Traumatic penile partial amputation of unusual occurrence: A case report.

We report the clinical case of a 9-year-old boy admitted for open trauma to the penis which occurred 3 hours before his admission by domestic accident. The child pounding vegetables, was awkwardly struck on the penis with a pestle. After conditioning, exploration in the operating room found partial amputation of the glans with complete rupture of the urethra. Washing with trimming and urethral anastomosis on a urinary catheter were performed. Healing was obtained without urethral stenosis. Injuries to the penis in children are not common and their management can be tricky.

Introduction

Open trauma to the penis is a rare urological emergency because the penis is an organ protected by its location and mobility. It can be iatrogenic during circumcision or caused by domestic accidents (animal bite). These traumas can cause serious injuries with considerable sequelae. Their delicate management will aim to restore a normal cosmetic and anatomical aspect of the penis as well as restore urinary and sexual function. We report the uncommon case of open trauma to the penis in a child under the unusual circumstance of occurrence. The aim of this work was to discuss the etiologies, anatomoclinical and therapeutic forms of trauma to the penis in children.

Case report

This is a 9-year-old boy received in the emergency room after transfer from another hospital, for an traumatic penile injury that occurred 3 hours before his consultation. This is a domestic accident. The child, trying to help his mother to pound vegetables, was awkwardly hit with a pestle on the penis (Fig. 1). The clinical examination upon arrival found an anxious child in good general condition, coloured conjunctivae, apyrexia and a compressive bandage soaked in blood. After conditioning and carrying out the preoperative assessment, the patient was admitted to the operating room for exploration. Under general anesthesia, exploration found partial amputation of the glans with complete section of the urethra (Fig. 2). Washing with trimming and anastomosis of the sectioned urethra on a urinary catheter was performed (Fig. 3A). Postoperative care consisted of the administration of an antibiotic therapy based on an amoxicillin - clavulanic acid combination, an analgesic (paracetamol) and local care of the operative wound. The postoperative follow-up was marked 4 days postoperatively by the occurrence of hyperthermia at 39 °C, infection postoperative and partial release of the sutures. Daily local care allowed controlled healing without urethral stenosis. The patient was discharged after 25 days of hospitalization. After a one-year follow-up, the postoperative results are satisfactory. There is no longer any local inflammatory phenomenon, no urethral stricture and painless and aesthetically acceptable healing (Fig. 3B).

Fig. 1

Photograph of the reconstruction of the cause of the trauma to the penis.

Fig. 2

Lateral view of partial amputated penis with complete section of the urethra.

Fig. 3

Replantation complete with foley's catheter in situ (A) and final aspect after 8 months (B).

Discussion

Trauma to the penis are rare urological emergencies whose psychological and physical, functional and emotional repercussions affect the patient and his parents. Injuries to the penis in children are sporadic injuries and are caused by circumcision accidents, animal bites and zipper injuries. The etiologies of pediatric penile injury are different from those of adult penile injury. El-Bahnasawy and El-Sherbiny identified 64 patients with penile injury and the most common cause was circumcision (63%), followed by strangulation with a rubber band. Home and sports accidents have also been reported. Traumatic penile injury causes various and varied lesions depending on the cause of the trauma and the damaged penile structures. There is no standard classification for injury to the external genitalia. Rashid et al. reported a classification of male genitalia injury by anatomical location. Type I injury includes distal portion of the penis with proximal part of the penis being preserved. Type II injury includes severe injury on shaft of penis with penile crus being preserved. Type III injury includes the injury when urethral catheterization is necessary with external urethral part being preserved. Type IV injury includes the injury when suprapubic cystostomy is needed. Our observation presented a partial amputation of the penis type I with complete rupture of the urethra by domestic accident. Sharp blade amputations are less of a problem than those caused by animal bites. These present contused tissue sometimes amputated stump not found or otherwise of poor quality and probably soiled. The risk of infection under these conditions does not favor the success of penile reimplantation. Their treatment requires washing and irrigation of the lesions, trimming, broad-spectrum antibiotic therapy, seroprevention and tetanus vaccination. In the event of a bite from an unimmunized dog, whatever the type of lesion, an anti-rabies vaccination should be carried out. Several authors agree on the realization of a reimplantation whether it is microsurgical or not as far as possible with preservation of the foreskin in the case of a circumcision accident before any penile amputation.,,

Conclusion

Injuries to the penis in children are not common and their management can be tricky. These are rare but often serious emergencies. They are largely caused by accidents in the home, sports and circumcision. Treatment in less serious forms poses fewer problems and gives better aesthetic and functional results, while the management of serious forms and their complications (amputations, fistulas) resulting from replantation or urethroplasty remains a challenge.