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

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InternationalJournalofSurgeryCaseReports29(2016)1–3

ContentslistsavailableatScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n al ho m e p a g e :w w w . c a s e r e p o r t s . c o m

A

case

report

of

a

complete

degloving

injury

of

the

penile

skin

Helena

Aineskog

(MD)

a,∗

,

Fredrik

Huss

(MD)

(Associate

Professor)

a,b

aDeptofPlasticandMaxillofacialSurgery,UppsalaUniversityHospital,Uppsala,Sweden bDeptofSurgicalSciences,PlasticSurgery,UppsalaUniversity,Uppsala,Sweden

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received16August2016 Accepted8October2016 Availableonline15October2016 Keywords:

Degloving Penis

Split-thicknessskingraft Caninemouthflora Smokingcessation Casereport

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INTRODUCTION:Malegenitaldeglovinginjuriesareunusualandrarelycausedbyanimalbite.Usually

patientsattendhealthcareimmediatelyifbitteninthegenitalarea.Prophylacticantibioticsisroutinely

used(Gomesetal.,2000).

Apeniledeglovingusuallybeginsjustproximalofthecoronallineandprogressdowntothebaseof

theshaft.Deeperectiletissueandthespermaticcordareseldomdamagedandtheendogenousskinof

glansusuallysurvives(BrownandFryer,1957;Moreyetal.,2004;FinicalandArnold,1999).

PRESENTATIONOFCASE:Aheavilysmokingmanwithaprevioushistoryofbladdercancerpresented

himselftotheemergencydepartment24hafteradogbitedeglovedhispenis.Theavulsedskinwas

necroticandsubsequentlyexcised.Antibiotictreatmentwasstarted.Abacterialswabwasfoundpositive

forcanineoralflora.

Theskindefectwasclosedusinga1:1meshedsplitthicknessskingraftfromtheinnerthigh.Smoking

cessationwasencouraged.

Atthethreemonthfollowupthepatientexpressedsatisfactionwithbothcosmeticandfunctional

resultandwasnownon-smoking.

DISCUSSION:Severalapproachestoreconstructpenileskinexist.Splitthicknessskingrafthasbeenlifted

asapreferablealternative(BrownandFryer,1957;FinicalandArnold,1999;Paraskevasetal.,2003)[5].

Inthiscase,theavulsedskinwasnecroticandcouldnotbeused.A1:1meshedsplit-thicknessgraftwas

chosenwithexcellentresults.

CONCLUSION:1:1meshofthegraftcanberecommendedforeasyattachmentwithagoodfunctional

andestheticalresult.Thepotentialriskoflosingintimacyappearanceorhavingtogothroughrepeated

proceduresinthegenitalareamotivatedsmokingcessationforthispatient.

©2016TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.Thisisanopen

accessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction

Whensearchingthescientificliteratureforreferencesonmale genitaldeglovinginjuriesthereareonlyfewarticlestobefound. Thoughveryfewcases,themajorityofthereportedadultinjuries areduetofarmequipmentaccidents.Asocalled“powertake-off injury”(PTO)modelhasbeenstipulated[2].PTOdescribesaninjury causedbypowerbeingtransmittedfromoneplacetoanother.The loosepenileskin,entrappedbysurroundingclothingiscaughtina stationarymachineryandthentraumaticallyrippedoff[2,3].Other causesmaybesecondarytovariousdevicessuchaspenilerings, vacuumcleaners, or excessivetraumaduring sex [4].Although animalbitesareaccountingfor asmany as1%ofallemergency visitsintheU.S.,veryfewcasesinvolvingthegenitalareahasbeen

Abbreviation:PTO,“powertake-offinjury”.

∗ Correspondingauthorat:DeptofHandandPlasticSurgery,LinköpingUniversity Hospital,58185Linköping,Sweden.

E-mailaddress:hs.aineskog@gmail.com(H.Aineskog).

describedintheliterature.Amongthosethataredescribed,utterly fewaredeglovinginjuries[1].

However,searchingtheliterature,onearticleconcerningpenile degloving injuries by Finical et al. in 1999 [4] and one article describinggenitaltraumaduetoanimalbitesbyGomesetal.in 2000[1]couldbefound.

Notably,itisdescribedthatdeglovinginjuriesofthepenileskin isnotapainfulcondition[2].

