Genital trauma due to animal bites

Honey dressing for penile skin avulsion caused by traditional circumcision: a case report

OBJECTIVE

Penile skin avulsion is a rare complication of circumcision but commonly encountered as the result of traditional practice. We aimed to present the use of honey dressing and the benefit of its wound healing properties for management of such a complex wound.

CASE

A 24-year-old male patient with penile bleeding presented to the emergency department after undergoing traditional circumcision. Complete degloving of the penis with active bleeding and foul odour, along with heavy contamination of chewed betel leaves and powdered amoxicillin was found. Honey (Madu Nusantara, PT. Madu Nusantara, Indonesia) was used as dressing after copious irrigation using saline and povidone-iodine with bleeding control.

RESULTS

Honey dressing was shown to be effective for secondary wound healing of such a complicated and contaminated wound-in this case due to its antimicrobial, anti-inflammatory, immunostimulatory and autolytic debridement properties. A complete re-epithelialisation of the wound was achieved without progression to the hard-to-heal state by day 43. Suboptimal sexual function and aesthetic result due to wound contracture were observed as surgical reconstruction via split-thickness skin graft was refused due to cost.

CONCLUSION

In this case report, honey dressing was shown to be effective for wound healing, even in a penile avulsion with complete skin loss and heavy contamination. In rural settings, where penile avulsion due to traditional circumcision is common, honey should be considered as one of the dressing choices.

A Rare Presentation of Donkey Bites Involving the Cheek and Ear: A Case Report and Literature Review

Although animal bites account for a fair number of emergency department visits, donkey bites account for a very limited proportion. A 12-year-old boy presented to our department with a severe donkey bite involving his face. The injury included his left cheek with a laceration of the left ear cartilage. The examination revealed no serious morbidity (no vascular or nerve involvement). The patient received prophylactic antibiotics and anti-rabies/anti-tetanus vaccination. The wound was cleaned thoroughly with copious irrigation. Afterward, the patient underwent surgery to correct the defect in the cheek using a rotational advancement cervicofacial flap, while the penetrated ear cartilage was repaired and the skin margins were approximated and sutured. During the follow-up period, no complications were observed and the functional and cosmetic outcomes were satisfactory. Donkey bites are rarely encountered and they can result in different presentations and morbidities/outcomes. It is suggested that the timing from the bite injury to presentation, the stage/extent of the bite, the use of anti-tetanus and anti-rabies vaccines, and the prophylactic use of antibiotics may play a role in determining the outcomes and/or complications of donkey bites.

Successful Microsurgical Replantation of Amputated Penis: A Case Report and Review of Literature

This study aims to explain microscopic replantation in a rare case of a wholly amputated penis after prolonged ischemia. A 36-year-old patient underwent microscopic replantation of the penis after 9 hours. The penis was completely amputated due to self-mutilation. Microvascular replantation was performed after pre-operative preparation. On the second day after surgery, congestion was observed in the penis, and three sessions of leech therapy were conducted each time the leeches were placed for 30 minutes and then detached by themselves. The patient was referred to a psychiatrist to continue treatment after discharge from the hospital. Penile amputation is a rare situation and has different causes. There are various treatments to repair the amputated penis, which are both microvascular and microvascular. The microsurgery methods have shown the best results. In the present case, due to microsurgical artery repair and the early start of leech therapy, there was limited and predictable necrosis in the area of the penoscrotal junction flap, which underwent debridement and skin graft. Complete amputation of the penis is a rare phenomenon. Efforts should be made to perform the replantation surgery as soon as possible. The venous outflow is an essential factor in the success of penile re-implantation, and completely restored vascular and sensory function in this case. Early initiation of psychological care to control underlying disease leads to further cooperation of the patient to handle complications and avoid the recurrence of self-injury.

Scrotal dog bite and mismatch between the skin and testis injury: a case report and review of literature

Dog bite injury to the genitalia is a rare condition, regarding which most of the studies have focused on prevention of infection and management of severe cases; and small, superficial lacerations have not been taken into consideration. We present a case of a patient whose testis was severely injured with minimal scrotal injury and without significant clinical findings other than pain. We found two other case reports with similar features during review of the literature. We suggest that in case of genital dog bite, regardless of the lesion size and appearance, imaging is necessary to make sure that the testes, corpus cavernosum, and urethra are intact.

