Penile glans amputation and caverno-spongiosal disjunction following a dog bite: a case report

¹Higher Institute of Medical Technology, Yaounde, Cameroon, ²Urology Service, Yaounde Central Hospital, Yaounde, Cameroon, ³Department of Surgery and Subspecialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde 1, Yaounde, Cameroon, ⁴Faculty of Health Sciences, University of Bamenda, Bamenda, Cameroon

^&Corresponding author
Mbassi Aurele Achille, Higher Institute of Medical Technology, Yaounde, Cameroon

Introduction    

Traumatic penile amputation is a rare surgical emergency. Although human injury due to dog bites is common, isolated dog bites to the male genitalia are rare. These injuries could be severe genital lesions to even emasculation [1]. Successful surgical reconstruction and reimplantation in patients with penile amputation could be challenging even in the hands of experienced surgeons [2]. We report the case of a 13-year-old boy who underwent successful non-microsurgical penile reimplantation following penile glans amputation from a dog bite injury.

Patient and observation     

The authors report a case of a 13-year-old male who presented following traumatic genital injury with total penile glans amputation and caverno-spongiosal disjunction resulting from a dog bite injury. The patient had successful genital reconstruction and was reviewed 8 years later with favorable cosmetic and functional outcomes. This case has been reported in accordance with the CARE guidelines.

Patient information: a 13-year-old male student presented at the emergency unit of the Yaounde Central Hospital (YCH) with penile pain and bleeding following a dog bite injury to the external genital which occurred 2 hours before consultation while he was returning from school. The patient does not report any mental or psychosocial disability.

Clinical findings: on arrival and upon physical examination, the patient was anxious with satisfactory vital signs and no source of active bleeding. There was a traumatic tissue lesion on the distal third of the penile shaft 0.5cm beneath the coronal sulcus with total transection of the penile glans, complete sectioning of the penile urethra, and caverno-spongiosal disjunction. There was also a puncture wound on the lateral aspect of the left hemi scrotum (Figure 1).

Diagnostic assessment: the differential diagnosis at entry included trauma to the external genitalia and penile amputation. The following investigations were requested, complete blood count (CBC), clotting profile, blood group and rhesus factor, urea, and serum creatinine. The results of biological investigations were as follows: haemglobin of 11g/dl, white cell count of 7300 cells/ mm³. The clotting profile and renal functions were normal.

Therapeutic intervention: following primary and secondary surveys, anaesthetic evaluation was done and the emergency management consisted of empiric broad-spectrum antibiotics, wound irrigation and debridement and the placement of a 10F silicon urinary catheter which allowed for tubulisation of the sectioned urethra using PDS 6/0 interrupted sutures. A caverno-spongioplasty was then performed by an end-to-end anastomosis using PDS 4/0 sutures with the urinary catheter in place (Figure 2, Figure 3 and Figure 4). The post-operative follow-up was uneventful and immunization against rabies and tetanus was done. Erection with the catheter in place was normal upon control.

Follow-up and outcome: patient was discharged on day 14 post-surgery after the removal of the transurethral catheter. Evolution was uneventful during patients´ monthly follow-ups. The patient was re-evaluated 8 years later and had a cosmetically acceptable penis, conserved erectile function, and void with a good urinary stream (Figure 5). Uroflowmetry showed satisfactory voiding with a max flow rate of 35ml/s and a mean flow rate of 12ml/s (Figure 6).

Patients perspective: the patient was satisfied with the medical attention and follow-up received at the hospital from the time of injury, during hospitalization, and even upon discharge. The patient explained having a terrifying experience after his penis was amputated following a dog bite. He expressed satisfaction with having his penis salvaged by the medical team of the YCH.

Informed consent: informed consent was sorted from the patient for the publication of this article.

Discussion     

Dog bite injuries to the external male genitalia occur rarely and those affected usually seek medical care urgently. Dog bite injuries though common, isolated genital injuries in children by a dog bite are seldom reported [3]. These injuries are usually severe injuries to almost emasculation and are mostly reported in developing countries due to poor housing facilities and the increase in the number of stray and unvaccinated dogs [4]. Morbidity following dog bite injury to the genitalia is usually high and the severity is influenced by the impact of the initial lesion. Infectious complications can be greatly reduced with the use of broad-spectrum antibiotics. We report the case of a 13-year-old male who presented following traumatic genital injury with total penile glans amputation and caverno-spongiosal disjunction resulting from a dog bite injury. Various management guidelines include resuscitation, wound irrigation, debridement, empiric antibiotics, immunization against tetanus and rabies, and primary wound closure or microsurgical reimplantation in patients with penile amputation [5]. Patients presenting immediately following injury without gross infection usually have satisfactory results following primary reconstruction.

