Isolated Penile Injury in Boys: Accident, Negligence, or Abuse?

AIM: The aim of the study was to highlight the etiology, spectrum of presentation, and management of isolated penile trauma in boys.
METHODS: A retrospective review of boys treated for isolated penile trauma between January 2015 and June 2019 at a tertiary-level hospital.
RESULTS: Nine children were admitted over 4½ years. Etiology: The mechanism of penile injury (PI) was penile hair tourniquet (n = 5), postcircumcision (n = 2), dog bite (n = 1), and scald injury (n = 1). Extent of injury includes complete urethral transection at corona (n = 4); loss of urethral plate in a case of hypospadias (n = 1); complete loss of glans (n = 1); penile transection at corona (n = 1); total penile amputation (n = 1); and deep partial-thickness burns of penile shaft and adjacent suprapubic skin (n = 1). Management: One patient absconded. The remaining patients were managed as follows: calibration of urethral meatus (n = 1); penile burn was managed with dressing and antibiotics; coring of glans with urethral end-end anastomoses (n = 4); Bettocchi's quadrangular lower abdominal flap phalloplasty (n = 1); and Bracka's staged urethroplasty (n = 1). Complications include wound infection following trauma (n = 4), postsurgical infection (n = 3), urethrocutaneous fistula (n = 2), and reapplication of penile hair tourniquet (n = 1).
CONCLUSION: Isolated PI in boys is not uncommon. Most are preventable if the parents are apprized and watchful. The clinician should also be vigilant regarding child maltreatment. A staged approach tailored to the type of injury provides a satisfactory outcome. Copyright:

INTRODUCTION

Penile injuries (PIs) in boys are not only uncommon but also have a different etiology than adults. Injury from circumcision, animal bite, burns, and sexual abuse predominate.[12] Fracture and penetration injuries are rare. Strangulation injury is mostly seen at the corona as opposed to adults where it is seen at the penile base. Besides, studies focusing on nonsexual, isolated genital injury in boys are fewer.[12] The main problems in the assessment of isolated genital injuries in boys are – these are perceived as less serious than genital injuries in girls. Second, there is a lack of substantive literature regarding such injuries. Moreover, health professionals are often not confident enough to identify such injuries as being due to abuse.[3] This paper highlights the etiology, spectrum of presentation, management, and outcome of isolated penile trauma in boys treated in our department.

METHODS

A retrospective review of cases presenting with isolated penile trauma from January 2015 to June 2019 was performed. Cases, where penile trauma was associated with cerebral, abdomino-thoracic, pelvic, perineal, and perianal trauma, were excluded as were cases of sexual assault. Data were collected for the mode of injury, the extent of the injury, initial and subsequent management, surgical procedures performed, complications, and the outcome. Initial treatment of these children included hemodynamic stabilization, wound cleaning/debridement, hemostasis (wherever required), and antibiotics. Staged management, including penile repair or reconstruction, was performed for those requiring surgery. The grading of PI is done as per the American Association for the Surgery of Trauma-Organ Injury Scale for PI.[4] The grading of the penile burn was based on the grading reported by Michielsen and Lafaire[5] The duration of follow-up is up to the last outpatient visit varying between 6 months and 2 years. Cases have been assigned numbers from 1 to 7 for easy reference as in Table 1, which also shows the mechanism, extent (severity), and grade of injury.

Table 1

Clinical details of patients with penile trauma

Case number	Mechanism of injury	Presentation	Extent of injury	Trauma grade/depth of injury or burn
1	Penile hair tourniquet	Delayed	Complete loss of glans penis	IV*
2	Penile hair tourniquet	Delayed	Complete urethral transection at corona	III*
3	Penile hair tourniquet	Delayed	Complete urethral transection at corona	III*
4	Postcircumcision	6 h	Penile transection at corona	IV*
5	Penile hair tourniquet	Delayed	Complete urethral transection at corona	III*
6	Postcircumcision penile infection (a case of hypospadias)	5 days	Loss of urethral plate and loss of corpus spongiosa up to penile base	IV*
7	Penile hair tourniquet	Delayed	Complete urethral transection at corona	III*
8	Scald (tea spill)	2 days	Circumferential burn over penile and adjacent suprapubic skin	Deep partial-thickness burns@
9	Dog bite	6 h	Complete penile amputation	V*

