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We report the case of a child with delayed presentation of partial amputation of the penis with complete transaction of the urethra following a self-inflicted constrictive band injury. Single-stage reconstruction of the urethra and corporae achieved a satisfactory immediate outcome.
A 7-year-old uncircumcised boy from Afghanistan presented to the plastic surgery services in Karachi with partial amputation of the penis sustained 6 months before. A thread tied around the base of the penis by the patient for unknown reasons had caused the injury. His parents had discovered the problem 2 weeks later, and the local doctor had removed the strangulating thread. The acute symptoms, such as pain, swelling and bleeding, settled with medication but he had sustained a partial division of the left corpora cavernosa and complete divisions of the right corpora cavernosa and corpora spongiosum, along with complete transection of the urethra (Fig. 1) .
Figure 1Late presentation of paediatric penile constrictive band injury resulting in subtotal amputation at its base. (A) Dorsal view showing complete division of the right and partial division of the left corpora cavernosa. (B) Right lateral view showing division of the corpus spongiosum. (C) Ventral view showing complete transection of the urethra.
Under general anaesthesia, after insertion of an indwelling urethral catheter, the corpora cavernosa, corpora spongiosum and tunica albuginia were repaired with absorbable sutures. End-to-end urethral anastomosis was performed using 7/0 vicryl interrupted sutures, and the anastomosis was covered by a local flap of subcutaneous tissue for waterproofing. The skin closure was completed with circumferential Z-plasties (Fig. 2) . His recovery was uneventful, and he was able to micturate through the penile urethra with a good stream on removal of the urinary catheter after one week. The appearance of the penis was satisfactory, although the erectile function could not be assessed at 6 months follow-up (Fig. 3) .
Figure 2Intraoperative view showing the indwelling urinary catheter, the urethral and corporal repairs and multiple annular Z-plasties.
Figure 3Postoperative result. (A) Dorsal view showing penile centralisation. (B) Right lateral view during micturition showing a good stream and continuity of the corporal bodies.
Penile fractures, partial amputations and strangulation are uncommon injuries in adults and even more uncommon in children. The commonest causes of these injuries in adults are blunt trauma during sexual intercourse,
To our knowledge, late presentation after the acute symptoms have settled, with complete transection of the urethra and near total amputation of the corporal bodies at the penile base, has never been reported in the literature.
Early removal of the object causing the tourniquet effect is essential. Urinary diversion and surgical exploration and repair of damaged corporae, tunica albuginia and urethra may be required, depending on the severity.
Urethrocutaneous fistulae, urethral strictures, chordae and erectile dysfunction are the usual complications reported after treatment for these injuries.
Owing to the diverse pathology and the variable severity of the injury at presentation, surgical results are not reported uniformly. We have shown a satisfactory outcome at 6 months follow-up after end-to-end anastomosis of the urethra, supported by a waterproofing layer, repair of the corporae and tunica albuginea, and multiple Z-plasties to prevent a constricting annular scar. Long-term follow-up in children and more reports of similar cases are required to formulate a definitive treatment for this problem.
References
Mydlo J.H
Harris C.F
Brown J.G
Blunt, penetrating and ischemic injuries to the penis.
Department of Plastic and Hand Surgery, Baqai Medical University, 51 Deh Tor, Gadap Road, Near Toll Plaza, Super Highway, P.O. Box 2407, Karachi 74600, Pakistan
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