Paediatric penile trauma

Introduction

Penile trauma is rare because the penis is mobile and largely protected by its position, although in the erect state, in adults the penis is more prone to trauma in the form of penile fracture^1,2. However, paediatric penile trauma has different underlying causes and forms of trauma, being rarely reported. It may be iatrogenic during circumcision^3-8 or caused by domestic animal attack^9-11, child abuse, motor vehicle accidents [10] or trapping in a zipper¹²; penile strangulation by hair or thread has also been reported^13-19. We report 64 cases of paediatric penile trauma, their causes, methods of management and the results of a long-term follow-up.

Patients and methods

Sixty-four boys (mean age 7.5 years, SD 4, range 1–18) with acute penile trauma or history of such trauma were admitted to our hospital between 1981 and 2000. Table 1 lists the different causes of penile trauma. Circumcision-related injuries were the most common and most were in the form of urethrocutaneous fistulae. Partial or complete glans amputations were unusual, as were skin or meatal trauma (Table 1). Human hair-tie strangulation injury was less common and in four boys resulted in a urethro-cutaneous fistula. Of the four cases caused by animal attack, three were from a dog bite and one from a buffalo kick. The first boy lost his glans completely, another lost his penis and scrotum, the third had a large mid-shaft urethral defect and the fourth had a split glans with a disrupted glanular urethra. Two of the boys involved in accidents had partially amputated glans and two had urethrocutaneous fistulae. Of the zipper injuries the first resulted in penile skin injury while the second caused a urethrocutaneous fistula. One child in the series was subjected to repeated attacks of electrical burning of his glans which resulted in meatal stenosis complicated by urinary retention.

Patients were managed according to the severity of injury (Table 1). Forty patients (62%) presented late after the injury with established urethrocutaneous fistulae and underwent a delayed repair. Table 1 shows the different methods of repair for urethrocutaneous fistulae, with a simple repair in most by circumferential incision around the fistula, trimming of the edges with subsequent closure in unopposing layers. In the five patients with a glans hanging on a thin pedicle after hair-tie strangulation, the tie was released and the glans and urethra reconstructed. Figure 1 shows the stages of repair for these advanced cases of hair-tie. Partial or complete amputation of the glans occurred in 10 patients (16%). Primary treatment consisted of haemostasis and meatoplasty; a delayed penile lengthening procedure was carried out in one. The most severe case, with complete avulsion of the penis and scrotum, underwent perineal urethrostomy and skin closure. During the follow-up we assessed the cosmetic appearance and voiding function; patients who became adults were asked about their erectile function.

Results

The mean (SD, range) hospital stay was 9 (4, 2–21) days; 54 patients (84%) were followed for a mean (SD, range) of 5.7 (4, 0.5–18.3) years and Table 1 shows the results. Excellent cosmetic and functional results were seen in 40 patients (74%), with fair results in five (9%), includ-ing three with a normal appearance but with minute fistulae and two with no glans but with good functioning penile length and a wide urethral meatus. The pro-cedures failed in nine boys (17%), with emasculation in one, insufficient penile length in two and persist-ent urethrocutaneous fistulae with insufficient local skin in six.

Fifteen patients are currently adults, seven in their third decade, while eight are teenagers; 13 reported normal sexual function. Sexual dysfunction in the remaining two patients was related to insufficient penile length in one and severe penile curvature complicating multiple attempts at repair of a large urethrocutaneous fistula in one.

Of the 40 patients with circumcision-related injuries who were followed, six (15%) had functional disability (Table 1); of the 10 with hair-tie strangulation injury, none lost his glans. Of the four injuries caused by animal attacks, three boys had poor results (one each with complete emasculation, short penis and severe ventral curvature). There was no functional disabilityin the remaining forms of trauma.

Discussion

Reports of trauma to the external genitalia in children are sporadic; the cause and type of penile trauma varies in severity from entrapment in a zipper to more serious injuries and total emasculation^3-11. Most children with zipper injuries are managed in the emergency department with no general anaesthesia¹², although in the present two cases a general anaesthetic was required.

