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InternationalJournalofSurgeryCaseReports29(2016)1–3ContentslistsavailableatScienceDirect
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,baDeptofPlasticandMaxillofacialSurgery,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
a
b
s
t
r
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c
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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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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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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
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