Management of Mammalian Bites to the External Genitalia: A Scoping Review

OBJECTIVE

To review the existing publications in literature in order to determine the approaches for the medical and operative management of mammalian bites to the external genitalia.

METHODS AND MATERIAL

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Scoping Review guidelines were followed. Four databases were searched. Articles were independently screened and analyzed by two reviewers. Publications were included if detailed summaries of genitalia bites and management were documented. Discrepancies were resolved by a third reviewer. Data was extracted from the final article cohort.

RESULTS

Forty-two articles were included in this scoping review. A total of 67 cases of mammalian bites to the genitalia were reported in the cohort. The most common injury site was the penis (44.9%). Dog and human bites were the most common type of mammalian bites (61.2% and 26.9%, respectively). 13.4% of cases were managed with medical therapy while 86.6% of cases required surgical intervention. The most common intervention was wound irrigation, debridement, and primary closure (32.8%). Though uncommon, other operative approaches included skin flaps (7.5%) and grafts (4.5%), re-implantation (4.5%), urethroplasty/repair (7.5%), penectomy (3.0%), scrotoplasty (3.0%), and perineal urethrostomy (1.5%). The reported complication rate was 19.4%. The mean follow-up time was 39.9 months.

CONCLUSION

Trauma related to mammalian bites is associated with high utilization of healthcare resources and cost. Though management of such bites to the genitalia is controversial, surgical intervention is often warranted ranging from simple debridement of devitalized tissue to complex reconstructive surgery. This review underscores the need for further investigation of mammalian bites to the genitalia to improve surgical options and monitor for long-term complication rates.

Neo-phalloplasty in children and adolescents for acquired penile loss

INTRODUCTION

From 2000 to 2019, the De Castro's neo-phalloplasty was used in 47 patients with congenital and acquired penile loss.

PURPOSE

Herein, the technical aspects of penile reconstruction and the outcomes in 17 children and adolescents treated for total or sub-total acquired penile loss are reported.

MATERIAL AND METHODS

The median age at the time of injury was 3 months (range: 2 days-15 years). Twelve patients were born with normal penis but suffered injuries (11) or underwent surgical resection of the penis (1). The remaining 5, affected by bladder exstrophy (2) or cloacal exstrophy (3), had penile loss due to surgical complications.

RESULTS

The median age at the time of surgery was 5 years (range: 2-20 years). The median length of the procedure was 5 h (range 4-8 h). Skin expander were inserted in preparation of phalloplasty in 9 patients. Corpora-cavernosa remnants were found and incorporated in the neophallus in 12 patients. In 7 patients, urethral remnants were also incorporated into the repair, placing the meatus at the tip of the neophallus. In the remaining patients the urethra was left in the acquired position after penile loss creating a perineal (2), scrotal (3), peno-scrotal (3), or posterior penile (1) urethrostomy. The first patient of this series was the only patient to receive simultaneously phalloplasty and total urethroplasty, with failure of urethral reconstruction. The median follow-up was 2 years (range 1-11 years). The overall complication rate was about 47%. All of the complications were late and required surgical revision. The results were assessed regarding overall functionality (voiding, erection/erogenous areas, masturbation/sexual intercourse) and aesthetic outcome using subjective and objective parameters. Psychological evaluation for both patient and parents was performed in 4 cases.

DISCUSSION

There are no specific guidelines for treating significant penile injuries in the pediatric population. We do not think secondary severe penile impairments should wait until adult age for repair. In this specific subgroup of patients technical aspects differ from phalloplasty done for congenital aphallia, due to the possible presence of corpora-cavernosa/urethral remnants and the feasibility to perform a "functional phalloplasty" with very encouraging results.

CONCLUSION

The De Castro's neo-phalloplasty remains one of the few techniques available for total penile reconstruction in pediatric age group. Data demonstrate that this technique for acquired aphallia is feasible and reproducible, however, it is a challenging procedure with a high complication rate and likelihood of revisions.

