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ORIGINAL ARTICLE
Penoscrotal degloving and amputation injuries
Syed Asif Shah, Firdous Khan, Mohammad Aslam, Naji Ullah Khan
Abstract
Background: Penoscrotal degloving and amputations injuries are rare surgical emergencies
that result from machinery accidents and after ritual traditional circumcision in our society.
These injuries vary from simple lacerations and degloving to complete emasculations. Treat-
ment options must be decided on a case-by-case basis and includes debridement, primary clo-
sure and skin grafting where applicable. The amputated part must be reimplanted or reapplied
as a composite graft.
Objectives: To evaluate the causes and severity of penoscrotal injuries in our community and
their management at Plastic Surgery unit, Hayatabad Medical Complex, Peshawar.
Materials and methods: 25 male patients who presented to our unit with penoscrotal injuries
between 2004 and 2009 were evaluated for the cause, type and severity of injury. Treatment
and factors determining outcome were also evaluated. Patients were followed up with regular
clinical examination to detect late complications.
Results: The mean age of the 25 patients was 18.24 years. 11 cases (44%) were below 12 years
and 14 cases (56%) were above 12 years of age. 9 cases (36%) presented within 24 hours after
trauma and 16 cases (64%) presented after 24 hours. 32% of injuries resulted from industrial
machine belts and 24% of injuries occurred following ritual circumcision. Penile shaft frac-
tures accounted for 16% of injuries. Penoscrotal degloving injuries occurred in 8 cases, includ-
ing complete avulsion of the penile skin, scrotum and testis in 4 cases; 2 cases involved penile
shaft amputations including one donkey bite and 6 cases glans penis amputations. 2 cases of
penoscrotal laceration resulted from fall on sharp objects and 1 case from fire arm injury. Main
treatment options were debridement and primary closure, split-thickness skin grafting, repair
of corpus spongiosum, marsupilization of urethra and penile replantation and glanular com-
posite graft. Complications included wound infection (12%), meatal stenosis (8%), urethral
Hayatabad Medical stricture (8%) and proximal penile fistula (1%).
Complex, Peshawar.
Conclusion: Penoscrotal degloving and amputations injuries are frightening for the patient
SA Shah
F Khan and formidable to the surgeon. Careful selection of which tissue to debride, along with proper
M Aslam selection of primary closure and grafts for reconstruction, allows satisfactory results to be
obtained and minimizes further morbidity. Surgeons must take a rational approach to provide
Khyber Teaching
Hospital, Peshawar. the patient with safe and timely care and produce a favorable outcome.
NU Khan
Keywords: Degloving injury penis, dog bite, graft or flap, penis, scrotum.
Correspondence:
Dr. Firdous Khan Introduction: avulsions (degloving), amputations, penile frac-
Medical officer,
Penoscrotal degloving and amputations injuries tures, iatrogenic (post circumcision), lacerations
Department of Plastic
surgery and Burns, are rare surgical emergencies1. These incapaci- and animal bites3.
Khyber Teaching Hospital, tating and psychologically devastating injuries
Peshawar are both physically and mentally traumatic2. Degloving injuries commonly occur while us-
firdous25@yahoo.com ing rotary-type machines typical in industrial
Cell: 0321-9099363 The common presentations of these injuries are
12%
5%
Debridement and closure 2%
5%
27% 0%
Wound Meatal Urethral
infection stenosis stricture
Figure 2: Treatment modalities Figure 3: Complications of treatment
closure, split-thickness skin grafting, repair of Penile degloving injuries commonly occur while
corpus spongiosum, marsupilization of urethra using rotary-type machines typical in industrial
and penile replantation and glanular composite and farm machinery4, 5. The penoscrotal area is
graft (fig. 2). Complications included wound particularly susceptible to degloving injuries19.
infection (12%), meatal stenosis (8%), urethral Thirty two percent of our patients suffered from
stricture (8%) and proximal penile fistula (1%) degloving injuries of the penis and scrotum
(fig.3). (fig.4, 5). The mechanism in the majority of
cases was the same as mentioned in the litera-
Discussion: ture3. The rotatory mechanism can catch loose
Penoscrotal degloving and amputations injuries clothing and in the process can catch and tear-
are rare surgical emergencies1. These incapaci- off the redundant skin of the genitalia in what
tating and psychologically devastating injuries is referred to as a power take-off injury17, 18. Tis-
are both physically and mentally traumatic2. The sues separate along the subdartos plane5. Severe
common presentations are avulsions (deglov- injuries lead to penile fracture, hematomas and
ing), amputations, penile fractures, iatrogenic urethral injury6. In 1958, Kubacek presented the
(post circumcision), lacerations and animal first case report of this type of injury20.
bites3.
