GENITAL TRAUMA DUE TO ANIMAL BITES

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0022-5347/00/1651-0080/0 THE JOURNAL OF UROLOGY® Copyright © 2000 by AMERICAN UROLOGICAL ASSOCIATION, INC.®

Vol. 165, 80 – 83, January 2000 Printed in U.S.A.

GENITAL TRAUMA DUE TO ANIMAL BITES CRISTIANO M. GOMES, LEOPOLDO RIBEIRO-FILHO, AMILCAR M. GIRON, ANUAR I. MITRE, ESTELA R. R. FIGUEIRA AND SAMI ARAP From the Division of Urology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil

ABSTRACT

Purpose: Animal bites to the external genitalia are rare. We retrospectively evaluated our experience with treating genital trauma caused by animal attacks. Materials and Methods: We studied the medical records of 10 patients treated in the surgical emergency department at our hospital who presented with genital injury caused by an animal bite from 1983 to 1999. Special attention was given to the severity of injury, surgical treatment, antibiotic prophylaxis and outcome. Results: Of the 2 men and 8 boys 8 were attacked by dogs, 1 by a horse and 1 by a donkey, respectively. In all cases initial local treatment involved de´bridement and copious wound irrigation with saline and povidone-iodine solution. Five patients who presented with minimal or no skin loss underwent primary skin closure, including 2 in whom urethral lacerations were surgically repaired. There was moderate to extensive tissue loss in 5 patients, including degloving penile injury in 2, traumatic spermatic cord amputation in 1, complete penile and scrotal avulsion in a 5-month-old infant, and partial penectomy in 1. Reconstructive procedures provided satisfactory cosmetic and functional results in 8 cases. Antibiotic prophylaxis was administered in all patients and no infectious complications developed. Conclusions: Animal bite is a rare but potentially severe cause of genital trauma and children are the most common victims. Morbidity is directly associated with the severity of the initial wound. Because patients tend to seek medical care promptly, infectious complications are unusual. Management involves irrigation, de´bridement, antibiotic prophylaxis, and tetanus and rabies immunization as appropriate as well as primary wound closure or surgical reconstruction. Good functional and cosmetic results are possible in the majority of cases. KEY WORDS: penis, scrotum, bites and stings, wounds and injuries, antibiotics

pious irrigation of the wound with saline and povidone-iodine solution with de´bridement of devitalized tissue. Reconstructive procedures were performed according to injury severity.

Animal bite injury usually caused by dogs occurs in many countries.1–5 The majority of mammalian bite wounds are minor and victims never seek medical attention.3 Nevertheless, in the United States bite wounds account for approximately 1% of all emergency department visits, of which 60% to 70% involve children.1 Such attacks have the potential to cause significant morbidity, especially in regard to soft tissue injury and infection. Despite these rates genital trauma caused by animal bite is rare with few cases reported in the literature.6 – 8 Thus, urologists are not usually familiar with management principles for treating this condition. We describe our experience with treating 10 patients with genital trauma due to animal bite. To our knowledge this series is the largest on patients treated at a single institution for this type of accident.

RESULTS

Minimal or no skin loss in 5 patients was managed by primary skin closure in 4 and conservative treatment in 1 with a puncture wound. Skin loss was significant in 5 patients, including a 5-month-old boy with penile amputation, and complete testicular and scrotal avulsion (fig. 1). Primary surgical reconstruction consisted of perineal urethrostomy and skin closure. In a 1-year-old boy partial traumatic penile amputation and significant shortening of the penile shaft skin loss did not preclude primary reconstruction (fig. 2). A horse bite in 1 case caused amputation of the left spermatic cord and significant scrotal skin loss but no trauma to the penis (fig. 3). Treatment involved surgical ligation of the spermatic cord and primary skin closure. Degloving penile injury in 2 patients was managed by a scrotal skin flap in 1 with good functional and cosmetic results, and in the other the inner prepuce was advanced and sutured to the base to cover the penile shaft (fig. 4, A and B). There was associated urethral injury in 4 patients, including those with complete and partial penile amputation. Treatment consisted of de´bridement of the urethral wound margins, primary closure with absorbable suture and urethral catheterization. An additional corpus cavernosum lesion in 1 case was treated with de´bridement of the lacerated margins and approximation with interrupted absorbable 2-zero polyglycolic acid sutures. Traumatic orchiectomy in 2 patients was due to complete amputation of the external

MATERIALS AND METHODS

We retrospectively evaluated the medical records of 10 male patients 5 months to 46 years old (median age 8) with genital animal bites treated at the surgical emergency department at our hospital from October 1983 to September 1999. Records were reviewed with special attention to the severity of injury, time from injury to medical assistance, local wound care, antimicrobial prophylaxis, surgical reconstruction and outcome. Of the 10 patients 9 sought medical care within 6 hours after injury (range 1.5 to 48, median 4), while 1 presented to the emergency department 48 hours after the accident without previous treatment. Injury was caused by dogs, a horse and a donkey in 8, 1 and 1 cases, respectively. In all cases initial local treatment involved coAccepted for publication August 18, 2000. 80

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GENITAL TRAUMA DUE TO ANIMAL BITES

FIG. 1. Patient 10. Late postoperative appearance of complete penile amputation and scrotal avulsion after primary wound closure and perineal urethrostomy.