*The grading of penile injury is based on Moore et al.[4] adopted by the AAST-Organ Injury Scale of penile injury, @The grading of penile burn as described by Michielsen et.al.[5] AAST: American Association for the Surgery of Trauma

RESULTS

Nine boys, mean age of 6 years and range 1–12 years, with isolated penile trauma were treated over 4½ years (January 2015 to June 2019). The mechanism of PI was penile hair tourniquet (n = 5), postcircumcision (n = 2), dog bite (n = 1), and scald (n = 1). The penile shaft distal to the injury was lost in three cases (cases 1, 4, and 9). Except one (case 2), all the cases of PI by hair tourniquet had been previously circumcised, and in all cases, the tourniquet was present at the coronal sulcus. In the two cases of postcircumcision injury, the circumcision had not been performed by a registered medical practitioner. All injuries were high grade between III and V. Reporting of the case to police authority was done only in cases no. 8 and 9.

Treatment

The five cases of PI secondary to hair tourniquet were treated as follows: the child with complete loss of glans penis [Figure 1a], had an acceptable penile appearance, an adequate penile length, and a good caliber urinary meatus. The projection of the urinary stream was normal. He was managed by urethral calibration alone. The rest [Figure 1b] and three similar cases were treated in a staged manner. Initially, they were managed by removal of the hair tourniquet, cleaning of the wound, and antibiotics. After 6 months, the repair was performed, which consisted of degloving, coring of glanular urethra and undermining the glans, mobilization of 1 cm. of spongiosa proximal to fistula, and end-to-end urethral anastomoses with 6-0 Vicryl suture over an infant feeding tube and glansplasty. There were two cases of PI secondary to circumcision. In both cases, the procedure was performed by an unregistered medical practitioner. The first [Figure 1c] case absconded after admission. The other was a case of hypospadias. He had undergone circumcision 8 days prior. The wound got infected. At arrival, he had a red swollen penile shaft and an edematous urethral plate. There was a purulent collection beneath the dartos. The child was initially managed by debridement and antibiotics. Later on, synechia developed between the skin overlying the penile shaft and that over the coronal sulcus [Figure 1d]. Moreover, the quality of the urethral plate had deteriorated. Seven months later, a buccal mucosal graft was applied (Bracka's Stage 1). Stage 2 was done after another 8 months. He developed a postoperative urethrocutaneous fistula, which resolved spontaneously. The boy with scald injury developed a circumferential deep partial-thickness burn of the penile shaft and the adjacent suprapubic skin [Figure 2a]. He was managed with intravenous antibiotics and local dressing. In the case of a dog bite [Figure 2b], the penile shaft, the adjoining supra- and infra-penile skin, and subcutaneous tissue were lost. It required an initial blood transfusion, antibiotics, wound dressing, and immunization against tetanus and rabies. He developed wound infection during the hospital stay, which was managed by a change in antibiotics. Subsequently, a phalloplasty was performed using a quadrangular lower abdominal flap after 6 months [Figure 2c]. Postphalloplasty, there was a stitch line infection at the base of the neophallus.

Figure 1

(a) Complete loss of glans penis caused by hair tourniquet (seen in coronal sulcus). (b) Complete urethral transection by hair tourniquet. (c) Penile amputation at circumcision. (d) Synechiae formation between the residual coronal skin and shaft

Figure 2

(a) Note the sharply demarcated wound margin in the suprapubic area and the absence of any adjacent spillage burns. (b) Penile amputation with loss of adjacent scrotal and pubic skin and subcutaneous tissue. (c) Lower abdominal quadrangular skin flap used for neophallus construction

Overall outcome following surgery was good. The boy managed with meatal calibration alone passes urine normally. The cases of urethral transection with hair tourniquet treated with urethral anastomoses required urethral calibration for 4–6 weeks. In three cases, there was a slight ventral angulation between the shaft and the glans. The boy with scald injury developed a slight upward deviation of the penis at the base. It is within acceptable limits. The boy who was treated with phalloplasty is waiting for further surgery, i.e., incorporation of the penile stump in the neophallus and urethroplasty. Case 3 presented with reapplication of the penile hair tourniquet a month after successful repair, resulting in the recurrence of urethral transection. He did not turn up for re-repair.

DISCUSSION

A PI can be a cause of anguish for both the patient and the parents. We came across nine patients over a 4½-year period. Lucknow district of North India has two more tertiary centers with a functioning pediatric surgery department like ours, suggesting that there could be more such cases. Penile hair tourniquet was the leading cause of PI in this series, with 55.6% cases, followed by circumcision 22.2%. Animal bite and scald injury comprised 11.1% cases each.

