Traumatic Penile Injuries in Children: An Experience

²Department of Obstetrics and Gynecology, Enugu State University Teaching Hospital, Enugu, Nigeria

*Corresponding author: Chukwubuike Kevin Emeka, Department of Surgery, Enugu State University Teaching Hospital, Enugu, Nigeria

Citation: Emeka CK, Nnanyereugo OL, Patrick AL. (2022) Traumatic Penile Injuries in Children: An Experience. 3(1):1-6.

UCF=Urethrocutaneous fistula; FB=Foreign body

Table 2: Clinical presentations (n=104).

Operative procedure performed

The operative procedure depended on the nature of the penile trauma. Urethrocutaneous fistula was repaired by urethroplasty, hemorrhage needed application of pressure with or without ligation of bleeding vessels and penile amputation was repaired meatoplasty and glanuloplasty. Injuries caused by foreign bodies entailed removal of the foreign body and appropriate repair.

Complications of treatment

Following repair of the urethrocutaneous fistula, 15 (14.4%) patients had recurrence, narrowed (stricture) urethra was observed in 5 (4.8%) patients and surgical site infection occurred in 4 (3.8%) children.

Treatment Outcome

Eighty-two (78.8%) patients achieved good cosmetic and functional outcome. However, 19 (18.3%) patients required repeat surgeries to achieve acceptable results. Two (1.9%) patients expired; one patient each due to anesthetic accident and overwhelming sepsis. One (1%) signed out against medical advice. 

Discussion

Penile injuries are urological emergencies that require immediate attention [9]. Penile injuries in children are not uncommon and have different etiology from those of adults. Penile injuries from circumcision predominate. Penile fractures and penetration injuries are rare in children [7, 8]. The incidence of penile injuries may be under-reported because many parents do not seek medical help for their children due to psychological reasons [10]. Historically, amputated penis can be salvaged by replantation. The first macroscopic penile replantation was reported by Ehrlich in 1929 [11]. In 1877, first microscopic penile replantation was reported [12].

In the present study, the mean age of the patients was 4 months. This finding is in contrast to the findings of Saiad et al [13]. The difference in the mean age of the patients may be explained by the age group of the patients recruited and the nature of the penile injury. For example, foreign body insertion is more likely to be seen in older children. There was delayed presentation of the patients to the hospital in the current study. This is evident on the mean interval between the injury and presentation to the hospital. The delayed presentation may be the reason there was no penile reimplantation performed in the current series because the amputated penis were nonviable. The nature of the injury may determine the time of presentation. For instance, children with bleeding from circumcision are more likely to present earlier than children with urethrocutaneous fistula. The time interval between presentation and treatment vary widely. Bleeding required immediate intervention whereas in urethrocutaneous fistula, time was required for scar tissue maturation before repair of the urethrocutaneous fistula was carried out. The duration of hospitalization of the patients is related to the nature, severity of the injury and the post-operative course.

Urethrocutaneous fistula was the most common traumatic penile injury in the current series. Other series also reported urethrocutaneous fistula as a frequent traumatic penile injury [8,13]. However, Oranusiet al reported genital mutilation as the most common penile injury [1]. The age range of the patients recruited into a particular study may determine the predominant penile injury. For instance, a study involving neonates will most likely report complications of circumcision as the most common penile injuries whereas older children will have other forms of penile injuries. Urethrocutaneous fistula is a common complication following circumcision especially when the circumcision is performed by poorly trained personnel [14]. Bleeding following circumcision usually result from the frenular artery or from the cut skin edges [15]. One study from United States of America reported bleeding as one of the most common complications of circumcision [15]. Control of bleeding following circumcision may be by pressure application, use of local hemostatic agents or ligation of the bleeding vessel without causing injury to the urethra. Patients with persistent bleeding need hematologic work up for coagulopathies. Penile/glans amputation is a rare penile injury. Amputation can be a complication of circumcision or can be self-inflicted in patients with psychiatric disorders [16]. Sow et al reported a case of accidental penile amputation following an attempt at circumcision [17].Foreign body can be inserted or placed around the penis. In the present study, we had cases of some children who inserted rubber bands around their penis while playing with rubber bands. The penises were viable but edematous and discolored. Penile strangulation is a disease which causes circulatory failure in the distal part of the penis by the penis strangulated by foreign objects [18]. Sasaki et al reported a case of gangrene of the penis due to strangulation by a rubber band [19]. Foreign body insertion into the penis by children is a very rare incident. Muraveji and Sherzad documented a case of self-inserted foreign body in an adolescent boy [20]. It is believed that psychiatric and mental defects are responsible for these abnormal behaviors. Use of electrocautery (diathermy) during circumcision/penile surgery can result in diathermy burns. And in extreme of cases, electrocautery can result to glans necrosis [21].

The predominant operative procedure performed was dependent on the most common penile injuries. For instance, repair/urethroplasty for urethrocutaneous fistula was the most performed procedure in the present study. However, one study from Nnewi, southeastern Nigeria reported penile refashioning as the most common procedure in patients with penile injury [1]. Recurrent urethrocutaneous fistula was the most common post-operative complication in the index study. The high number of urethrocutaneous fistulae repaired and poor vascularity of the tissues from scarring may explain the high complication rate.

Overall, the outcome of treatment is good. Cosmetic outcome was assessed by the appearance of the penis following repair. The cosmetic outcome assessed the following parameters: Shape of the glans penis, state of penile skin, position of the meatus and shape of the meatus. The functional outcome was evaluated by assessing the urinary stream.

Conclusion

Traumatic penile injuries in children may be infrequently but could be a significant cause of penile disfigurement and morbidity. Urethrocutaneous fistula and bleeding problems from malcircumcision are the most common traumatic penile injuries. Penile injuries from self-mutilation may be common in children with mental challenges. Traumatic penile injuries resulting from circumcision can by minimized be better training and good practice.

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