Traumatic penile injury: from circumcision injury to penile amputation

Genital self-mutilation in psychiatric patients: A case report

INTRODUCTION

Genital self-mutilation presents significant surgical challenges, particularly when complicated by psychiatric disorders. This case highlights the critical role of surgical intervention in the management of self-inflicted severe penile injuries and underscores the need to integrate surgical and psychiatric care to optimise results.

CASE PRESENTATION

A 43-year-old man, with progressive psychiatric issues, self-inflicted penile amputation. He arrived late in the emergency room with a poorly preserved amputated penis, complicating potential reimplantation. The surgeons extensively debrided and created a urethrostomy on the anterior scrotum wall, preparing for future phalloplasty. This planning ensured tissue viability and minimised postoperative complications. Early psychiatric evaluations revealed hebephrenic schizophrenia. Unfortunately, after psychiatric stabilisation, he was lost to follow-up and was not present for phalloplasty.

DISCUSSION

Severe penile lesions require restoration of appearance, preservation of functions, and minimisation of complications. The surgical approach depends on the hospital capabilities, expertise, and patient condition, our patient's case required an anterior urethral anastomosis of the scrotum wall in consideration of phalloplasty. Pairing surgical intervention with immediate psychiatric care is crucial for optimal outcomes. However, the loss of follow-up postpsychiatric discharge in our patient highlights the need for improved monitoring to ensure adherence to treatment.

CONCLUSIONS

This case highlights the interaction between severe genital trauma, psychiatric instability, and surgical management in patients who engage in self-genital mutilation. It underscores the importance of a multidisciplinary approach that involves both surgical and psychiatric. Enhanced strategies for psychiatric involvement and monitoring are crucial, especially for people scheduled for complex reconstructive surgeries such as phalloplasty.

Penile Trauma Burden and Aetiology in the Paediatric and Adult Population: A Scoping Review and Critical Analysis of the Literature

Penile trauma is rare. It is associated with the impairment of physiological functions and deterioration in patients' quality of life. Currently, the relevance of age demographics in the occurrence of this debilitating injury has not been well discussed. The objective of this study was to provide a scoping review of penile trauma within the lens of the legal age of maturity. A search of the PubMed, Scopus and Web of Science databases was conducted, and then, the identified publications were used to conduct this scoping review focussing on the study aim. The results identified were categorised into five themes. This included publication information (author, year, country, study duration); demographic information (age of presentation, number of patients, relative burden); penile trauma clinical pattern (type, severity, associated injury), risk factors and clinical consequences. While mobile and active young adults were at risk of outdoor trauma, the report on penile trauma in the paediatric population is rare and usually focussed on sexual trauma. Penetrating trauma has been more extensively studied in comparison to blunt penile trauma despite the significance of the latter in the paediatric population. Injury severity classification is not available for most studies limiting their usefulness in the universal comparison of trauma severity and injury prognostication. There is a diversity in the burden and presentation of penile trauma. Available research studies are limited in the paediatric population, mostly focussed on penile fracture in adults and generally devoid of a standardised penile trauma severity description. Additional studies with a specific focus on penile trauma are required to characterise aetiological risks and injury severity across the legal age of maturity.

Successful Pediatric Penile Replantation Following Amputation During Ritual Circumcision: A Case Report and Literature Review

BACKGROUND Circumcision is commonly performed in males, especially in Jewish and Muslim cultures, and is considered a safe surgical procedure with a low complication rate. Major complications, such as partial and total penile amputation, can occur, but those are rare complications. However, high replantation success rates have been reported and reviewed. CASE REPORT We describe the case of an 8-year-old boy who experienced total penile amputation during ritual circumcision performed by a layperson outside the hospital setting. Microsurgical penile replantation was performed after an ischemic period of 16 hours 43 minutes, with successful outcomes and without any major complications. In our technique, we repaired both dorsal and deep cavernosal vessels. At 1-year postoperative period, the results of two-point discrimination test were 4 mm, 7 mm, and 7 mm on the dorsal part, ventral part, and glans, respectively. After a follow-up period of 4 years, there were no late complications such as penile deformity, urethral fistula, urethral stenosis, absence of penile sensation, or erectile dysfunction. The results of two-point discrimination test were 3 mm, 5 mm, and 5 mm on the dorsal part, ventral part, and glans, respectively. The patient also experienced good penile sensation, morning erection, satisfaction with the cosmetic outcome, and a peak urine flow rate of 21 mL/s with a consistently strong void stream and a low postvoid residual urine volume of 20 mL. CONCLUSIONS Our experience suggests that a short ischemic time, prompt surgical correction, microscopic technique of replantation, and intensive postoperative care can result in good functional outcomes.

