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Traumatic Penile Injury: from Circumcision Injury to Penile Amputation

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Traumatic Penile Injury: from Circumcision Injury to Penile Amputation Hindawi Publishing Corporation BioMed Research International Volume 2014, Article ID 375285, 6 pages http://dx.doi.org/10.1155/2014/375285 Review Article Traumatic Penile Injury: From Circumcision Injury to Penile Amputation Jae Heon Kim,1 Jae Young Park,2 and Yun Seob Song1 1 Department of Urology, Soonchunyang University Hospital, College of Medicine, Soonchunhyang University, Seoul, Republic of Korea 2 Department of Urology, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Republic of Korea Correspondence should be addressed to Jae Young Park; [email protected] and Yun Seob Song; [email protected] Received 24 April 2014; Revised 16 August 2014; Accepted 16 August 2014; Published 28 August 2014 Academic Editor: Ralf Herwig Copyright © 2014 Jae Heon Kim et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The treatment of external genitalia trauma is diverse according to the nature of trauma and injured anatomic site. The classification of trauma is important to establish a strategy of treatment; however, to date there has been less effort to make a classification for trauma of external genitalia. The classification of external trauma in male could be established by the nature of injury mechanism or anatomic site: accidental versus self-mutilation injury and penis versus penis plus scrotum or perineum. Accidental injury covers large portion of external genitalia trauma because of high prevalence and severity of this disease. The aim of this study is to summarize the mechanism and treatment of the traumatic injury of penis. This study is the first review describing the issue. 1. Introduction injury by anatomical location [4]. Type I injury includes distal portion of the penis with proximal part of the penis Among the hospitalized patients, the admission rate of beingpreserved.TypeIIinjuryincludessevereinjuryonshaft genitourinary trauma patients has been assumed to be 2–10% of penis with penile crus being preserved. Type III injury and one-third or two-thirds of them were found to have the includes the injury when urethral catheterization is necessary injury on external genitalia [1]. Male is prone to have external with external urethral part being preserved. Type IV injury genitaliamorefrequentlythanfemalebecausethemaleis includes the injury when suprapubic cystostomy is needed more exposed to violence or extreme exercise [1]. [4]. However, this classification could not reflect the nature External genitalia injury can be categorized as acciden- of injury mechanism such as penetrating or strangulation tal in origin including during circumcision and as other injury. The other classification for male external genitalia traumatic origins including animal bite, gunshots, or self- mutilation [2].Mostinjuriesofthemalegenitaliainclude could be suggested as adult or pediatric injury, iatrogenic. penetrating injury with foreign bodies owing to psychiatric In this report, authors suggest the classification by pediatric illness and abnormal sexual behaviors [3]. and adult injury and also including self-mutilation injury. For In this study, we reviewed the traumatic injury of external detailed etiologies, there are circumcision injury, animal bite genitalia in male by describing diverse traumatic nature of the injury, strangulation injury, penetration injury, zipper injury, injury.Thisissuehasneverbeenreviewedbefore. andpenilefractureandself-mutilationinjury. 2. Etiologies and Classifications 2.1. Pediatric Injury. Pediatric injury of penis includes cir- cumcision injury, animal bite injury, and zipper injury. To date, there is no standard classification for external geni- Reports of penile injury in the pediatric population are talia injury. Main reasons for this include the diverse natures sporadic and often related with sexual abuse. Most reports of injury mechanism and various anatomical landmarks. about the pediatric penile injury were based on a small Rashid et al. reported the classification of male genitalia number of cases [5–11]. 