Penetrating penile injury due to the splintering of the floorboards in the gymnasium

INTRODUCTION

We present the case of a patient with penetrating penile injury caused by splintering floorboards in a gymnasium.

CASE PRESENTATION

A 24-year-old man was brought to the emergency department of our hospital because of an unintentional penetrating penile injury sustained while playing volleyball at a gymnasium. He dove into the wooden floor to fly-receive the ball. When sliding with his abdomen on the floor, a wooden splinter from the floorboard stuck from the base of his penis to near the glans penis. The splinter was gently removed without bleeding under local anesthesia.

CONCLUSIONS

Splintering floorboards in gymnasiums can cause serious trauma, including penile injuries. Health-care workers and users of public facilities, such as gymnasiums, should be aware of the accident risk associated with wooden floors.

Domestic donkey bite of genitalia: an unusual etiology of penile glans amputation in Burkina Faso (case report and literature review)

A 15-years-old boy was admitted in our hospital emergency unit with complaints of injured and hemorrhagic penile glans after donkey bites. The accident occurred during domestic activity with the animal when the boy attempted to guide the donkey. After thorough physical examination, the patient presented a penile glans amputation. Tetanic prophylaxis was started. The patient benefited from hemostatic suturing, stump regularization and penile glans reconstructive surgery and there was no complication. Functional and cosmetic results were satisfactory with good quality of micturition after six months' follow-up.

Unusual Mechanisms of Penile Amputation

Penile amputation is an uncommon and highly morbid injury. Many mechanisms have been reported ranging from self-mutilation and domestic violence to traumatic circumcisions. We present two unusual cases of traumatic penile amputation. An older gentleman endured extensive perineal trauma after being trapped underneath an industrial-sized lawnmower, and a young adolescent was bitten by an English bulldog and suffered amputation of the glans of his penis. These unique and very different cases of penile amputation highlight differences in operative managements, complications, and reconstructive possibilities.

Outcomes and special techniques for treatment of penile amputation injury

INTRODUCTION

Management of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases.

MATERIALS AND METHODS

A total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction.

RESULTS

Follow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula.

CONCLUSIONS

Severe penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

Autopsy Features of Fatal Donkey Attack

Lethal donkey attacks have very rarely been described. The case of a 65-year-old man who was found deceased on a country road with 2 domestic donkeys nearby is, therefore, reported. Examination of the body revealed contusions and lacerations of the face and scalp, a comminuted fracture of the left maxilla, comminuted fracturing of the right radius and ulna and of the left anterior superior iliac spine, a flail chest, and pulmonary contusions. In addition, there were bite marks on the left thigh, right buttock, right axilla/upper arm, and left cheek which corresponded to the dental arcades of the donkeys. Death had resulted from blunt chest trauma due to an attack by 1 or 2 donkeys. Deaths and serious injuries are much more commonly caused by horses; however, this case shows that even domesticated donkeys may also rarely be capable of inflicting significant trauma and so should be approached with circumspection.

Bilateral Testicular Loss due to Dog Bite in a Child

Although animal bites are common, genital trauma caused by animal bites is rare. Here we report a case of bilateral testicular loss in an infant due to a dog bite. The patient was bitten by a friend’s dog while his mother was intoxicated and, therefore, did not receive immediate medical attention. Although initial treatment with subsequent genital reconstruction and hormone replacement is important for children with genital trauma, it is too important to make home safe for them.

A case report of a complete degloving injury of the penile skin

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A split-thickness skin graft gave functional and cosmetically acceptable results to this completely degloved penis.

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A 1:1 mesh made it possible to use any direction of the graft and achieve a good cosmetic result and can be recommended.

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The risk of having to go through repetetive surgery in the genital area, made smoking cessation possible for this specific patient.

Introduction

Male genital degloving injuries are unusual and rarely caused by animal bite. Usually patients attend health care immediately if bitten in the genital area. Prophylactic antibiotics is routinely used (Gomes et al., 2000).