ImportantlyregardingPTOinjuries,isthattheskintearslooseat thecorona,sothattheglansisusuallyleftintact.Theseparationalso seemstofollowthesuperficial,Dartos,fasciaanddoesnotdamage deeperectiletissuesorthespermaticcord[2].Thecutaneousblood supplyofthepenileshaftisderivedfromapairofaxialarteriesin thesuperficialfasciawhereastheglanshasadditionalsupplyfrom thedeepdorsalarteryandcorporalvessels[6].Thisanatomical sit-uationexplainswhydifferenttypesoflocalflapsorsplit-thickness skingraftshavebecomethemostpopularwaystoreconstructthe penileskinafteradeglovinginjuryifre-implantationofthe endoge-nousskinisnotpossible.InthesummaryreportbyFinicaletal.,a onestageproceduretotreattheseinjuriesispresented[4].This

http://dx.doi.org/10.1016/j.ijscr.2016.10.024

2210-2612/©2016TheAuthor(s).PublishedbyElsevierLtdonbehalfofIJSPublishingGroupLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

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2 H.Aineskog,F.Huss/InternationalJournalofSurgeryCaseReports29(2016)1–3

Fig.1.Deglovedpenis,skinstillattachedthroughasmallbridgeatthebase,24h afterinjury.

typeofsplit-thicknessskingraftisalsopreferredbyotherauthors [2,4]

2. Presentationofcase

A67yearoldretiree,smokingabouttwopacksofcigarettesper day,presentedhimselftotheemergencydepartmentatUppsala UniversityHospitalapproximately24hafterbeingbitbyadogin hishome.Thepatientrecalledthrowingball,inthenude,witha Germanshepherdwhenthedogmistakenlybithispenisandripped offtheskin.Acircumferentialavulsionoftheskinfromthe coro-nalsulcustothebaseoftheshaft,includingasmallerpartofthe scrotalskinwasseen.Theerectilecolumns,urethraandtesteswere intact,thetissuessplitbetweenDartos’andBuck’sfasciae,justas describedforPTOinjuries.

Askinbridgeofabout1cminwidthwasholdingthedegloved skinattachedventrolateraltothebaseoftheshaft.Thependent skinwasnecrotic,blackandfoulsmellingandthussubsequently excised.Presumablyduetothedoublearterialsupplyofglansand thesubcoronalregionasdescribedabove,thisareawasintact.

Serum chemistry, hematology, and qualitative wound cul-turetestingwasperformed.Tetanus-/diphteriatoxoidvaccineand Piperacillin/Tazobactam4gq8hwasadministered.Thepatientwas advicedimmediatelytostopsmoking.Thepatientalsogaveoral andwritteninformedconsenttophotographyandscientific com-munication.Surgerywasperformed36hpostinjury(Fig.1).

2.1. Intraoperativeprocedure

Duetotheclosenatureofthiswoundtodescribedpowertake offinjuries,wechosetousethedescribedtechniquebyFinicaletal.

[4].Afterhavingintroduceda12Gaugeurinarycatheter,thepenis wasthoroughlywashedwithchlorhexidinesoap,sodiumchloride, and1,5%hydrogenperoxide.Atowelclampwascarefully intro-ducedtodistal glansforeasierhandling.Devitalisedtissuewas excisedasweretheskinedges.Asmalllocalskinflapwasturned tocomplete thescrotum.A0.3mm(12/1000-in)splitthickness skingraftwasharvestedfromtheleftmedialthigh,meshed1:1, andsuturedcircumferentiallyendtoendalong thepenile shaft andtothesubcoronalandscrotaltissue.Theaxialrowofsutures wascarefullyplacedaxiallyalongtheventralaspectofthepenis tomimicthenaturalraphe.Anelasticcompressivedressingwas appliedwithHypafix®incross-wiseL-shapestokeepthepenisin anerectpositionforoptimaltakeofthegraft(Fig.2).

Fig.2. Perioperativepicture.A1:1meshedsplitthicknessskingraftsuturedinplace.

Fig.3.Threemonthspostoperative.

2.2. Postoperativeresult

Firstpostoperativeweekwasuneventful.On firsttake-down slightclinicalsignsofinfectionwerepresentwithsmallareasof thickyellow/greendebrisbutnoredness,swollennessorpain.

Fromthebacterialswabstaken,NeisseriaWeaveri(bacteria asso-ciatedtocanineflora),mixedcoliformfloraandfloraassociatedto humanskinwasfound.

By the time of discharge (six days post-operatively), Piperacillin/Tazocine intravenously was changed to a combi-nationofHeracillin,1g,q8handCiprofloxacin,500mg,q12hfor 14days.

C-reactiveproteinandleucocytecountwasmeasuredwitha decliningtrendoverthehospitalcourse.

Patientwasdischargedwithregularcontrolsintheout-patient clinic.

Threemonthspostoperativelythepenileandscrotalskinwas completelyhealed.Therewerenosignsofinfection,nopainandthe patienthadreturnedtopre-traumafunctionalstatus.Hecontinued tobesmoke-free(Fig.3).