Penile trauma complicating circumcision has been reported more frequently, with varying degrees of severity ranging from skin or meatal injury, partial glanular amputation to total penile amputation^3-7. Total penile ablation by electrocautery during circumcision was also reported⁸ but the most common circumcision complications are haemorrhage and primary infection^3-5. Wiswell and Geschke³ reviewed the records of 136 086 circumcised boys and reported an overall complication rate of 0.19%, while the rate of associated injuries was 0.025%. Gee and Ansell⁴ reported similar complication rates for circumcision. However, others have reported higher rates (1.6%) with more serious complications, including death (in five cases) when circumcision was carried out by unqualified village barbers⁵.

In the present series, circumcision-related trauma was the most common form of penile injury (67%); such a high incidence is not unusual in a country where circumcision is routine among all Moslems and most Egyptian Christians. Three-quarters of circumcision-related trauma was in the form of urethrocutaneous fistulae (32 cases), usually inflicted during circumcision through inadvertent entrapment of excess ventral skin, including the urethra, into the bone-cutting clamp (or similar device) during excision of the preputial skin. Of the 32 urethrocutaneous fistulae, 27 (85%) were successfully repaired.

More serious circumcision-related complications include glanular amputation⁵. Ozkan and Gurpinar⁷ reported successful re-attachment of the glans after amputation during circumcision but in the present series such patients were less fortunate. They were referred after a significant delay, precluding attempts at re-attachment. Tank et al.⁹ described a method for penile reconstruction after penile amputation and a similar technique was used successfully in one patient with such amputation in the present series. An additional patient with no glans and an unacceptably short penile stump is scheduled for the same procedure.

Penile strangulation caused by various objects, from wedding rings to rubber bands, has been reported, but none as insidious as entrapment by human hair^13-19. The rings and bands are usually used in adults to improve erection, while strangulation by hair or thread is more common in children. In most such cases it is hard to believe that the trauma is purely accidental and not deliberate. The role of the mother in some of these episodes remains suspect¹⁵. The human hair-tie causes gradual chronic ischaemia, resulting in little dis-comfort to the child. Initially the hair-tie causes gradual swelling of the glans, infection, then skin ulceration. Removal of the constricting agent at this stage usually results in no long-term complications. One of the present patients was saved at this stage, but delayed recognition may lead to more serious consequences. The hair may cut dorsally through the neurovascular bundle, sparing the urethra but resulting in the loss of glanular sensation, or cut through the spongiosa and the urethra, resulting in a urethrocutaneous fistula. The hair tie may eventually transect the cavernosa, leading to partial or complete glanular amputation. The largest series was reported by Harouchi et al.¹⁹ (38 cases) from Morocco; they classified the severity of lesions as type I to IV. A staged repair for the severe degrees of tourniquet injury was suggested^15,18. In the present five boys with severe hair-tie injury (resulting in a glans attached by a thin pedicle to the penis), a one-stage repair was success-ful in four, while in the other the glans was re-attached in one stage and the urethra repaired after a delay.

Domestic animal attack was reported by different authors to produce severe forms of penile trauma, up to total emasculation^9-11. In this study, compared with other types of penile trauma, animal attack injuries had the worst results cosmetically and functionally. Of the four such injuries three had poor results. Urethral and penile injuries in the setting of an animal bite are at high risk of complications because of tissue destruction and contamination, and the consequent requirement of a more liberal debridement.

In conclusion, in our region, ritual circumcision and hair-tie strangulation injuries are the most common causes of penile trauma in children. Good functional and cosmetic results are possible in most cases but animal attacks are associated with the highest rate of long-term functional and cosmetic disability, and represent the greatest surgical challenge.

Authors

M.S. El-Bahnasawy, MD, Lecturer in Urology.
M.T. El-Sherbiny, MD, Lecturer in Urology.
Correspondence: M.S. El-Bahnasawy, Urology and Nephrology
Centre,  Mansoura University, Mansoura, Egypt.
e-mail:  mbahnasawy@yahoo.com

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