FIG. 3. Patient 8. Traumatic amputation of left spermatic cord and significant scrotal skin loss caused by horse bite.

patients and combined with ampicillin in 3. Cephalexin was given in 1 case. The course was uneventful in 6 patients. Scarring and a suboptimal cosmetic result developed in 1 patient with a degloving penile injury but the family refused additional treatment (fig. 4, C). Meatal stenosis and retraction to a ventral position in a case of urethral injury required distal urethroplasty. In another case of urethral injury a urethrocutaneous fistula was successfully repaired. Decision making on reconstruction of the 5-month-old infant with complete amputation of the external genitalia was challenging. After psychological evaluation of the patient and family he underwent a surgical procedure for feminization of the genitalia 1 year after trauma. None of the patients had infectious complications. The table shows clinical data. DISCUSSION

FIG. 2. Patient 9. Late outcome after partial penectomy due to dog bite.

genitalia in 1 and amputation of the left spermatic cord due to horse bite in 1 (fig. 3). Management included primary closure and implantation of a testicular prosthesis 3 months after trauma. All patients in our series received antibiotics for a minimum of 10 days. Chloramphenicol was the most commonly prescribed antimicrobial, which was administered alone in 6

Animal bites are a common cause of emergency room admission and children are the most common victims.1, 2, 5 In the United States bites account for 800,000 injuries yearly requiring medical attention and it is estimated that 1 of 2 Americans is bitten by an animal or person in their lifetime.1–3 Despite these rates genital trauma due to animal bite is rare. In the largest series in the literature Wolf et al presented 4 new cases of dog bite and reviewed 4 previously reported cases.7 Cummings and Boullier reported on 8 patients treated for dog bite of the scrotum.8 Applying general therapeutic principles of animal bites and knowledge of genital trauma are necessary for the management of such injury.6, 7, 9 –11 De´bridement of devitalized tissue, and wound irrigation with saline and antiseptic solutions are the cornerstones of therapy. When there is no infection, wounds may be safely sutured closed.7 Depending on the type of injury various reconstructive procedures may be necessary, including skin grafts or flaps.6, 7, 10 In our series 5 patients had significant tissue loss, including a 5-month-old infant with penile amputation, and complete testicular and scrotal avulsion. Due to the severity of

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GENITAL TRAUMA DUE TO ANIMAL BITES

FIG. 4. Patient 7. A, degloving injury to penis after dog bite. B, immediate postoperative penile appearance after suturing inner preputial margin to penile base skin. C, late outcome with poor cosmetic result despite good functional status.

Clinical data on patients with genital trauma due to animal bite Pt. No. — Age

Animal

Hrs. From Trauma to Emergency Room

Injury Severity

Antibiotics

Glans ⫹ urethral meatus laceration Penile puncture wound ⫹ hematoma Penile degloving preserving internal preputial layer Penile laceration proximal to frenulum involving corpus spongiosum, urethra ⫹ corpus cavernosum Min. penile laceration Mid third penile laceration involving corpus spongiosum ⫹ urethra Penile degloving from base

Chloramphenicol

Primary closure

Uneventful

Chloramphenicol

Conservative treatment

Uneventful

Chloramphenicol

Internal preputial layer mobilization ⫹ scrotal skin flap Primary repair of urethral ⫹ associated injuries

Uneventful

Chloramphenicol Chloramphenicol ⫹ ampicillin

Skin closure Urethral ⫹ primary skin closure

Cephalexin

Inner preputial layer sutured to penile base skin Spermatic cord ligation ⫹ primary skin closure

Uneventful Urethrocutaneous fistula repaired after 4 mos. Suboptimal cosmesis due to scarring Uneventful ⫹ testis prosthesis insertion after 3 mos. Uneventful

1 — 8 Yrs.

Dog

3

2 — 5 Yrs.

Dog

48

3 — 13 Yrs.

Dog

2

4 — 46 Yrs.

Dog

6

5 — 7 Yrs. 6 — 10 Yrs.

Donkey Dog

6 4

7 — 8 Yrs.

Dog

4

8 — 35 Yrs.

Horse

1.5

Lt. spermatic cord ⫹ testis amputation, ⫹ moderate scrotal skin loss

Chloramphenicol ⫹ ampicillin

9 — 1 Yrs.

Dog

2

Partial penile amputation

Chloramphenicol ⫹ ampicillin

10 — 5 Mos.

