1 Background

Traumatic amputation of the phallus is a rare form of injury that can result in varying degrees of psychosocial disturbances. Penile injuries are generally uncommon because the penis is enveloped by loose skin, protected by the thighs and buttocks, and highly mobile [1]. The main causes of penile amputations are assault, industrial and automobile accidents, circumcision, animal attacks, and self-mutilation [2]. In children, it is mostly iatrogenic from circumcision, hypospadias surgery, or neonatal surgery for bladder exstrophy [3]. Traumatic amputation from a grinding machine is mostly due to entrapment of the clothes worn by the operators or bystanders. Due to the increase in armed banditry activities in northwestern Nigeria, penile injuries may become more common as a component of other injuries. Amputation injury to the phallus can be partial or complete when both the corpora cavernosa and urethra are transected [2]. Distal penile amputation can be managed by wound closure with wide urethral spatulation. Similarly, microsurgical techniques can be used to reimplant the amputated penis. When a detached penis is not available or microreplantation is not feasible, musculocutaneous phallic reconstruction is an alternative form of treatment [4].

We report two cases of penile amputation managed in the previous year to highlight that this injury is not as uncommon as previously thought and to highlight the danger of grinding machines and increased firearm conflicts in our society. We also reviewed the literature on the treatment of penile amputation injuries.

2 Case presentation

2.1 Patient 1

A 6-year-old boy with no medical or psychiatric history was brought to the accident and emergency department with a 4-day history of complete penile amputation, which he sustained when his clothes were trapped by the belt of a grinding machine; an example of the machine is shown in Fig. 1. There was profuse bleeding from the penile stump with severe pain. There were no other associated injuries. He was initially taken to a secondary health facility, where he received initial resuscitation and stabilization, and the passage of a urethral catheter before being referred to our centre for definitive care. At presentation, he was found to be in pain but was otherwise stable. Examination of the amputated penis revealed a completely transected penis almost flush with the pubis. There were areas of mild bleeding and some were covered by necrotic slough, as shown in Fig. 2A, B. The distal penile stump was said to have been thrown away. A diagnosis of complete penile amputation was made. He had intravenous ceftriaxone for 72 h, analgesics, and 0.5 ml of intramuscular tetanus toxoid. Similarly, He had wound irrigation, and the stump was covered with a crepe bandage. His preoperative urinalysis, blood sugar, electrolytes, urea, and creatinine were normal except for the packed cell volume which was 27% for which he was transfused with 200mls of whole blood intraoperatively. He underwent wound debridement, penile stump refashioning, and meatoplasty as a single stage procedure as shown in Fig. 2C, D.

Fig. 1
figure 1

A grinding machine

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Fig. 2
figure 2

A Patient 1 at Presentation (Anterior View). B Patient 1 at presentation (Lateral View). C and D Patient 1 after refashioning

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2.2 Patient 2

A 25-year-old man was referred to our accident and emergency department from a secondary healthcare facility, 36 h after sustaining penile amputation from a gunshot injury he sustained from a machine gun. He had associated bilateral testicular rupture and open left femoral and right ulnar fractures. He received initial resuscitation and blood transfusion at the referring hospital. At presentation in our facility, he was febrile with a temperature of 38.9 °C. He was in painful distress and had a pulse rate of 120 beats/minute, a blood pressure of 110/80 mmHg, and a respiratory rate of 32 cycles/minute. The penis was amputated at the proximal part and held to the gangrenous glans by the penile skin as shown in Fig. 3A. Similarly, there was a sutured scrotal laceration. The right hand and forearm were gangrenous and foul smelling while on the left thigh, there was a sutured wound on the anteromedial proximal aspect. The thigh was swollen and had abnormal mobility suggesting a fracture. A diagnosis of polytrauma with penile amputation, scrotal injury, open left femoral fracture, and right forearm gangrene secondary to gunshot injury complicated by sepsis was made. He received intravenous 0.9% saline solution (1 L 8 hourly), intravenous ceftriaxone (1 g 8 hourly), and intravenous metronidazole (500 mg 8 hourly). Similarly, he received analgesics, 0.5mls, and 1500 IU of intramuscular tetanus toxoid and anti-tetanus serum, respectively. His laboratory investigations revealed a packed cell volume of 30%, normal renal function tests, two pluses of blood on urinalysis, normal blood glucose, and leucocytosis. He subsequently underwent single-stage genital exploration, wound debridement, penile stump refashioning, and spatulated meatoplasty. Figure 3B, C show the injuries after debridement and refashioning respectively. Similarly, his musculoskeletal injuries were managed by orthopedic surgeons through wound debridement and external fixation of the femoral fracture and above-elbow amputation of the right upper limb. Postoperative, Gentamycin (80 mg 8 hourly) was added to the treatment regimen. However, the patient died 2 days later from overwhelming sepsis with pulmonary embolism as a differential.