Urethrocutaneous fistula following VMMC: a case series from March 2013 to October 2019 in ZAZIC's voluntary medical male circumcision program in Zimbabwe

Background

Urethrocutaneous fistula (subsequently, fistula) is a rare adverse event (AE) in voluntary medical male circumcision (VMMC) programs. Global fistula rates of 0.19 and 0.28 per 100,000 VMMCs were reported. Management of fistula can be complex and requires expert skills. We describe seven cases of fistula in our large-scale VMMC program in Zimbabwe. We present fistula rates; provide an overview of initial management, surgical interventions, and patient outcomes; discuss causes; and suggest future prevention efforts.

Results

Case details are presented on fistulas identified between March 2013 and October 2019. Among the seven fistula clients, ages ranged from 10 to 22 years; 6 cases were among boys under 15 years of age. All clients received surgical VMMC by trained providers in an outreach setting. Clients presented with fistulae 2–42 days after VMMC. Secondary infection was identified in 6 of 7 cases. Six cases were managed through surgical repair. The number of repair attempts ranged from 1 to 10. One case healed spontaneously with conservative management. Fistula rates are presented as cases/100,000 VMMCs.

Conclusion

Fistula is an uncommon but severe AE that requires clinical expertise for successful management and repair. High-quality AE surveillance should identify fistula promptly and include consultation with experienced urologists. Strengthening provider surgical skills and establishment of standard protocols for fistula management would aid future prevention efforts in VMMC programs.

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.

Case Report: Non-microscopic surgical management of incomplete penile amputation

Background: Penile amputation is an emergency urologic condition requiring immediate attention in order to maximize functional outcomes. Unfortunately, there is limited experience and publication of case reports describing the successful replantation of penis after incomplete amputation, especially in facilities without adequate microsurgical tools and means. We hereby present a case of penile amputation caused by a mechanical grass cutter and a discussion of its surgical management.

Case description: A 33-year-old Indonesian male presented to the emergency department with incomplete penile amputation six hours post injury. The patient has no prior medical history and presented with penile amputation due to a mechanical grass cutter trauma. He underwent immediate non-microsurgery reconstructive replantation of the penis, reattaching all visible vascular, corporal, and fascia layers. After replantation, the patient recovered well and showed preserved normal appearance and sensitivity of the penis. Subsequent Doppler ultrasound investigation revealed adequate arterial flow at the distal end of the anastomosis. The patient was discharged five days after surgery. 

Conclusion: In the absence of microsurgical tools and means, the use of non-microsurgical replantation with an at least 2.5x loupe magnification should be the choice of treatment in the case of incomplete penile amputation. The technique showed good outcomes involving adequate functional and cosmetic restoration.

Penile Glans Amputation following Circumcision: A Case Report of a Rare Complication

Circumcision is the most prevalent surgery among men. Like any other surgical intervention, it is associated with several complications. A rare shocking complication is glans amputation which is a urologic emergency. Herein, we present a 4-year-old boy with penile glans amputation following circumcision. The reimplantation was performed in less than two hours. We approximated the ends over a size 4 : 0 catheter. The urethral anastomosis was performed via 6 : 0 Vicryl sutures. Then, we sutured amputated glans in place via Vicryl 4 : 0. We immobilized the penis for a week via bandages used in penile reconstruction surgeries. We also used pentoxifylline to treat glans ischemia after surgery. The patient and his parents did not mention any difficulties or abnormalities while voiding, and the cosmetic result was favorable after three months of follow-up.

Glans injury during ritual circumcision

BACKGROUND

Circumcision is one of the most performed surgical procedure in the world, often performed for nontherapeutic reasons. Depending on cultural and social backgrounds, the procedure may be performed by various sources; from trained health care practitioners to laypeople, giving rise to different frequencies and types of complications. Glans injury during ritual circumcision is a rare yet serious complication due to its associated morbidity and long-term consequences.

OBJECTIVE

In this study we describe the experience of two medical centers with the management and follow up of glans injury after ritual circumcision.

METHODS

We have retrospectively reviewed the medical files of all pediatric patients who presented to the ER with glans injury, following ritual circumcision, over a 17-year period from two medical centers.

RESULTS

A total of 8 patients were identified, who underwent ritual circumcision between 7 and 9 days of age. On presentation, 1 infant had complete glans amputation, the others presented with partial amputation of the glans. 6 of the 8 patients had a simultaneous urethral injury. All patients underwent surgical correction for their injury; Patients with isolated glans injury, underwent primary glans anastomosis. Of the 6 cases with simultaneous urethral injury: 3 underwent end-to-end urethral anastomosis following anastomosis of the amputated glans, one patient with complete glans amputation underwent a similar procedure, with initial end-to-end urethral anastomosis followed by glans anastomosis to the corpora cavernosa and 2 were managed by urethrostomy together with anastomosis of the amputated glans tissue to the remaining glans. Both patients with urethral injury, in whom end to end urethral anastomosis has not been performed, were found to have hypospadias on follow up. The rest had good functional and cosmetic results.