Dog

6

Complete avulsion of penis, scrotum ⫹ contents

Chloramphenicol ⫹ ampicillin

injury and patient age de´bridement and primary wound closure were performed. A year later after psychological evaluation of the patient and family he underwent a surgical procedure for genital feminization, which may potentially provide better cosmetic and functional results. A 1-year-old boy experienced partial traumatic penile amputation with significant shortening of the penile shaft. Degloving penile injury in 2 cases was managed by a scrotal skin flap in 1 with good functional and cosmetic results, and by primary skin suture of the inner preputial border to the penile base in 1 with poor cosmetic results. As recommended by others,6, 7, 10 a split-thickness graft obtained from the thigh or abdomen may have been more appropriate in this case with better cosmetic and functional results.6, 7, 10 Outcome was poor in the 2 patients in our series presenting with partial urethral injury, including 1 with a urethrocutaneous fistula, and 1 with meatal stenosis and retraction. It is possible that urethral injury in the setting of an animal bite causes a higher risk of complications because of tissue destruction and contamination. More liberal de´bridement may be warranted in these injuries. The administration and choice of antibiotics for treating

Chloramphenicol

Surgical Treatment

Corpora cavernosa ⫹ urethra trimming ⫹ primary skin closure as in final step of formal partial penectomy Bilat. spermatic cord ligation, perineal urethrostomy ⫹ primary closure

Followup

Meatal stenosis ⫹ retraction

Feminizing genitoplasty 1 yr. after trauma

patients with animal bite remain controversial.9, 11–15 Even when properly de´brided and irrigated, animal bites may harbor potential pathogens. Talan et al recently reported a prospective multicenter study on the bacteriology of infected dog and cat bites.16 Pasteurella species was the most common isolate, followed by anaerobic organisms. Staphylococcus aureus and Streptococcus pyogenes, which are typical agents of cutaneous infection not associated with bites, were relatively rare. Based on the microflora of canine oral cavity and isolates obtained from bite wounds the first choice for prophylaxis after dog bite should be amoxicillin with a ␤-lactamase inhibitor.9, 11, 16 Whether antibiotic prophylaxis prevents infection after bites also remains controversial.11, 13, 14 The meta-analysis of Cummings of 8 randomized studies indicated that prophylactic antibiotics decrease the incidence of infection in patients with dog bite wounds but the complete costs and benefits of antibiotics in this situation are not known.14 Antibiotic prophylaxis is usually indicated when there are risk factors for infection, such as injury affecting the extremities or articulations, puncture wounds and patients who are elderly, diabetic, immunocompromised or have a prosthesis.11, 15

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GENITAL TRAUMA DUE TO ANIMAL BITES

Goldstein also considered genital area wounds an indication for prophylactic antibiotics.11 Although there is still no consensus on the impact of prophylaxis, antibiotic administration seems to be justified in patients with genital injury due to the high morbidity that an infection in this area may cause as well as the good results achieved to date by this approach.7 Antimicrobial prophylaxis was administered in all patients in our series for a minimum of 10 days. Chloramphenicol (50 mg./kg. daily) was given alone in 6 patients and combined with ampicillin in 3, while 1 received cephalexin. None of the patients had infectious complications. Chloramphenicol is an effective, readily available and inexpensive broad-spectrum antibiotic used as first line therapy for infection in many parts of the world.17–20 Because it is associated with bone marrow suppression and aplastic anemia, it is considered alternative therapy for special conditions in the United States and other developed countries.19 Chloramphenicol is extremely active against the majority of pathogens that are most commonly isolated from bite wounds, including anaerobic bacteria and Pasteurella species.19 –21 Based on its spectrum and our results we believe that chloramphenicol may be a good alternative for the prophylaxis of this specific type of lesion in countries where this medication is liberally used. The interval from genital injury to initial treatment is important for outcome since it seems to correlate directly with the infection rate.12 Of the 10 patients treated at our department only 1 presented more than 6 hours after trauma at 48 hours. This patient had only superficial wounds. The course was satisfactory in all cases in terms of infectious complications, which reinforces the importance of early treatment to ensure a low incidence of these complications. Several systemic diseases may be transmitted via dog bite. Tetanus and rabies are the most serious conditions and prophylaxis is fundamental when clinically indicated.9, 11, 22, 23 Tetanus immunoglobulin and tetanus toxoid should be administered to patients with 2 or fewer primary immunizations. Tetanus toxoid only should be given to those who previously completed the primary immunization series but who have not received a booster for more than 5 years.9 For rabies prophylaxis it is important to observe animal behavior for at least 10 days. If the animal becomes aggressive or erratic, it should be sacrificed and microscopic study of the brain should be performed for typical rabies pathological alterations. If rabies is confirmed or the aggressor animal is not captured, prophylaxis is indicated. The prophylactic regimen consists of a series of 5 doses of human rabies vaccine associated with 20 IU/kg. of rabies immunoglobulin.9, 23 Children are the most common victims of animal bites1 and 8 of our patients were younger than 14 years. The possibility of neglect or abuse should always be considered, and social and law enforcement authorities should be notified in suspicious cases.6 CONCLUSIONS