Fig. 3
figure 3

A Patient 2 at presentation. B Patient 2 during wound exploration showing the penile stump, gangrenous glans penis, and sutured testicles. C Patient 2 after refashioning

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3 Discussion

Traumatic penile amputation can occur at different levels of the penis. Our first patient presented with a complete penectomy leaving him with a penile stump almost flush with the pubis. In contrast, the second patient had proximal penile shaft amputation with some residual stump. Penile amputation can be accidental, self-inflicted, or iatrogenic such as the overuse of electrocautery during circumcision [5]. In Nigeria, grinding machines are a cause of penile amputation as reported by another author [6]. This usually occurs when loose-fitting clothes are trapped by the belt of the grinding machine Gunshot injury is becoming a major cause of genital injury in northwestern Nigeria due to increased firearm violence. Patients with complete penile amputation may experience bleeding from the penile stump and pain. Bleeding can be significant to warrant blood transfusion, such was the case in our first patient. In the acute setting, the initial step in the management of penile amputation is emergency resuscitation and stabilization of the patient [4]. This is achieved through adequate fluid resuscitation and blood transfusion if blood loss is substantial. Similarly, the patient should receive adequate analgesia and an attempt should be made to pass a urethral catheter through the penile stump. However, this may be difficult, and in such situations, suprapubic cystostomy is an alternative approach. Bleeding from the penile stump can be controlled by using a Penrose drain tied around it, while in the absence of a stump, a pressure dressing may suffice [7]. Potentially contaminated wounds should be generously irrigated with saline and managed with broad-spectrum antibiotics. Additionally, tetanus prophylaxis should be instituted especially if the patient is not fully immunized or his tetanus immunization status is unknown. Penile injuries are graded according to the American Association for the Surgery of Trauma (AAST) with penectomy corresponding to Grade V injury [2]. If recovered, the distal stump should be rinsed with saline or sterile running water, wrapped in moist gauze, and put in a sterile bag which in turn should be placed on ice slush [4, 7]. The definitive management of penile amputation depends on the mechanism of trauma, site of amputation, duration of trauma, availability of the distal stump, and surgical expertise. The primary treatment is replantation and irrespective of the technique employed, the aims are to preserve penile length and maintain erectile and voiding functions [8]. Successful penile replantation depends on the level of amputation, the type and severity of injury (incision vs. crush injury), the ischemia time, and the expertise of a microsurgeon [5]. A properly preserved distal stump can be reimplanted up to 23 h postamputation [9]. Microvascular anastomosis is the preferred method of penile replantation. However, when this expertise is unavailable, macrovascular or corporal reattachment techniques can be employed at the expense of greater failure rate and skin necrosis [9]. Furthermore, complications such as glans necrosis, urethral stricture, urethral fistula, poor sensation, and erectile dysfunction are more common with macrovascular techniques [7]. When the distal stump is not available or when it is not suitable for replantation, treatment options include refashioning of the penile stump and performing a meatoplasty or phallic reconstruction if the stump length is not adequate for sexual satisfaction. There are several techniques for penile reconstruction when the stump is inadequate, and these mainly involve microvascular transfer of myocutaneous flaps, such as radial forearm flap, fibular flap, latissimus dorsi flap, and extended pedicle island groin flap [3]. However, they produce unpleasant donor-site scars, and the neophallus constructed has no erectile function; hence, prosthesis implantation is needed [3]. Another viable option for management is penile allotransplantation, as reported by Van der Merwe et al. [10]. The drawback of transplantation is the need for immunosuppressive therapy which has side effects. Finally, gender reassignment to a female has been used for young children with complete penile amputation. However, there is a risk of sex dysphoria and the possibility of requiring sex reversal later in life [3]. Penile amputation from a grinding machine can be prevented by limiting children’s access to the machines and avoiding wearing loose-fitted clothes when working or coming close to the grinding machines. Similarly, civilian firearm conflicts can be prevented through the provision of jobs and the improvement of the quality of life of the citizens. The limitation of this case series is the lack of long-term follow-up to assess patient satisfaction.

4 Conclusion

Penile amputation is a devastating injury with a negative effect on the quality of life. Grinding machines and firearms are some of the causes of penile amputation. Late presentation and lack of microvascular expertise usually lead to the loss of the amputated segment of the penis. When the distal stump or microvascular expertise is unavailable, penile stump refashioning is a viable treatment option in the emergency setting.