A penile degloving usually begins just proximal of the coronal line and progress down to the base of the shaft. Deep erectile tissue and the spermatic cord are seldom damaged and the endogenous skin of glans usually survives (Brown and Fryer, 1957; Morey et al., 2004; Finical and Arnold, 1999).

Presentation of case

A heavily smoking man with a previous history of bladder cancer presented himself to the emergency department 24 h after a dog bite degloved his penis. The avulsed skin was necrotic and subsequently excised. Antibiotic treatment was started. A bacterial swab was found positive for canine oral flora.

The skin defect was closed using a 1:1 meshed split thickness skin graft from the inner thigh. Smoking cessation was encouraged.

At the three month follow up the patient expressed satisfaction with both cosmetic and functional result and was now non-smoking.

Discussion

Several approaches to reconstruct penile skin exist. Split thickness skin graft has been lifted as a preferable alternative (Brown and Fryer, 1957; Finical and Arnold, 1999; Paraskevas et al., 2003) [5]. In this case, the avulsed skin was necrotic and could not be used. A 1:1 meshed split-thickness graft was chosen with excellent results.

Conclusion

1:1 mesh of the graft can be recommended for easy attachment with a good functional and esthetical result. The potential risk of losing intimacy appearance or having to go through repeated procedures in the genital area motivated smoking cessation for this patient.

Self-Inflicted Nailgun-Induced Penetrating Penile Injury: Case Report and Discussion

Penetrating penile injuries occur mostly in industrial/work accidents, automobile accidents, or as a result of sexual curiosity and attempts at self-expression/mutilation. In this case report, the authors describe an accidental nailgun injury to the penis of a 46-year-old man. We discuss the management of such injuries in the emergency department, including the utility of a dorsal penile block for regional anesthesia. Although exceptionally rare, familiarity with penetrating lower urinary tract injuries may reduce their long-term repercussions on genitourinary and sexual health.

Sonographic findings of typical and atypical scrotal trauma

This review article illustrates sonographic findings in the setting of accidental and nonaccidental scrotal trauma. Although sonographic findings may be irrespective of the type of trauma, the goals of sonographic evaluation are similar in both atypical and typical mechanisms of scrotal injury. Familiarity with findings such as disruption of testicular integrity or vascularity facilitates prompt diagnosis and plays a critical role in clinical management.

Lower genitourinary tract trauma

Lower genitourinary tract trauma comprises a substantial portion of the trauma burden in the USA. Some key trends and findings are described. Mortality is relatively high in patients with bladder trauma due to associated injuries. Urethral injuries should be suspected in patients presenting with the triad of blood at the urethral meatus, suprapubic fullness indicative of a full bladder, and urinary retention. Urethral injury is common in penetrating penile trauma, and stab wounds to the penis are more likely to involve the urethra than gunshot wounds. Penile fracture is largely a clinical diagnosis and suspicion of fracture requires urgent surgical exploration. Zipper injuries are the most common cause of presentation to the emergency department for penile trauma in adults. Toilet seat injuries are the leading cause of penile pediatric trauma presenting to the emergency department. In the setting of testicular trauma, rates of testicular salvage are excellent when exploration is prompt. Trauma in the form of animal or human bites requires treatment with broad-spectrum antibiotics in addition to repair of the injury. Military trauma has seen an increase in explosive injuries to the lower urinary tracts due to evolution of warfare tactics. Increasing awareness of presentation and context of lower genitourinary tract trauma can reduce delay of diagnosis and morbidity associated with such injuries.

Benign penile skin anomalies in children: a primer for pediatricians

BACKGROUND

Abnormalities involving the skin coverage of the penis are difficult to define, but they can significantly alter penile appearance, and be a cause of parental concern.

DATA SOURCES

The present review was based on a nonsystematic search of the English language medical literature using a combination of key words including "penile skin anomalies" and the specific names of the different conditions.

RESULTS

Conditions were addressed in the following order, those mainly affecting the prepuce (phimosis, balanitis xerotica obliterans, balanitis, paraphimosis), those which alter penile configuration (inconspicuous penis and penile torsion), and lastly focal lesions (cysts, nevi and vascular lesions). Most of these anomalies are congenital, have no or minimal influence on urinary function, and can be detected on clinical examination. Spontaneous improvement is possible. In the majority of cases undergoing surgery, the potential psychological implications of genital malformation on patient development are the main reason for treatment, and the age generally recommended for surgery is after 12 months of age.