In traditional treatment, after cleaning and de-
Surgical outcome of penoscrotal injuries de- bridement of devitalised tissues, the exposed
pends upon the type and severity of the injury, tissues are covered with viable flaps from the
age, time elapsed, causative agent and associated remaining skin. When there is no available skin,
trauma6. In our series, we came across mostly penile burial in the scrotum or in the suprapubic
with degloving and amputation injuries as re- region is performed3. The use of posterior scro-
ported elsewhere5, 18. Fifty-six percent of our pa- tal skin for primary closure of the scrotum is also
tients were above the paediatric age (>12 years) supported by Finical and Arnold2. Other tech-
and presented mostly after 24 hours (64% versus niques, such as banking of the testicles in the
36%). This is of great clinical significance. inner thighs or reconstruction of the scrotum
by tissue expansion, as described by Still and
The goals in managing such injuries are resusci-
Goodman21, bear the disadvantage of time de-
tation, restoration of normal urinary and sexual
lay. Conley22 has recognised the disadvantages
function and achieving acceptable cosmesis8.
that accompany multistage operations, namely,
Treatment depends on type and severity. The
the negative psychological effects experienced
different modalities of treatment are debride-
by the patient of losing his sexual apparatus. We
ment and primary closure, split thickness skin
treated these patients mostly by primary approx-
grafting, composite grafts and replantation16,17.
imation of the degloved skin and skin grafting
A thorough debridement and irrigation are a
in few cases. The most frequent complications
mandatory part of the operation5.
of avulsion injuries are postoperative infection,
from thrusting an erect penis against the sym- three cases of penoscrotal lacerations due to fall
physis pubis or perineum. As these patients are on sharp objects and fire arm injury. There was
mostly referred to general surgeons and urolo- one young little boy who sustained amputation
gist and because of patient reluctancy, only 16% of distal penile shaft due to donkey bite. This
of patients presented with penile fracture. Penile is very strange and unusual cause not reported
fractures are commonly diagnosed from their elsewhere in the literature. Bite injuries to the
stereotypical clinical presentation28: a cracking penis require extra care, as they have the poten-
sound from the erect penis at the moment of tial for infection with unique organisms3. The
injury rapidly followed by acute swelling, pain, most common animal bites are dogs followed
and penile deformity12. Current treatment rec- by humans and horses7. They consist of multiple
ommendations for penile fractures are immedi- pathogens such as Staphylococcus and Strepto-
ate surgical exploration and repair; proper surgi- coccus species, Escherichia coli, and Pasteurella
cal repair requires evacuation of the hematoma, multocida3. Management involves irrigation,
identification of the tunica injury, local corpora dbridement, antibiotic prophylaxis, and teta-
debridement, closure of the tunica lacerations, nus and rabies immunization as appropriate as
and ligation of any disrupted vasculature29. Re- well as primary wound closure or surgical recon-
ported long-term complaints after penile frac- struction7. Good functional and cosmetic results
ture repair include penile deviation, painful are possible in the majority of cases.
intercourse, painful erection, erectile dysfunc-
tion, priapism, skin necrosis, arteriovenous Conclusion:
fistula, urethrocavernous fistula, and urethral Penoscrotal degloving and amputations injuries
stricture12,29. There was one patient in our study are frightening for the patient and formidable
who developed urethral stricture. to the surgeon. Urgent referral to the unit spe-
cialized in these injuries is necessary to achieve
Circumcision remains one of the oldest and good results. Careful selection of which tissue to
commonest operations performed all over the debride, along with proper selection of primary
world14,30. In our country, circumcision is per- closure and grafts for reconstruction, allows sat-
formed mostly by the quacks, barbers, tech- isfactory results to be obtained and minimizes
nicians and also by the general practitioners, further morbidity. Surgeons must take a rational
paediatricians, gynaecologist, urologist, general approach to provide the patient with safe and
surgeons and by the paediatric surgeons31. Cir- timely care and produce a favorable outcome.
cumcision by quacks is performed at all ages by
various methods mostly bone cutters using un- References:
1. Godec CJ, Reiser R, Logush AZ. The erect penis: injury prone
sterilised techniques and dressings with animal organ. J Trauma 1988 ;28: 124-6.
dung. The reported incidence of complications 2. Finical SJ, Arnold PG. Care of the degloved penis and scrotum:
a 25-year experience. Plast Reconstr Surg 1999; 104: 2074-8.
varies from 0.1% to 35% the most common be- 3. Mathur RK, Lahoti BK, Aggarwai G, Satsangi B. Degloving in-
ing infection, bleeding, glans amputation and jury to the penis. African Journal of pediatric surgery 2010;
7: 19-21.
failure to remove the appropriate amount of 4. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genito-
foreskin15. In our series, 24% of patients devel- urinary trauma: external genitalia. BJU Int. 2004;94:507-15.
5. Tycast J, Palagiri A, Cummings J. Farm Accident Causes Penos-
oped complications following ritual circumci- crotal Degloving. Surg Rounds 2007;30:192-5.
sion. Our six patients (17%) sustained glans 6. Sarin YK, Sinha A, Ojha S. Snapped in penis: An unusual pre-
sentation of degloving injury of the penis. Case report. Indian
amputations during circumcision performed by journal of urology 2004; 20: 56-7.
bone cutter (fig.6). This is of great significance 7. Gomes CM, Ribeiro-Filho L, Giron AM, Mitre AI, Figueira
as the use of bone cutter for circumcision is on ER, Arap S. Genital trauma due to animal bites. J Urol.
2001;165:80-3.
the rise in our country and measures should be 8. Jezior JR, Brady JD, Schlossberg SM. Management of Penile
taken to stop this practice. Amputation Injuries. World J. Surg.2001; 25: 16021609.
9. Sanford, E., Acosta, R., Rayhack, J., Grzonka, R., Persky, L.:
Management of autoemasculation in the psychotic state. J.
Laceration and animal bites are other rare but Urol. 1991; 145:560.
fatal causes of penoscrotal trauma7. We got 10. Muangman V: Amputated penis, a mans nightmare. 1980;Thai