The case presented was received 2hr following injury, without active bleeding. However, the patient had a de-gloving lesion at the penile glans with a complete section of the penile urethral requiring immediate reimplantation of the penile glans. Severe de-gloving injuries of the penis may require deferred reconstruction with the use of skin grafting or local skin flaps [6]. Furthermore, exploration for scrotal wounds should be systematic in these patients and should be closed primarily. Injuries involving loss of scrotal skin with an exposition of testis might occur and this is usually associated with increased morbidity. The exposed testicles could be salvaged and protected by placing them in the superior medial aspect of the thighs, by creating pouches in the inguinal region. Other techniques which have been reported include the use of local flaps and split skin grafts to cover and protect the exposed testicles [7]. Emasculation following a dog bite injury is usually cumbersome with increased morbidity. Management options usually include genital reconstruction, hormonal replacement therapy, and in some cases gender reassignment. Penile reconstruction and hormone supplement therapy using testosterone are more effective when administered during the pre-pubertal period [8]. Infection rate increases with the degree of wound contamination and the delay in seeking healthcare following dog bite injury and this may greatly affect management outcomes. The patient's age, number, and the type of breed of attacking animals also determine the gravity of trauma [9]. Complications following dog bite genital injuries reported include cosmetically bad genitalia which usually causes psychosocial distress to the victim, stenosis of the urethral meatus, urethrocutaneous fistula, and penile retraction. The case reported was reviewed 8 years following a dog bite genital injury and presented with cosmetically good genitalia, apical urethral meatus, and a good urinary stream during voiding with satisfactory uroflowmetry results.

A study conducted by Gomes and colleagues reported eight boys and two men who sustained genital injuries due to animal bites among which (8 were due to a dog bite, and one by a horse). In these cases, debridement and wound irrigation with physiologic saline solution was used. 5 patients sustained minimal skin loss and benefited from primary skin closure. Urethral injuries were noted in two of these patients which were also repaired. Five patients sustained extensive soft tissue and skin loss including degloving injuries which were reported in two patients. One infant suffered from complete scrotal and penile skin avulsion and one patient sustained partial penile amputation. The results obtained following surgical reconstruction in these patients were satisfactory. Antibiotic prophylaxis, tetanus, and rabies prophylaxis were administered to all of these patients [10]. This is consistent with our index-reported case. However, the duration between the onset of injury to surgical reconstruction was not specified among all the victims in the above study.

Conclusion     

Animal bite injuries to the genitals are rare but potentially severe causes of genital trauma in children. The morbidity from these injuries is directly associated with the severity of the initial wound and the quality of surgical management. Successful non-microsurgical penile reimplantation in pediatric patients following traumatic penile amputation remains a challenging task, especially in resource-limited settings. Management includes wound irrigation, debridement, broad-spectrum anti-biotherapy, genital reconstruction, and immunization against rabies and tetanus. Primary closure is advised in most cases and usually achieves good cosmetic and functional outcomes.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Patient management: Mbassi Aurele Achille, Mbouche Landry Oriole and Pierre Joseph Fouda. Data collection: Orock Agbor Tanyi, Ngwa Titus Ebogo Manuscript drafting: Orock Agbor Tanyi. Manuscript revision: Ngwa Titus Ebogo, Kamadjou Cyril, Epoupa Ngalle, and Fru Fobuzshi Angwafo III. All authors read and approved the final manuscript.

Figures     

Figure 1: image showing penis following dog bite injury with the following lesions; total amputation of penile gland, complete section of the urethral and carveno-spongial disruption and a puncture wound on the scrotum

Figure 2: per-operative images during urethroplasty, spongio-cavernoplasty by termino-terminal anastomosis

Figure 3: image showing primary soft tissue reconstruction of the penis

Figure 4: image showing appearance of penis at the end of reconstruction by primary closure following dog bite injury

Figure 5: image showing appearance of patients´ penis 8-year post reconstruction following dog bite injury with normal size and shape and the presence of apical urethral meatus

Figure 6: uroflometery done 8 years post penile reconstruction with satisfactory voiding; max flow rate of 35ml/s and a mean flow rate of 12ml/s

References