CONCLUSION

This review provides the pediatrician with a handy tool to identify the most common penile skin anomalies, counsel parents adequately, make sensible and evidence based choices for management, and recognize complications or untoward outcomes in patients undergoing surgery.

The case of the missing testicle: blunt scrotal trauma in the pediatric emergency department

Serious blunt scrotal trauma in the pediatric population is rare and can pose significant danger to the viability of the testes. The following case describes an adolescent boy who presented with a single testis in his scrotum after low-impact perineal trauma, consistent with testicular dislocation. The literature regarding scrotal trauma includes few cases of testicular dislocation from low-impact perineal trauma. Included is a brief review of the most recent data including epidemiology, differential diagnosis, acute management, and complications pertinent to the pediatric emergency clinician.

Penile injuries: A 10-year experience

We report our 10-year experience with penile injuries. We retrospectively reviewed the records of 156 cases of male external genitalia injuries between May 2002 and December 2012. Of these, only 26 patients presented without urethral injuries and were included in this study. Patients were divided into 4 groups: Group 1 (n = 12) with patients with penile fractures injuries; Group 2 (n = 5) with patients with penile amputation injuries; Group 3 (n = 2) with patients with penile penetrating injuries; and Group 4 (n = 7) with patients with penile soft tissue injuries. Grading of injury was done using the American Association for the Surgery of Trauma (AAST)-Organ injury scale of penile injury. Penile injuries without urethral injuries are urological emergencies which require immediate attention.

Traumatic penile injury: from circumcision injury to penile amputation

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.

Urotrauma: AUA guideline

PURPOSE

The authors of this guideline reviewed the urologic trauma literature to guide clinicians in the appropriate methods of evaluation and management of genitourinary injuries.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (search dates 1/1/90-9/19/12) was conducted to identify peer-reviewed publications relevant to urotrauma. The review yielded an evidence base of 372 studies after application of inclusion/exclusion criteria. These publications were used to inform the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinions.

RESULTS

Guideline statements were created to inform clinicians on the initial observation, evaluation and subsequent management of renal, ureteral, bladder, urethral and genital traumatic injuries.

CONCLUSIONS

Genitourinary organ salvage has become increasingly possible as a result of advances in imaging, minimally invasive techniques, and reconstructive surgery. As the field of genitourinary reconstruction continues to evolve, clinicians must strive to approach clinical problems in a creative, multidisciplinary, evidence-based manner to ensure optimal outcomes.

The impact of genital trauma on wounded servicemen: qualitative study

BACKGROUND

Recent military operations in Afghanistan have resulted in considerable lower limb trauma. Associated with this trauma have been serious injuries to the genitalia. No previous study has looked at the effect of traumatic genital injury on the individual. This study expresses the impact of these injuries.

METHODS

A qualitative evaluation, interviewing 13 male patients with extensive genital injuries, including 11 patients with orchidectomies.

RESULTS

Patients attach a very high importance to their genital injury, rating this injury as having more impact than lower limb amputations. They also have a high expectation for the recovery of sexual function. Psychological outcomes are better when an individual's future fertility is known at an early stage.

CONCLUSION

Better outcomes are achieved for the patient when psychological and surgical support if provided throughout the long treatment and recovery process It is important that every effort is made to preserve fertility right from the point of injury.

Pediatric genital injury: an analysis of the National Electronic Injury Surveillance System

OBJECTIVE

To describe the characteristics of pediatric genital injuries presenting to United States emergency departments (EDs).

METHODS

A retrospective cohort study utilizing the U.S. Consumer Product Safety Commission (CPSC) National Electronic Injury Surveillance System (NEISS) from 1991-2010 to evaluate pediatric genital injuries was performed.

