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Case Report

Degloving injury to the penis

Raj K. Mathur, Brajesh K. Lahoti, Gaurav Aggarwal, Bhaskar Satsangi

use of a local flap or graft (taking into account his age).

ABSTRACT
The exposed penile shaft was regloved with the same
A case of reconstruction after penile skin avulsion is penile skin whilst, keeping the vascular pedicle as the
described in an eight-year-old boy. Penile coverage base for reconstruction [Figure 3]. Sutures used were
was gained by use of the avulsed skin flap itself, without of a fine calibre and absorbable variety, and interrupted
a graft or local tissue flap. The procedure avoids any suturing technique was used. Hitching sutures were
valuable time delay; thus, enhancing the chances to
also taken along the penile shaft to ensure adequate
obtain adequate flap viability, avoids patient discomfort
caused by perineal expansion, gives a satisfactory approximation with the avulsed skin. After penile shaft
cosmetic appearance, and taking into account his coverage, an intraoperative decision of constructing
age, avoids future psychosomatic and psychosexual a neoprepuce, using the redundant skin, was taken
problems. and subsequently the patient was catheterised with
a 10 French Foleys catheter. The immediate results
Key words: Avulsion injury penis, dog bite, no graft or were excellent and adequate cosmesis was achieved
flap [Figure 4]. His postoperative period was uneventful,
PMID: ******* DOI: 10.4103/0189-6725.59354
with vasodilators and antibiotics being the mainstay of
therapy. He was subsequently discharged on his sixth
postoperative day after catheter removal. Six month
INTRODUCTION follow-up revealed a normal appearing penis with no
phimosis or skin necrosis [Figure 5].
Avulsions or degloving injuries of the penile and scrotal
skin are rare urology emergencies and occur mainly due
DISCUSSION
to accidents with industrial machines and agricultural
machine belts.[1] Such lesions are incapacitating and have
The penis is particularly susceptible to avulsion
a devastating psychological impact.[1] Avulsions may
injuries. The overlying skin of the penis is loose and
vary from simple lacerations to virtual emasculations.[2] elastic. The penile skin must be highly mobile to
Generally, lesions reach only the skin, causing minimal accommodate both the rigid and flaccid state of the
bleeding without producing damage to the cavernous penis. This loose base predisposes the skin to be ripped
body, the spongy body or the testes.[1,2] off easily from the penis.

CASE REPORT Penile soft tissue injuries can result through multiple
mechanisms, namely infection, burns, human or
An eight-year-old boy presented with a degloving animal bites, and degloving injuries that involve
injury of his penile skin, following a dog bite, nearly machinery. Although not life threatening, such lesions
eight hours ago. The entire penile shaft was exposed, are incapacitating and psychologically devastating. [1]
with penile skin dangling from the glans via a thin Avulsions vary from simple lacerations to virtual
vascular pedicle [Figures 1,2]. Without further ado, he emasculations.[2]
was taken to the operation theatre, where under spinal
anaesthesia, a primary repair was done without the Examination of the penis reveals soft tissue loss.
Those who have undergone laceration secondary to a
Department of Surgery, 1Division of Paediatric Surgery, MGM Medical human or animal bite, usually present late because of
College and MYH Group of Hospitals, Indore, Madhya Pradesh-452 embarrassment of the injury. This results in increased
001, India risk for infection, which may be seen in the form
Address for correspondence: of abscess, cellulitis, or tissue necrosis; and further
Dr. Raj K. Mathur, worsens the postoperative prognosis.
Department of Surgery, MGM Medical College and
MYH Group of Hospitals, Indore, Madhya Pradesh-452 001, India.
E-mail: [email protected] The anatomy of the penis and scrotum accounts for the

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Mathur, et al.: Degloving injury to the penis

Figure 1: Preoperative photographs revealing the avulsed penile skin Figure 2: Preoperative photographs revealing the avulsed penile skin
dangling from the edge of the glans dangling from the edge of the glans

