient is doing well 3 months after the operation.

INTRODUCTION

Total penile amputation is an uncommon injury.[12] About 87% of the patients reported had psychiatric problems. Self-amputation of the external genitals is also known as Klingsor syndrome.[23] Here, we present a case of a neonate who had traumatic amputation of the penis that was repaired by macroscopic penile replantation. To the best of our knowledge, this is only the second case to be reported in the English literature.

CASE REPORT

A male baby weighing 2.1 kg was brought to our hospital with the penis dangling from the root by a narrow strip of skin attached ventrally to the scrotum within 3 h of injury. As per the history given by the mother, the incident occurred when the mother went to the toilet, and when she returned, she saw that the baby was lying in a pool of blood. The probable cause of injury was thought to be rat bite as the village area to which the patient belongs is known for rat bites. The penile stump was wrapped in a piece of cloth and no effort was made to keep the organ cool during transportation. Soon after arrival in the hospital (3 h from the time of noting the injury), the neonate was taken to the theatre, and on examination, there was no evidence of circulation in the distal penile stump [Figure 1]. The urethra was completely transected. The wounds on either side were gently cleaned with warm normal saline and repair was started after putting in a 6Fr Nelaton's catheter per urethra. The urethra was aligned by taking sutures in the periurethral spongiosum by 7-0 Vicryl. All sutures were taken before tying them one followed by another. The corpora were sutured with 6-0 Vicryl. The edges of the Buck's fascia and skin on both sides were trimmed and sutured using interrupted Vicryl 6-0 round body for the fascia and 5-0 Vicryl for the skin. The procedure was done with the help of a 2.5 magnifying loupe. No vessels were anastomosed [Figure 2].

Figure 1

Injured penis with transectedurethra

Figure 2

Immediately after the replantation on Nelaton catheter

The 6 Fr Nelaton's catheter was used as a splint for the urethra. In the postoperative period, low-molecular weight dextran and heparin 2500 units every 8 h (s.c.) were administered. Both were withdrawn on the third postoperative day, when the penis gradually regained normal color. On the 12th postoperative day, the urethral stent was removed [Figure 3]. The patient passed urine normally and was discharged after 2 weeks. Both the size and the strength of the stream appeared to be normal on clinical examination. The patient was seen again 1 and 4 months after discharge, and was doing well. The penis looked normal and the urine stream was good. There was erection of penis at the time of passing of urine.

Figure 3

Appearance of penis at the time of discharge

DISCUSSION

The first documented case of macroscopic penile replantation was reported in 1929 by Ehrlich.[2] Cohen et al. reported the first microvascular replantation of penis in 1977.[4] A review of the literature revealed that approximately 80 cases underwent penile replantation, of which 50 cases underwent macroscopic replantation since 1970. But majority of the reports are from the adult literature, and this report presents a neonatal case of penile amputation and its management.

We feel that the small connecting tag of skin could not be an adequate source of blood supply for the replanted penis because, preoperatively, the distal penile stump had no circulation. The penis is supplied by branches of pudendal artery; dorsal artery, deep artery, bulbo-urethral artery and accessory pudendal artery (variable). Variation is present in the origin, distribution and symmetry of these arteries. It is organized into three planes: inferior or ventral, middle or deep and superior or dorsal.

We agree with Mendez et al.[5] and Ninavah[6] that the circulation after macroscopic repair is re-established through the spongy tissue of the penis. Experimental work by Raney et al.[7] supports this view. The current concept of microvascular replantation for penile amputation is the treatment of choice, with the best prospects for cosmetic restoration, physiological micturition and preservation of sensation and erectile function. The macrosurgical replantation of the penis depends on corporal sinusoidal blood flow, with the distal amputated part acting as a composite graft. Complications of skin necrosis, fistula formation, loss of sensations and erectile dysfunction have been reported after macrosurgical replantation of the penis.[2]

But, as we do not have the facilities of microvascular anastomosis at our institute, we were forced to go for a macroscopic replantation, and the eventual outcome was satisfactory. Analysis of our case revealed that the cleanly incised injury with a short duration of cold ischemia was an important factor that influenced the outcome. We have observed good stream and erection of penis while passing urine during follow-up. As the time of follow-up is only 4 months, we are not in a position to comment about the possibility of developing urethral stricture.