RESULTS

Pediatric genital injuries represented 0.6% of all pediatric injuries with the incidence of injuries rising through the period studied, 1991-2010. The mean age at injury was 7.1 years old and was distributed 56.6% girls and 43.4% boys. A total of 43.3% had lacerations and 42.2% had contusions/abrasions. The majority of injuries occurred at home (65.9%), and the majority of patients (94.7%) were treated and released from the hospital. The most common consumer products associated with pediatric genital trauma were: bicycles (14.7% of all pediatric genital injuries), bathtubs (5.8%), daywear (5.6%), monkey bars (5.4%), and toilets (4.0%).

CONCLUSION

Although pediatric genital injuries represent a small proportion of overall injuries presenting to the emergency department, genital injuries continue to rise despite public health measures targeted to decrease childhood injury. Our results can be used to guide further prevention strategies for pediatric genital injury.

Bear attack--A unique fatality in Finland

Fatalities due to animal bites, the vast majority of which are associated with dogs and big cats, are relatively uncommon and rarely described in the literature. Especially rare are fatal bear attacks on humans. We herein present a forensic investigation of a fatal assault, involving numerous bites on a 42-year-old man in Finland by an European brown bear (Ursus arctos arctos).

Dog bite injuries of genitalia in male infant and children

The aim of the study is to highlight genital dog bites in male infant and children in developing countries and their management. We managed three cases (9 months, 5 years, and 8 years) of genital dog bite between January 1997 and July 2008. Two had unprovoked stray dog bites and the third was bitten by his pet dog when disturbed during eating. Extent of injury varied from small-lacerated wound to near emasculation. Primary repair was done after thorough washing and debridement under antibiotic cover. In the 9-month-old male infant who was near emasculated, scrotum was closed with the available skin and a small penile stump was reconstructed after meatoplasty. Immunization against tetanus and rabies was done for all cases. Postoperative recovery was uneventful, and the wound healed primarily in all cases. Parents of the infant were asked for feminizing genitoplasty but they refused so they were advised for hormonal replacement and penile reconstruction at adolescence. Male children are the most common victims of genital dog bites. These injuries can be repaired primarily with good outcome provided strict cleaning, debridement, wound repair, antibiotic cover, and immunization is applied.

Death secondary to a donkey's bites

We present a unique case of death due to the assault and bites of a donkey on a 65-year-old man. The farmer, found dead in his farmyard, had a very deep wound in the anterior region of the neck, with a sharp transection of the trachea and severe bleeding by several minor vessels wall disruptions. The cause of death was established to be massive bleeding combined with asphyxia due to aspiration of the blood. Moreover, multiple contusions with associated skin abrasions and perforations were present. The general impression of the injuries was consistent with an animal's bite marks. Herbivorous or omnivorous bite attacks on humans are rare; instead, these animals attack by kicking, trampling, and kneeling, resulting in secondary blunt injuries. The donkey is usually a docile animal, but its behavior can be aggressive during the mating season, and the possibility of biting should not be underestimated, as illustrated by the 2 cases published previously as well as by the case presented here.

Analysis of nonsexual injuries of the male genitals in children and adolescents

AIM

This study analysed nonsexual male genital injuries in boys with regards to aetiology, age, management and outcome.

METHODS

Patients were identified from the hospital database (between 1999 and 2009) were analysed retrospectively.

RESULTS

Seventy-four patients (2-17 years) were identified which included 24 toddlers and small children (2-5 years), 36 school age children (6-12 years) and 14 adolescents (13-17 years). Traumas were related to falls (n=14), kicks (n=11), sport (n=10), toilet seats (n=9), motor vehicles (n=8), bicycle (n=4), outdoor activities (n=4) and others causes (n=14). The leading cause of injuries in (i) toddler and small children was related to toilet seat (n=7) and falls (n=7), (ii) school age children to sport (n=8), kicks (n=7) and falls (n=6), and (iii) adolescents to motorcycle accidents (n=5). There were 45 scrotal and 29 penile injuries ranging from lacerations to contusions. Sixty-eight patients required hospital stay (0.5-36 days, Σ=2.4 days). Follow-up examinations were uneventful, except for one minor wound infection.

