P Garg, S Verma, S Mittal, P Rohilla
accidental, avulsion, bilateral testes, complete, penoscrotum
P Garg, S Verma, S Mittal, P Rohilla. Accidental Complete Avulsion Of Penoscrotum And Bilateral Testes: A Misery Of Illiteracy. The Internet Journal of Urology. 2012 Volume 9 Number 4.
A 20 years male avulsed the complete penoscrotum while climbing down a pole. This type of injury usually occurs in blasts, assault or penetrating injuries. Treatment should be microsurgical re-implantation of avulsed part if facilities are available, or at least corporal reattachment if such facilities are not available. But in this case as the part avulsed was not available none of the desired options was not possible so a permanent Perineal Urethrostomy was done converting the patient to an Eunuch.
A 20 years old laborer presented to the Accident & Emergency department of this institute with alleged history of accidental injury to penoscrotum while climbing down a pole few hours back. On examination the patient was conscious with a pulse rate of 100 per minute, blood pressure 116/70 mm of Hg and active bleed in the penoscrotal area. A lacerated wound of 5x12 cms size was present below the pubis without any remanant of the penis, scrotum and biletaral testes. The attendants did not bring the avulsed parts. The patient was resuscitated. The wound was explored under local anaesthesia, washed thoroughly and complete haemostasis was achieved. The visible part of bulbar urethra was mobilised and perineal urethrostomy was done with a foley's catheter. Skin flaps were mobilised from both the sides and loose suturing was done over a corrugated drain. The patient was dressed daily for next few days. The post operative period was uneventful. The wound healed well. The drain was removed on the 4th day and the catheter on 11th day. The patient passed urine comfortably. He was advised testosterone supplements and regular dilatation of uretharal meatus. The patient did not report after 1st follow up.
Amputation of penis and scrotum is an uncommon injury1. Modes of injury are mostly penetrating injuries to the genitalia either by sharp weapon or fire arms injury. But the injury may be avulsion injury specially due to clothing like dhoti ( a classical Indian wear of rural males in the form of long, thin, white cloth wrapped around the west ) caught in a revolving machinery . The injury may be self inflicted by a mentally disturbed man, a frustrated wife, a homosexual partner or a victim of sexual harassment by a weapon or a bite2. This may also be done by a Surgeon on patients request as a gender reassignment surgery3. 87% patients have some sort of psychiatric problems2. We could not lay hands on a single case report in the literature of accidental complete amputation of penile shaft and scrotum along with bilateral testes. In modern day practice for such type of injuries microsurgical reimplantation of the amputated part is the standard of care. Amputated part should be well preserved, washed gently with water and placed as quickly as possible in a saline soaked gauze, and that bag is placed in a second bag filled with saline slush for cold preservation. Unlike amputation of the penis where successful reimplantation has been done as long as 18-24 hours after the injury, the testicle must be replanted within 6-8 hours due to very high metabolic rate of testicular tissue4. If facility for microreplantation are not available then penis may be replanted simply by older corporal reattachment technique although microreplantation procedures make for uniformly good results with a minimum of post operative complications. The results of macroscopically replanted penis may be gratifying, skin necrosis is commonly reported5. The survival of penis and its functions depend no doubt on the unique penile vascular system. Cohen et al and Tamai et al reported reimplantation of the penis by microsurgical technique in which the blood vessels and the nerves were also anastomosed6. Erectile function is usually well maintained after recovery, there might be some skin necrosis and loss of sensation but far less than corporal suturing technique. Rare mode of injury and zero concern of the patient or attendants about the avulsed penoscrotum & testes which is largely due to illiteracy in rural India even now have prompted the authors to contribute the case to the literature.