Successful One-Step Skin Replantation After Degloving Peno-Scrotal Injury in an 8-Year-Old Boy: A Case Report

Introduction

A degloving injury is a type of soft-tissue avulsion injury that occurs when skin and subcutaneous tissue are torn away from the underlying anatomical structures [1]. Isolated traumatic degloving of the penis and scrotum is a rare presentation of urological trauma and plastic emergency, especially in the pediatric population [2].

Partial or complete penile and scrotal skin loss typically occurs due to high-power blunt injury to the male external genitalia. Most of the reported adult injuries are caused by industrial or agricultural machinery and are called in the literature “power take-off injuries”. These types of injuries are described as being caused by power being transmitted from one place to another, in this case, loose skin of the penile shaft entrapped by surrounding clothing is caught in the moving equipment and then traumatically ripped off [3]. However, these injuries are very rare in children [4]. Causes and forms of degloving penile injuries in the pediatric population are different from those in adults. The main causes of penile trauma are iatrogenic circumcision-related injuries, injuries from a pet attack, injuries from monkey bars, and injuries associated with consumer products, such as bicycles, toilet seats, and zippers [5,6].

Mobility of the testes and presence of the protection by tunica albuginea and cremasteric muscles usually limits the damage to the superficial structures, without embracing cavernous bodies, spongy bodies, or testes [2,7]. However, although degloving injury is non-life-threatening trauma, it is a urological emergency that requires immediate surgical intervention to manage cosmetic and functional restoration. Reconstructive procedures are usually challenging and require complex actions, including immediate surgical wound exploration with irrigation and adequate debridement of necrotic tissue [8,9]. Proper management is also crucial for a patient’s mental health. Complications from genital trauma, such as disrupted sexual function, urethral stricture, and external distortion, can lead to decreased self-esteem, anxiety, and depression [10,11].

Considering the complexity of these injuries and lack of data in the literature, we present a case of a 8-year-old boy with a traumatic penile and scrotal injury due to sliding off of an agricultural machine. Single-stage replantation of the amputated skin shaft was performed, with a satisfactory outcome.

Case Report

The 8-year-old boy was brought by the emergency medical team to the Emergency Department after an avulsion injury of the perineal region, which had occurred 10 h before. The family reported that the unsupervised boy had climbed on a hay tedder and slipped from it, getting injured without either loss of consciousness or injury to the head, chest, or abdomen. The exact mechanism of injury was unwitnessed; therefore, neither the patient nor the caretakers could provide a consistent history of the incident.

On admission, the patient was conscious, in verbal and logical contact adequate to his age, and hemodynamically stable. He reported having moderate pain of the perineal region.

On physical examination, there was a massive injury to the perineal region, with complete degloving of the penile skin that extended from the glans to the base of penis, exposing the suspensory ligament of the penis and both spermatid cords, and rupture of the scrotal skin, exposing bilateral testes and epididymis, without features of active bleeding (Figure 1). Numerous scratches and lacerations were also present on the inner surface of the thighs and hips. Furthermore, the presence of injuries to the other areas were excluded. The abdominal ultrasound showed no injury to the abdominal organs. Amputated skin was taken from the place of the incident by the emergency medical team and transported in cold 0.9% saline (Figure 2).

Inspection of the wound and testicular ultrasound showed absence of injury to the tunica vaginalis of the testes, no disruption to the testicular integrity and blood flow, and no sign of vascular damage. The wound of the scrotum was debrided and closed with absorbable stitches. The amputate of the penile skin was cleansed in saline wash and reattached to the abdominal skin at the base of the penis and coronal sulcus with single absorbable stitches, assuming its viability, due to the presence of a pedicle with seemingly good vascularization. After the procedure, a 10 Fr Foley catheter was administered for bladder drainage, and a light pressure dressing was applied to the penis and the scrotum. On admission to the Surgery Unit, due to the increased risk of infection from the potential contamination of the wound, the patient received broad-spectrum prophylactic antibiotic therapy of cefuroxime and metronidazole, and an additional dose of tetanus toxoid.

After the surgery, diuresis through the catheter was maintained, and the urine was clear. The patient took antibiotics for 12 days and had his dressings changed daily, using Prontosan Gel, Atrauman Ag, and sterile swab. During the healing process, slight swelling on the top of the prepuce and focal necrosis only along the suture line was observed, with no signs of further disruption of the graft’s viability or inflammation, and no urethral dysfunctions appeared (Figure 3). There was no fever or reports of spontaneous discomfort or pain requiring analgesics. Twelve days after surgery, the catheter was removed from the bladder, with good urethral diuresis. Due to the satisfactory healing of the graft, with no signs of the progression of the necrosis, after 17 days of hospitalization, the patient was discharged home with recommendations for lubricating the penis and scrotum with an ointment and continuing to cleanse the area with Prontosan gel (Figure 4).

Six months later, the patient came to the follow-up visit to review the long-term consequences of the accident. He had returned to primary mobility and function, as well as a satisfactory esthetic cosmetic effect (Figure 5). Despite the positive outcome, since the patient is still growing, it is required to continue monitoring to assess potential long-term complications, such as scarring, disrupted penile growth, and erectile dysfunction.

Discussion

External genital trauma, especially in the pediatric population, is a very rare presentation, making up 0.6% of all injuries in this group, and is not often reported in the medical literature [6]. Reports on genital trauma in children usually focus on those related to sexual abuse, with few mentions on the role of accidental injuries [2,5,12]. Most genital trauma in children is caused in the mechanism of a blunt injury (90%), which is usually manifested as lacerations (43%), followed by abrasions and contusions (42%) [6]. Common causes of pediatric penile injury are iatrogenic circumcision, which is responsible for approximately 63% of the reported cases, domestic animal attack, motor vehicle accidents, or injuries associated with consumer products, such as clothing, toilet seats, and bicycles [5,6]. Due to the lack of data in this field, no standard approach has been established for such injuries, and every case should be considered individually [13].