CONCLUSION

Nonsexual traumas to the male external genitalia occur mostly in 6- to 12-year-old boys, with sport accidents, kicks and falls being the major causes. Scrotal and penile lacerations and testicular contusions are the most common injuries. Complications after injuries to the male genitals in children are rare.

Threatened fertility and gonadal function after a polytraumatic, life-threatening injury

Trauma literature regarding management of genitalia trauma affecting future fertility and gonadal function in the face of coexisting life-threatening injuries is underdeveloped. We present a unique case that necessitated integrative management of a 24-year-old male who became entangled within the blades of a manure spreader and presented with life-threatening trauma in addition to severe genital trauma, including penile degloving, bilateral testicular avulsion and bilateral spermatic cord laceration. During the initial stabilization and surgical management, urology and plastic surgery were consulted to assess the urogenital injuries. Together, the surgical team orchestrated potentially life-saving interventions while successfully performing both a testicular sperm extraction and a testicular revascularization. Viable sperm was collected on the day of surgery and initial follow-up showed preserved sexual function and adequate perfusion to the testicle. This report presents a case and provides a review discussing the management of traumatic genital injuries and the importance of early involvement of surgical specialties in genitalia trauma to optimize future fertility and gonadal function. The literature search was performed in August 2008 using Medline for articles only in English, including any of the following terms: polytrauma, trauma, penis, testicle, degloving, avulsion, spermatic cord, laceration, fertility, reproduction or revascularization.

Management of female genital trauma

The management of female genital trauma is complex and should be performed by a well-trained team of health care professionals. It is important to remember that many female genital injuries will cause not just physical injury, but also significant psychological and emotional distress that may lead on to future physical dysfunction. The approach of any health care professional in the immediate diagnosis and management of females with a genital injury must be aimed at getting the best and most appropriate care to the patient as soon as possible. It is also important to remember that many of these injuries are the result of crimes and careful documentation is required so as not to remove or invalidate evidence that may later be required by the courts. This article is aimed at non-specialist healthcare providers who may find themselves faced with a female genital trauma patient. It will cover the range of injuries and conditions that should be expected and describes the treatment that should be given for the best possible physical and psychological outcomes. At all times it should be remembered that the patient should be assessed and resuscitated in accordance with recognised ATLS protocols.

Traumatic degloving lesion of male external genitalia

Injury to the male external genitalia is relatively uncommon when compared with other parts of the human body. Trauma to external genitalia could result from accidents involving motor vehicles, power farm machinery, gun shot and stab injuries. We present a rare case of traumatic degloving injury of male external genitalia associated with partial penile amputation and loss of both testes sparing the internal abdominal and pelvic organs, resulting from run over by a heavy vehicle tyre.

Genital trauma in children and adolescents

Traumatic wounds of the female genitalia include accidental straddle injuries or impalement, chemical or thermal burns, insufflation injuries, blunt trauma, or crush injuries. Children and adolescents may be victims of rape, sexual abuse, and female genital mutilation. Information is provided on epidemiology, pathophysiology, and management. Treatment guidelines are offered using the best evidence available, and recommendations are provided when data are limited.

Inguinal phlegmon and positive serology for syphilis after penile bite laceration: true, true and unrelated

Among many causes of penile injury, sexual activity is infrequently reported. The present case involved delay in recognition, which led to development of a phlegmon near major vascular structures. Positive serologic evidence of syphilis was an incidental finding.

Management of ileostomy trauma produced by a dog bite in a patient with thoracic paraplegia

Urologic trauma produced by dog bites is uncommon. Several previous single reports and small case series have described the treatment of dog bite-induced injuries to the external genitalia. In this report, we describe our treatment of a patient with thoracic paraplegia and an ileal conduit who had extensive trauma to his ileostomy as a result of a bite by the family dog. To our knowledge, the current case is the first report of dog bite-induced ileostomy trauma.