All five patients of PI due to hair tourniquet had a prior circumcision. This is as per literature.[678] While the majority consider the hair coiling to be accidental, some regard it as deliberate[19] or even as child abuse.[10] Detected early, uncoiling the hair suffices, and the result is good.[678] Delayed detection results in severe consequences such as urethral transection, penile gangrene, and loss of glans penis, as noted in our series. Postoperatively, apart from urethral calibration, the examination of the corona is also necessary since one of our patients returned with a penile hair tourniquet reinjury 1 month after a successful repair.

Partial or complete transection of glans is an uncommon event (5%–8% of total) at circumcision.[1112] To date, 42 cases have been reported.[121314] Adequate training, to the personnels doing circumcisions, is necessary as is the awareness among parents and the general public regarding the availability of trained personnels in the vicinity.[11]

A notable aspect of presentation in the single case of scald injury was the ambiguity in parental history and its discrepancy with the local examination. A circumferential scald injury (tea spill) to the penile shaft without any adjacent spillage burns cannot be accidental. Moreover, a sharply demarcated burn margin in the suprapubic area suggests contact burn. Accidental burns have a more irregular border and a nonuniform burn depth and are mostly superficial,[15] unlike in our case, which was a deep partial-thickness burn. The case is invariably of child abuse.

Genital injury in boys from a dog bite is rare, with 25 reported cases.[11617] In the West, 9 of 21 injuries were inflicted by a family dog and only three by a stray dog.[16] In India, four cases out of five were bitten by a stray dog.[17] The event might appear accidental, but it highlights the failure of parents to give physical protection to their child, i.e., “parental negligence.” Measures such as training programs for parents/aspiring parents and social concepts such as community monitoring of children may be beneficial as is the regulation for the management of stray dogs.

Our treatment strategy was based on the type and extent of the injury. Trauma from an unhealthy circumcision, hair coil, animal bite, and burn are prone to infection as seen in four of our cases. Furthermore, tissue edema due to delayed arrival precluded a primary reconstructive surgery. On the contrary, there are reports of single-stage repair of hair coil injuries with uncoiling, cleaning, and repair being done in a single sitting.[67] We treated the cases of urethral transection from hair coils by degloving, coring of the ventral glanular urethra along with undermining the glans, and end-to-end urethral anastomosis with 6-0 Vicryl over an infant feeding tube and glansplasty. This technique has been used by others.[89] Furthermore, we mobilized 1 cm of spongiosum proximal to fistula to decrease tension on the anastomosis. Three patients developed a slight ventral angulation of the glans, but it was acceptable. Other approaches reported for the repair of such injuries are stitching of the glans to the shaft over a silastic stent without taking sutures on the urethra,[6] discarding the distal intraglanular urethra, and advancing the fistula site as in meatal advancement.[18]

Phalloplasty in the case of the dog bite was done using a quadrangular lower abdominal flap described by Bettocchi et al.[19] and De Castro et al.[20] for patients with gender dysphoria and aphalia, respectively. Both performed a single-stage phalloplasty with urethroplasty. While the former used skin from the clitoris and labia majora for urethroplasty, the latter has used oral or buccal mucosa. The base of their flap was fashioned in the region where the penile base is supposed to be and forms the base of the neophallus incorporating the superficial external pudendal vessels. In our case, the dimensions of the flap were 4 cm × 5 cm, and it included the skin, subcutaneous tissue, and Scarpa's fascia. However, the base of our flap was a bit cranial since the parietal tissue over and caudal to pubic bone including the superficial external pudendal vessels was lost during the initial trauma. Our flap was based on the superficial circumflex epigastric vessels. Therefore, we could not incorporate the penile stump in the phalloplasty in one attempt. We have planned to perform it in the next stage and subsequently do a Bracka's two-stage urethroplasty using a buccal mucosal graft. This procedure has not yet been tried for a penile loss by an animal bite.

CONCLUSION

Isolated PIs are not infrequently encountered in clinical practice. While most are accidental and preventable if the parents are observant, a high degree of suspicion for child maltreatment based on an intelligent history and a thorough examination is essential on the part of the clinician. Using a multistage approach for such cases, the surgical outcome is acceptable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.