Although rare, genital trauma caused by animal bite is a potentially severe condition with distinctive characteristics of which urologists should be knowledgeable. Irrigation and de´bridement of devitalized tissue are the basis of treatment and they should always be performed. Primary closure is possible in most cases and usually achieves good functional and cosmetic results. Empirical antibiotic prophylaxis is recommended in all cases based on the flora commonly present

in animal bite wounds. Systemic diseases potentially transmitted by animals must be considered and prophylaxis should be administered accordingly.

REFERENCES

1. Weiss, H. B., Friedman, D. I. and Coben, J. H.: Incidence of dog bite injuries treated in emergency departments. JAMA, 279: 51, 1998 2. Sacks, J. J., Kresnow, M. and Houston, B.: Dog bites: how big a problem? Inj Prev, 2: 52, 1996 3. Griego, R. D., Rosen, T., Orengo, I. F. et al: Dog, cat, and human bites: a review. J Am Acad Dermatol, 33: 1019, 1995 4. Matter, H. C.: The epidemiology of bite and scratch injuries by vertebrate animals in Switzerland. Sentinella Arbeitsgemeinschaft. Eur J Epidemiol, 14: 483, 1998 5. Chomel, B. B. and Trotignon, J.: Epidemiologic surveys of dog and cat bites in the Lyon area, France. Eur J Epidemiol, 8: 619, 1992 6. Donovan, J. F. and Kaplan, W. E.: The therapy of genital trauma by dog bite. J Urol, 141: 1163, 1989 7. Wolf, J. S., Jr., Turzan, C., Cattolica, E. V. et al: Dog bites to the male genitalia: characteristics, management and comparison with human bites. J Urol, 149: 286, 1993 8. Cummings, J. M. and Boullier, J. A.: Scrotal dog bites. J Urol, 164: 57, 2000 9. Fleisher, G. R.: The management of bite wounds. New Engl J Med, 340: 138, 1999 10. McAninch, J. W.: Management of genital skin loss. Urol Clin North Am, 16: 387, 1989 11. Goldstein, E. J. C.: Bites. In: Principles and Practice of Infectious Diseases. Edited by G. L. Mandell, J. E. Bennett and R. Dolin. Philadelphia: Churchill Livingstone, p. 3202, 2000 12. Brakenbury, P. H. and Muwanga, C.: A comparative double blind study of amoxycillin/clavulanate vs placebo in the prevention of infection after animal bites. Arch Emerg Med, 6: 251, 1989 13. Callaham, M.: Controversies in antibiotic choices for bite wounds. Ann Emerg Med, 17: 1321, 1988 14. Cummings, P.: Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med, 23: 535, 1994 15. Morgan, M. S.: Prophylaxis should be considered even for trivial animal bites. BMJ, 314: 1413, 1997 16. Talan, D. A., Citron, D. M., Abrahamian, F. M. et al: Bacteriologic analysis of infected dog and cat bites. New Engl J Med, 340: 85, 1999 17. Mulhall, A., Berry, D. J. and de Louvois, J.: Chloramphenicol in paediatrics: current prescribing practice and the need to monitor. Eur J Pediatr, 147: 574, 1988 18. Smyth, E. G. and Pallett, A. P.: Clinicians’ guide to antibiotics. Chloramphenicol Br J Hosp Med, 39: 424, 1988 19. Standiford, H. C.: Tetracyclines and chloramphenicol. In: Principles and Practice of Infectious Diseases. Edited by G. L. Mandell, J. E. Bennett and R. Dolin, Philadelphia: Churchill Livingstone, chapt. 24, p. 336, 2000 20. Kucers, A.: Chloranphenicol and thiamphenicol. In: The Use of Antibiotics: A Clinical Review of Antibacterial, Antifungal and Antiviral Drugs. Edited by A. Kucers, S. M. Crowe, M. L. Grayson et al. Oxford: Butterworth-Heinemann, p. 548, 1997 21. Gaillot, O., Guilbert, L., Maruejouls, C. et al: In-vitro susceptibility to thirteen antibiotics of Pasteurella spp. and related bacteria isolated from humans. J Antimicrob Chemother, 36: 878, 1995 22. Presutti, R. J.: Bite wounds. Early treatment and prophylaxis against infectious complications. Postgrad Med, 101: 243, 1997 23. Dreesen, D. W. and Hanlon, C. A.: Current recommendations for the prophylaxis and treatment of rabies. Drugs, 56: 801, 1998

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