2 BioMed Research International The types and severity of nonsexual pediatric penile comorbidities. Delayed disease includes the edema and infec- injury vary from a small injury to total emasculation. Owing tion of entrapped skin, which complicates the treatment [9]. to their rarity and disparity there is no universal therapeutic Various methods of zipper removal have been described strategy in their management. including both surgical and nonsurgical methods. Docu- The etiologies for pediatric penile injury are different mented methods are manual disengagement of the zipper from that of adult penile injury [6–11]. El-Bahnasawy and with lubrication [21], cutting the median bar with bone cutter El-Sherbiny reported the pediatric penile injury in large or hacksaw [20, 22], dismantling the fastener [23–25], or population group of 64 patients [5]. The most common cause removaloftheentrappedskin[26, 27]. was circumcision (63%), followed by hair-tie strangulation. The most common sequel after replantation was the loss of 2.2. Adult Injury. Most of adult penile injuries are penile the coronal sulcus, in which buccal graft has been used with fracture and other causes include strangulation injury and the successful outcome [12]. penetrating injury. 2.1.1. Circumcision Injury. Circumcision is one of the most 2.2.1. Penile Fracture. Penile fracture is a rupture of the tunica common operations in urology, which is usually a safe albuginea, which is the outer membrane of the penile corpora and simple procedure with low morbidity. However, serious cavernosum, occurring during penile erection. The etiology complications can occur because unprofessional practice of this injury can be divided into two parts: sexual and performs it [13]. The penile injury from circumcision is nonsexual causes. The primary mechanism of this injury is an diverse: from infections to disfigurement or partial to total abrupt, blunt trauma by forceful bending of the erect penis amputation of the penis. over the pubic bone or perineum [28]. For sexual causes, vigorous intercourse and masturbation were reported [28– Gee et al. reported the postoperative complication rate 30] and, for nonsexual causes, falling off from bed, placing as 0.2–0.6%, which ranges from bleeding, lymphedema, an erect penis in the underwear, and spontaneous fracture fistula formation, and iatrogenic hypospadias to the partial during urination were reported [28–31]. Most penile fractures or complete amputation of the glans penis [14, 15]. El- are underreported because of culture issues. Bahnasawy and El-Sherbiny [5] reported the largest series of pediatric penile injury. Sixty-four boys with penile injury Penilefracturecouldbediagnosedbasedonclinicalpre- were hospitalized over 20 years and among them 43 boys sentation and physical examination. It rarely needs radiologic (67%) had penile injury caused by circumcision. evaluation except in cases with gross hematuria that requires retrograde urethrography [32, 33]. Physical examination Although circumcision is regarded as a minor surgical procedure,itisnotfreeofcomplications.Urologistshave reveals swelling of the penile shaft with eggplant deformity, to pay more attention to reducing the complication by discoloration, and deviation of the penile shaft. In cases circumcision. Penile injury by circumcision also can have when the hematoma is contained within Buck’s fascia, the lifetime functional, psychological, and cosmetic sequel. rolling sign which is a palpable clot felt direct over the tear in the tunica albuginea could be manifested [30]. Surgical exploration warranted when penile fracture is suspected 2.1.2. Animal Bite Injury. The sequel of penile injury by because either clinically or radiologically penile fracture animal bite is related with initial severity of the wound. could not be excluded [34]. If the depth of injury extended Pediatrics has more tendencies to be exposed to animal bite into Buck’s fascia, bloody discharge can extravagate into injury,ofwhichthemostcommoncauseisadogbite[16]. Although most of the injuries are not severe condition, total the subcutaneous plane of the scrotum, perineum, or pubic or nearly total amputation of penis is being reported [17]. areas, resulting in significant swelling with discoloration. Nowadays, infective complications occur less because most Concomitant urethral injuries have been reported to be 3% to wounds are initially treated properly with antibiotics [18]. 38 [35]. Total urethral rupture also could happen and its rate Initial treatment strategy includes sufficient clean irrigation, is up to 2.32%, which needs end to end urethral anastomosis excision of infective wound, and administration of broad [29]. spectrum antibiotics [19]. In some cases, vaccination against The location of the fractured site is usually transverse and tetanus and rabies is needed [1, 18, 19]. unilateral in nature [36]. There could be many complications such as erectile dysfunction and urethral stricture, which 2.1.3. Zipper Injury. Penile zipper injury occurs most com- depends on the time interval since initial injury [36]. Many monly in boys with phimosis; in particular it occurs when the reports support the immediate surgical repair offers, which redundant foreskin gets entrapped during hastened dressing yield better long-term results than conservative treatment or undressing. Entrapment
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