Figure 3: Postoperative photographs demonstrating the regloved penis Figure 4: Postoperative photographs demonstrating the regloved penis
with adequate skin viability with adequate skin viability

that surrounds it. The avulsed segment of the skin

from the penis includes the loose areolar tissue with
its subcutaneous veins, the dartos fascia, and the skin
as a unit. Because the Buck’s fascia is preserved, the
corpora cavernosa and corpus spongiosum, including
the urethra, are spared, as are the deep dorsal vein and
dorsal artery, and nerve. The avulsion injury travels
along the level of the areolar tissue on the underside
of the penis, because the Colles’ fascia is included in
the scrotum, and this most probably pulls the anterior
half of the scrotal skin. Testicular sparing is the rule
with this injury, and the cremasteric reflex has been
implicated as a cause.[3] In traditional treatment, after
cleaning and debridement of devitalised tissues, the
Figure 5: Postoperative follow-up: at 6 months
exposed tissues are covered with viable flaps from
reproducible nature of this injury. The skin of the penile the remaining skin. When there is no available skin,
shaft is loosed up to an area just behind the coronal penile burial in the scrotum or in the suprapubic
sulcus. The glans penis is essentially fixed in position. region is performed. The use of posterior scrotal skin
The natural cleavage plane along the shaft of the penis for primary closure of the scrotum is also supported by
is between the Buck’s fascia and the loose areolar tissue Finical and Arnold.[1] Posterior scrotal skin can usually

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Mathur, et al.: Degloving injury to the penis

be stretched to cover the defect and any subsequent antibiotics similar to those used in animal bites, despite
defect from the expansion of the posterior scrotal skin, the fact that bacterial cultures may differ.
to cover the injured area, can be skin-grafted anteriorly.
When scrotal remnants are available, the results are Surgical repair of soft tissue loss to the penis should
optimal as far as size, cosmetics, and function measured be undertaken quickly. Prolonged exposure of the
by sperm count, are concerned.[2] Other techniques, denuded penis increases the risk of secondary infection
such as banking of the testicles in the inner thighs or as well as significantly compromise the vascularity.
reconstruction of the scrotum by tissue expansion, as The most frequent complication of avulsion injuries
described by Still and Goodman,[4] bear the disadvantage is postoperative infection. If the graft does not take in
of time delay. Conley[5] has recognised the disadvantages patients who undergo split-thickness skin grafting, the
that accompany multistage operations, namely, the consequences can be devastating and complications
negative psychological effects experienced by the such as erectile dysfunction, curvature, and fistula are
patient of losing his sexual apparatus. associated risks.

Industrial machines, such as pulleys, chains and rotary Thus, the crux lies in considering the fact that in
discs, are responsible for genital injury, when they young children, taking into account the age, better
snag the operators’ clothes and pull out the skin of vascularity, negligible disadvantages and in order to
the penis. Although, not common, this kind of injury avoid future psychological problems, a single attempt
occurs occasionally; particularly in the farm industry. at penile reconstruction without a graft or a flap can
Mechanised farming is involved in a majority of these be attempted.
injuries. In 1958, Kubacek presented the first case report
of this type of injury.[6] REFERENCES

Bite injuries to the penis require extra care, as they have 1. Finical SJ, Arnold PG. Care of the degloved penis and scrotum: a
the potential for infection with unique organisms. Dog 25-year experience. Plast Reconstr Surg 1999;104:2074-8.
2. Gencosmanoglu R, Bilkay U, Alper M, Gurler T, Cagdas A. Late
bites, the most common animal bite, consist of multiple
results of split-grafted penoscrotal avulsion injuries. J Trauma
pathogens such as Staphylococcus and Streptococcus 1995;39:1201-3.
species, Escherichia coli, and Pasteurella multocida. 3. Qiang Fu. Repair of necrosis and defects of penile skin with
Antibiotic treatment should generally include oral autologous free skin ß ap. Asian J Androl 2006;8:741-4.
dicloxacillin or cephalexin. Patients with possible 4. Still EF 2nd, Goodman RC. Total reconstruction of a two compartment
scrotum by tissue expansion. Plast Reconstr Surg 1990;85:805-7.
Pasteurella resistance can be treated with penicillin V. 5. Conley JJ. A one-stage operation for the repair of the denuded penis
In addition, chloramphenicol has also shown to have and testicles. N Y State J Med 1956;56:30146.
good efficacy. 6. Kubacek V. Complete avulsion of skin of penis and scrotum. Br J
Plast Surg 1958;10:25..
Human bites are considered infected by definition
and should not be closed. They can be treated with Source of Support: Nil, Conflict of Interest: None.

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