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Primary Suture of a Child’s Penis Degloving Injury: Anatomical Basis for Succes

Cristophe Gapany, Stephane Tercier, Peter Frey

Paediatric Surgery, Centre Hospitalier Universitaire Vaudois and University of Lausanne

Lausanne, Switzerland

 

Correspondence:

Dr Cristophe Gapany

Paediatric Surgery

Centre Hospitalier Universitaire Vaudois,Rte du Bugnon 46, CH-1011 Lausanne, Switzerland

Phone +41 21 314 31 71; Fax +41 21 314 30 76, E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Serious injuries to the penis are rare in paediatric patients. In the adult literature, such injuries often require local flaps or skin grafting, with subsequent neurological or erectile disorders. We report the case of a traumatic penis degloving in an eleven year-old boy that healed very nicely after primary suture. Vascular anastomosis supplying the penile skin and the patient’s young age may account for this successful outcome.

Key words: blunt penis trauma, degloving injury.

  

Introduction:

Traumatic injuries to the penis are rarely reported in the paediatric literature. Iatrogenic trauma during circumcision seems to account for the larger part of injuries, with electric burns and entrapment in industrial equipment, so-called power take-off also described. Penile fractures remain very uncommon in children.

While penis amputation requires complex reconstructive surgery, degloving injuries and other skin lesions with or without tissue loss are often treated by partial- or full-thickness skin grafting, or by local flaps with possible subsequent skin sensitivity disorders, chronic lymphedema and even loss of the erectile function.

We report the case of a complete traumatic degloving of a child’s penis treated by primary suture, and review the anatomical basis of this successful outcome

Case report

An eleven year-old boy suffered sub-total degloving of the penile skin caused by a bicycle handlebar (Fig. 1). At clinical examination under general anaesthesia the cavernous bodies, urethra and scrotum were found in tact. A balloon catheter was inserted for postoperative urine drainage. After irrigation with povidone iodine, the shaft skin was primarily sutured to the remaining proximal skin of the penile basis (Fig. 2), and the suture covered with antibiotic ointment. A non-compressive dressing was changed every second day and the patient could be discharged on day 3. At day 40, the skin showed focal superficial necrosis which was handled conservatively with eosin application (Fig. 3). At 3-months all necrotic areas had dried off and were removed. The underlying tissue showed full epithelium coverage, scarring was minor and cosmetically satisfying (Fig. 4). The boy described full sensitivity to touch and normal erectile function.

penis degloving 1 penis degloving 2
Figure 1. Traumatic penile shaft skin degloving Figure 2. Immediate postoperative result after primary suture
penis degloving 3 penis degloving 4
Figure 3. Penile skin appearance at 1 month postoperatively. Note partial superficial skin necrosis Figure 4. Penile skin appearance at 3 months postoperatively

Discussion

Except for zipper and toilet-seat injuries, which often are benign and readily cared for [1], penile injuries are rare in children. Excessive skin removal during circumcision is usually treated with topical ointments and secondary wound healing [2], but long-term results are not known. Bhangarada in Thailand has extensively described surgical management of iatrogenic amputation in a series of 100 patients [3].

Reports on the treatment of degloving penile injuries come mainly from the adult literature, and most authors advocate debridement and primary closure using local scrotal flaps and split-thickness skin grafts [4]. Specific complications include oedema due to impaired lymphatic drainage, painful erections, and hyper- or hyposensitivity. Psychological distress resulting from an injury to the genitalia may be worsened by multiple operations [5].

Several features may account for the excellent outcome in our case. In contrast to most reports, this accident did not involve industrial engines or animal bites [6] so that the wound was not contaminated; the shaft skin was not torn to pieces as in power take-off mechanisms; and children’s skin has a unique healing potential. Anatomically, the blood supply of the penile skin is guaranteed by the superficial penile arterial plexus, arising from the two external pudendal arteries, up to the preputial ring, where it penetrates Buck’s fascia and joins the dorsal penile artery [7]. This intact distal anastomotic ring probably accounted for persisting retrograde vascularization of the shaft’s skin in our patient.

Although the short-term result showed very nice wound healing, adequate sensitivity and erectile function, only time will tell the appropriateness of our treatment, and this patient will be followed-up after puberty.

We conclude that in this rare type of paediatric injury, primary suture may provide excellent primary cosmetic and functional results.

 

 

REFERENCES

1. Flowerdew R, Fishman IJ, Churchill BM Management of penile zipper injury. J Urol 1977;117:671

2. Casale AJ, Beck SD, Cain MP, Adams MC, Rink RC. Concealed penis in childhood: a spectrum of etiology and treatment. J Urol 1999162: 1165-1168

3. Bhanganada K, Chayavatana T, Pongnumkul C, Tonmukayakul A, Sakolsatayadorn P, Komaratat K, Wilde H. Surgical management of an epidemic of penile amputations in Siam. Am J Surg 1983;146:376-382

4. Finical SJ, Arnold PG. Care of the degloved penis and scrotum: a 25-year experience. Plast Reconstr Surg 1999;104: 2074-2078

5. Zanettini LA, Fachinelli A, Fonseca GP. Traumatic degloving lesion of penile and scrotal skin. Int Braz J Urol 2005 ;31: 262-263.

6. Gomes CM, Ribeiro-Filho L, Giron AM, Mitre AI, Figueira ERR, Arap S. Genital trauma due to animal bites. J Urol 2000;165: 80-83

7. Zachariou Z. Blood supply of the penile skin. In: Hadidi AT, Azmi AF (eds) Hypospadias Surgery: Springer, Berlin Heidelberg New York 2004:73