DISCUSSION

There is no single method for managing glans injury following circumcision. Some authors describe healing by secondary intention with delayed formal repair, while others advocate for primary anastomosis of the amputated glans, together with distal urethra-urethrostomy, in cases with simultaneous urethral injury. In this study, both patients without urethral anastomosis, developed secondary hypospadias due to meatal regression and required additional surgery, while the others showed good results. The limitations of our study are its retrospective nature and the small number of cases, preventing us to come to a definitive conclusion regarding the best way to treat such a rare injury.

CONCLUSION

Prompt surgical correction by glanular replantation with urethro-urethrostomy, in case of concomitant urethral injury, give good cosmetic and functional results.

Isolated Injury to Prepuce After Motor Vehicle Collision

A four-year-old male restrained passenger in the rear seat was in a motor vehicle collision. He had pain and swelling in the tip of the penis with the inability to micturate. The patient on evaluation had an isolated injury of the prepuce. The patient underwent an evaluation to rule out underlying penile/urethra and associated injury of kidney and bladder. The patient had an isolated injury to prepuce, causing urinary retention for which he underwent circumcision.

Acute penile trauma: imaging features in the emergency setting

In an emergency department, penile traumas are uncommon and a prompt diagnosis is necessary. Penile injury may result from penetrating and non-penetrating trauma. Non-penetrating injuries can produce cavernosal hematomas or fractures: if not treated promptly, these lesions can result in fibrosis or erectile dysfunction. Penile traumatic lesions need a clinical approach first, but a radiological study is often required: ultrasonography with color and spectral Doppler study is usually the first approach. In some cases, magnetic resonance imaging may be performed to better recognize even small discontinuity of the tunica albuginea. Radiologists have to be aware of the various radiological patterns of penile traumatic lesions, in order to establish a prompt and correct diagnosis.

Neonatal circumcision and prematurity are associated with sudden infant death syndrome (SIDS)

BACKGROUND

Sudden infant death syndrome (SIDS) is the most common cause of postneonatal unexplained infant death. The allostatic load hypothesis posits that SIDS is the result of cumulative perinatal painful, stressful, or traumatic exposures that tax neonatal regulatory systems.

AIMS

To test the predictions of the allostatic load hypothesis we explored the relationships between SIDS and two common phenotypes, male neonatal circumcision (MNC) and prematurity.

METHODS

We collated latitudinal data from 15 countries and 40 US states sampled during 2009 and 2013. We used linear regression analyses and likelihood ratio tests to calculate the association between SIDS and the phenotypes.

RESULTS

SIDS mortality rate was significantly and positively correlated with MNC. Globally (weighted): Increase of 0.06 (95% CI: 0.01-0.1, t = 2.86, p = 0.01) per 1000 SIDS mortality per 10% increase in circumcision rate. US (weighted): Increase of 0.1 (95% CI: 0.03-0.16, t = 2.81, p = 0.01) per 1000 unexplained mortality per 10% increase in circumcision rate. US states in which Medicaid covers MNC had significantly higher MNC rates (χ̄ = 0.72 vs 0.49, p = 0.007) and male/female ratio of SIDS deaths (χ̄ = 1.48 vs 1.125, p = 0.015) than other US states. Prematurity was also significantly and positively correlated with MNC. Globally: Increase of 0.5 (weighted: 95% CI: 0.02-0.086, t = 3.37, p = 0.004) per 1000 SIDS mortality per 10% increase in the prematurity rates. US: Increase of 1.9 (weighted: 95% CI: 0.06-0.32, t = 3.13, p = 0.004) per 1000 unexplained mortalities per 10% increase in the prematurity rates. Combined, the phenotypes increased the likelihood of SIDS.

CONCLUSIONS

Epidemiological analyses are useful to generate hypotheses but cannot provide strong evidence of causality. Biological plausibility is provided by a growing body of experimental and clinical evidence linking aversive preterm and early-life SIDS events. Together with historical and anthropological evidence, our findings emphasize the necessity of cohort studies that consider these phenotypes with the aim of improving the identification of at-risk infants and reducing infant mortality.

RELEVANCE FOR PATIENTS

Preterm birth and neonatal circumcision are associated with a greater risk of SIDS, and efforts should be focused on reducing their rates.