Because of the mobility and protection by the anatomical position of the male external genitalia, this region is less prone to get injured, despite the external location that would potentially increase the risk of trauma from an external force. Among all of the reported cases, skin avulsions are extremely rare, and most of them mainly affect the penis. Cases of total penoscrotal degloving injury have not been reported [7]. The skin shaft of the penis is elastic and mobile, loosed up on its full length, and fixated to the Buck’s fascia only in the area of the coronal sulcus and glans. This loose attachment to the underlying tissue predisposes the skin of the penis to be avulsed easily. Usually, the avulsed segment of the skin is separated at the corona, leaving the glans intact, and follows Dartos fascia and superficial fascia of the penis, with its sub-cutaneous veins. In this type of injury, the lesion is usually limited to the skin, with minimal bleeding. Deep erectile tissues are rarely affected, because the Buck’s fascia that surrounds the corpora cavernosa, corpus spongiosum, urethra, dorsal artery, deep dorsal vein, and nerve is preserved. Due to the fact that the external spermatic fascia is an extension of the superficial fascia of the penis on the scrotum, the detachment of the skin shaft can also involve the anterior half of the scrotal skin [3,4,7].

Even though degloving injuries are usually not life-threatening, they have to be treated immediately. Prolonged exposure of a denuded penis and scrotum can lead to serious complications, such as secondary infection or vascular damage [14]. The surgical procedure should be radical enough to restore the natural anatomical relation but not too radical, to maintain optimal functioning of the organ [3,14,15]. After the surgical procedure, the most frequent complications are postoperative infection, partial graft loss, formation of a fistula, curvature, and erectile dysfunction [14]. Approach to the management of such injuries can differ depending on the extent of injury, availability of viable tissue, and the patient’s condition. In the literature, there is a recommendation to use, if possible, the least injured remaining skin to cover the wound [16]. The aim of the operation is to remove the necrotic, soiled tissue and preserve the viable skin for primary closure of the wound. The use of a patient’s avulsed skin for the reconstruction provides no delay in treatment, faster healing, and relatively the best cosmetic outcome, with minimal scarring [17]. Due to the abundant vascularization of the penis and the potential serious contamination, some authors advocate the use of skin grafts, usually full-thickness skin grafts, along with antibiotic treatment over the replantation of the avulsed skin [3,16]. Due to its functional and esthetic value, a full-thickness skin graft is a preferable method over other grafts in reconstruction of penile skin. Compared with split-thickness skin graft, a full-thickness skin graft is more elastic and less prone to trauma, which minimizes the potential risk of contracture or voiding and erectile disruption. However, it is also difficult to harvest, and the graft survival in the full-thickness skin graft is lower than that of other techniques [17]. Taking into consideration the age of the patient and presence of intact avulsed skin, we chose replantation as the preferable method in this case because of the elasticity of the penile skin and less scaring, compared with a skin graft, which can result in contracture that restricts the mobility, function, and growth of the penis. The exposed tissues were covered with avulsed penile skin that had been debrided from any contaminants and necrotic tissue and was attached with single stitches. The results of the replantation were satisfactory, and the patient was discharged 17 days after the procedure, with no complications or functional impairment. The use of the avulsed skin to cover the penile shaft also contributed to a better cosmetic outcome, which plays a significant role in this case. Restoration of the functions and as natural as possible appearance of the external genitals is crucial when it comes to pediatric patients, because any distortions or urination and erection disorders due to incorrect treatment can cause severe psychological damage, especially in puberty.

Inappropriate treatment of a peno-scrotal injury in childhood could have had enormous influence on the patient’s life and his puberty process. Satisfaction with genital appearance is correlated with psychosexual development. The perception of genital appearance greatly influences individual self-esteem and self-perceived sexual attractiveness, regardless of patient sex and sexual orientation [11]. Complications of inadequate treatment can be an abnormal erection, shortening due the contracture of the penis and residual curvature, which can lead to embarrassment, lower self-esteem, inhibition in entering into sexual relationships, depressive states and even suicidal thoughts, as well as many other behavioral or sociological problems. Although our patient showed no signs of psychological distress related to the injury, we cannot exclude the necessity of psychological help in the future. Therefore, continued assessment of physical and psychological functioning, especially in patients treated before puberty, is crucial to achieve long-term full recovery. We must remember to look at the patient holistically and make every effort to return the patient to complete health if possible. That is why immediate and correct treatment is so important.

Conclusions

We conclude that appropriate treatment of peno-scrotal skin degloving injuries in the acute setting can lead to full recovery. While this outcome was successful, we also need to remember that each case can differ depending on the extent of injury, availability of viable tissue, and the patient’s condition at the time of treatment. The most important actions to take are proper transport of amputated skin shaft in 0.9% saline, a thorough review of the injured area, and a very precise debridement of the wound from necrotic tissue; also, psychological support should be provided. Surgical repair undertaken immediately, combined with adjusted aftercare, can leave patients with efficient erectile and micturition functions. It is important to remember that long-term outcomes (beyond 6 months of follow-up) could present challenges, such as scarring or erectile dysfunction and resulting psychological problems, especially as the patient grows and enters puberty. Monitoring the patient until adolescence is necessary to assess sustained function and cosmetic outcomes exquisitely. We believe that this case report can contribute to the creation of a broader database on such rare injuries as penile degloving, which could serve as a source for the development of more structured guidelines for such cases for future clinical practice.