Laboratory diagnosis of equine rabies and its implications for human postexposure prophylaxis

Laboratory diagnosis is essential to confirm suspected cases of equine rabies and to determine the medical care needed for human postexposure antirabies prophylaxis. Equine rabies transmitted by the vampire bat, Desmodus rotundus, has increased gradually in the State of São Paulo. The present study has several objectives, the most important being the evaluation of fluorescent antibody test (FAT) and virus-isolation laboratory tests performed with different equine nervous system tissues (cortical, hippocampus, cerebellar, brainstem and cervical medullar) to determine the tissue for which the two techniques have the highest sensitivity. Analysis by FAT of these five regions of the central nervous system (CNS) from 35 animals showed that there was a greater amount of viral antigen in the brainstem and cervical medullar tissues than in the hippocampus, cortical and cerebellar tissues. While there were no significant differences in the mortality rate of mice inoculated with suspension prepared from the different tissues, a trend towards higher mortality rate was detected with brainstem and cervical medullar tissues. Laboratory diagnosis was not affected by whether the animal had been vaccinated or not, or whether it had died following the natural course of the disease or as a result of euthanasia. Isolation of the rabies virus in equine salivary glands demonstrated the potential risk for humans exposed to infected animals.

Penile amputation and emasculation: hazards of modern agricultural machinery

We report a case of 20-year-old farmer with penile amputation and emasculation secondary to crushing injury inflicted by agricultural machinery. His entire penis, scrotum and both the testis had been avulsed after falling onto a rotating axel wheel of an electronically driven thrashing machine. After resuscitation the wound was thoroughly washed with saline, hemostasis achieved and a perineal urethrostomy was made from the remnant urethra.

Penile dog bite in an adolescent

Dog bites to the external genitalia are rare. In this case, a 16-year-old boy suffered a dog bite wound to the penis. The wound was cleansed with copious amounts of sterile normal saline by means of high-pressure syringe irrigation. The child had an uneventful recovery.

Genital trauma in children: Classification and management

OBJECTIVES

To determine the severity and, accordingly, the treatment of genital trauma in a pediatric population.

METHODS

A total of 116 children with genital trauma and anorectal injury were retrospectively reviewed. The severity of trauma was graded according to the genital injury score (GIS), which we developed as a genital trauma scoring system.

RESULTS

The median age was 8 years. Of the 116 children, 80 were girls and 36 were boys. The etiology of the trauma was traffic road accident (53 patients), fall, sexual abuse, and gunshot wound. Sixty-one patients had additional organ injuries. The GIS was I for 25 children, II for 19, III for 32, IV for 23, and V for 17. In addition to the primary repair, colostomy was performed in 22 patients. The most frequent postoperative complication was wound infection. The postoperative complication rate was significantly greater in patients with an injury severity score greater than 15, severe contamination, prolonged delay (longer than 8 hours), and a GIS of IV or V.

CONCLUSIONS

The clarification of the mechanism and severity of the genital injury and associated organ injuries under general anesthesia may help in the appropriate classification. Primary repair should be the standard approach in genital trauma patients with a GIS of IV or less. Those with a GIS of V associated with severe contamination and prolonged delay require colostomy for improved outcome.

Vulvar and genital trauma in pediatric and adolescent gynecology

PURPOSE OF REVIEW

This review will look critically at recent research articles that pertain to children and adolescents who present with genital injuries.

RECENT FINDINGS

Many recently published articles have noted that the history as given by the child or adolescent is the most important factor in determining the etiology of genital injuries as abuse or accidental. The history is more important than any documented or lack of documented findings on physical examination. Distinguishing whether the injury was accidental or caused by abuse is of significance to the family and the injured child or adolescent. Genital examinations of victims of documented abuse are often normal. Examinations of pregnant adolescents may appear normal, the only evidence that intercourse has taken place being pregnancy. Documented accidental genital injuries are described; unfortunately such injuries can easily be confused with sexual abuse. Photographic documentation of injuries by colposcopic photography has allowed a new level of peer review, improving the understanding of what are normal and non-specific findings, many of which were considered to be abnormal in the past. The psychological impact of living in a violent, war-torn culture, or surviving a traumatic genital injury are reviewed. New ideas on the management of genital trauma are also reported.

SUMMARY

Increasingly, victims of sexual abuse are found to have normal examinations, and the victim's history becomes the most important determining factor. Peer review has led to a better understanding of the wide variations in the normal genital examination. Psychological support for these victims is important in the management of genital injuries.