3. Discussion

Penileskinavulsionsareveryrareinjuries,asareanimalbites inthegenitalregion.However,animalbitesinthisregionis rou-tinelytreatedwithprophylacticantibiotics[7].Possiblythisiswhy infectionswithtypicalcanineoralbacteriainthegenitalarea,to ourknowledge,hasnotbeenreportedpreviously[1].Thiscaseis thereforespecialoutofseveralperspectives.

Routinelytheendogenousskinwouldhavebeenwashed thor-oughlyandimmediatelyreattachedasitwasdeglovedinonepiece, butthenecroticstatusoftheskinmadethisapproachimpossible. Possiblyduetothemultipleandrichvascularisationofthepenis, areconstructionusingapreviouslydescribedsplit-thicknessskin graft,alongwithantibiotictreatmenthasinthisspecificcasegiven

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H.Aineskog,F.Huss/InternationalJournalofSurgeryCaseReports29(2016)1–3 3

anexcellentresult.Inafewpreviouspublications,split-thickness skingraftshasbeenliftedasapreferablechoicefor reconstruct-ingthepenileskin[2,4,5].Asabonus,thepatient,whopreviously continuedsmokingthoughsufferingfromurinary-bladdercancer, nowpermanentlystopped.Itmaybepostulatedthattheemotional distressofpossiblyloosingintimacyappearancefunctionedasa potentfactorforbehaviouralchangesinthiscase.

4. Conclusion

Althoughsuperinfected,asplit-thicknessskingraftgave func-tional,andforthepatientcosmeticallyacceptable,resultsforthe coveringofthiscompletedeglovinginjuryofthepenis.Thechoice of1:1meshmadeitpossibletouseanydirectionofthegraft,with thesuturelineaxiallyontheventralaspectoftheshaft, imitat-ingraphe,givingagoodcosmeticandfunctionalresult,waseasily achievedandcanberecommended.

Conflictsofinterest

Noconflictofinterest.

Funding

Nofundinghasbeenusedforthisresearch.

Ethicalapproval

Noethicalapprovalhasbeenappliedforthiscasereportstudy, onlythewrittenandoralconsentbythepatient.

Consent

Awrittenconsenthasbeenobtainedfromthepatientfor publi-cationofthiscasereportandaccompanyingimagesandisavailable forreviewonrequest.

Authorcontribution

Bothauthorshascontributedequallytothepaper.

Guarantor

FredrikHuss. HelenaAineskog.

Acknowledgement

Thisresearchdidnotreceiveanyspecificgrantfromfunding agenciesinthepublic,commercial,ornot-for-profitsectors.

References

[1]C.M.Gomes,etal.,Genitaltraumaduetoanimalbites,J.Urol.165(1)(2000) 80–83.

[2]J.B.Brown,M.P.Fryer,Peno-scrotalskinlosses,repairedbyimplantationand freeskingrafting:reportofknownnormaloffspring(preliminaryreporton totalanddeeplosses),Ann.Surg.145(5)(1957)656–664.

[3]A.F.Morey,etal.,Consensusongenitourinarytrauma:externalgenitalia,BJU Int.94(4)(2004)507–515.

[4]S.J.Finical,P.G.Arnold,Careofthedeglovedpenisandscrotum:a25-year experience,Plast.Reconstr.Surg.104(7)(1999)2074–2078.

[5]K.I.Paraskevas,D.Anagnostou,C.Bouris,Anextensivetraumaticdegloving lesionofthepenis.Acasereportandreviewoftheliterature,Int.Urol.Nephrol. 35(4)(2003)523–527.

[6]J.A.Grossman,etal.,Cutaneousbloodsupplyofthepenis,Plast.Reconstr.Surg. 83(2)(1989)213–216.

[7]V.Sabhaney,R.D.Goldman,ChildhealthupdateManagementofdogbitesin children,Can.Fam.Physician58(10)(2012)1094–1096(e548-50).

OpenAccess

ThisarticleispublishedOpenAccessatsciencedirect.com.ItisdistributedundertheIJSCRSupplementaltermsandconditions,which permitsunrestrictednoncommercialuse,distribution,andreproductioninanymedium,providedtheoriginalauthorsandsourceare credited.

Figur

Fig. 1. Degloved penis, skin still attached through a small bridge at the base, 24 h after injury.
Fig. 1. Degloved penis, skin still attached through a small bridge at the base, 24 h after injury. p.2
Fig. 2. Perioperative picture. A 1:1 meshed split thickness skin graft sutured in place.
Fig. 2. Perioperative picture. A 1:1 meshed split thickness skin graft sutured in place. p.2
Fig. 3. Three months postoperative.
Fig. 3. Three months postoperative. p.2
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