The management of dog bite injuries of genitalia in ...

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Review Article

DOI: 10.4103/0189-6725.120875

The management of dog bite injuries of genitalia in paediatric age

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Mirko Bertozzi, Antonino Appignani

ABSTRACT Dog bite injuries are common in children and represent an important health-care problem. Most dog bite injuries involve the face or an extremity. Victims tend to seek medical care quickly. Dog bites to the external genitalia are rarely reported, but they potentially result in morbidity if improperly managed. Morbidity is also directly related to the severity of initial wound. Guidelines for the management of dog bites include irrigation, débridment, antibiotic therapy, consideration of tetanus and rabies immunisation and suture of wounds or surgical reconstruction. Literature review was conducted and focused to analyze the management of dog bite lesions involving external genitalia. Key words: Children, dog bite, genitalia, management

INTRODUCTION Human injuries due to dog bites are very common and are a major world-wide public health problem. Several systemic diseases may be transmitted via dog bite. Tetanus and rabies are the most serious conditions. Animal bites to external genitalia in children are rare and only few cases are reported in Literature. A review of published data was performed to analyse the management of this kind of lesions. Dog bites are a common form of trauma in the United States with incidence of 12.9/10,000 individuals.[1] 25,0000 people/year bitten by dogs attend minor injuries in the UK[2] with a hospital admission for some of them for surgical intervention or intravenous antibiotics. Department of Pediatric Surgery, S.C. di Clinica Chirurgica Pediatrica, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, Loc. S. Andrea delle Fratte, 06100 Perugia, Italy Address for correspondence: Dr. Mirko Bertozzi, Department of Paediatric Surgery, S.C. di Clinica Chirurgica Pediatrica, Università degli Studi di Perugia, Ospedale S. Maria della Misericordia, Loc. S. Andrea delle Fratte, 06100 Perugia, Italy. E-mail: [email protected]

African Journal of Paediatric Surgery

Children have a 3.2-fold higher bite rate than adults.[3] The annual incidence of bites in children aged under 15 years was 22/100.[4] Therefore, it is surprising that genital dog bites are not a more commonly reported source of morbidity. Dogs are well-known for being attracted to the perineal area not only of other dogs, but other species as well, reason of this attraction might be dog coprophagia.[5] Dogs are attracted to the perineum and genitalia in subjects few dressed, defenceless or immobilised. Interest of dog to the external genitalia is not due to soft-tissue appendage alone and this concept is suggested by reported cases of dog bite to the external genitalia in females.[6] Dog bites to the external genitalia are rarely reported with only 21 cases founded in Literature. [6-14] A schematic and detailed analysis of the paediatric Literature is shown in Table 1. Age of reported cases range from 3 weeks to 13 years and males are more represented than females (9.5:1).

NATURE OF DOG Dog bite lesions to the external genitalia in children, when nature of dog is reported, are produced for the most part by the family dog. For this reason Tuggle et al.,[6] recommend that families with small children and large dogs should never be complacent about mixing the two, even if, the dog is docile and had never shown signs of aggressiveness because six out of seven of the family dogs had attacked the children of his casuistic had “never done it before!” Redman[11] suggests that when a child is injured by a family dog, thought should be given to investigation of the home environment because as reported by Donovan et al.,[9] trauma to the external genitalia should alert the physician to the possibility of abuse or neglect. July-September 2013 / Vol 10 / Issue 3

205

206

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3

1

1

Cummings et al., 2000

Budhiraja et al., 2002 Bertozzi et al., 2009

3

4 years old

1 7

Redman 1995 Gomes et al., 2000

Bothra et al., 2011

9 years old 9 years old 5 years old 5 months old

2

Tuggle et al., 1993

M

M M

M

10 years old

8 years old

1 years old

5 months old

M

M M

9 months old

5 years old

8 years old

M

M M M M

M M M M

F

6 months old

9 years old 8 years old 5 years old 13 years old

F

M

2 years old

3 weeks old

1

M

2 months old

Wolf et al., 1993

M

Sex

6 weeks old

2

Age

Donovan et al., 1989

Cases (ner)

Family dog

Stray dog

Stray dog

Family dog

Unknown Unknown Family dog Stray dog

Family dog Unknown

Family dog

Family dog

Family dog

Family dog

Family dog

Dog

Wound at the root of penis

Amputation of the glan, both testes loss and full thickness avulsion of skin from the ventral shaft of the penis and scrotum Partial avulsion of preputial skin

Resection of right vas deferens

Right testis loss

Scrotal wounds without involvement of intrascrotal contents in all cases

Complete testicular and scrotal avulsion with penile amputation

Partial penile amputation

Avulsion of the external anal sphincter and laceration of the vagina Suspected both testes loss Glans+urethral meatus laceration Penile puncture wound+ematoma Penile degloving preserving internal preputial layer Mid third penile laceration involving corpus spongiosum+urethra Penile degloving from base

External genitalia and anus loss

Both testes loss

Full thickness avulsion of skin from the ventral shaft of the penis and scrotum+left testis loss Amputation of the glans

Injury

Table 1: Dog bites to the external genitalia: an analysis of the paediatric literature

Débridment and primary closure of the wound

Irrigation and circumcision

Irrigation, débridement, primary suturing of the wound Irrigation, débridement + microsurgical vasoepydidimal anastomosis and primary closure of the wound Irrigation, débridement + bilateral ligation af vas. Penil shaft, scotal reconstruction and meatoplasty

Inner preputial layer sutured to penile base skin Corpora cavernosa + urethra trimming + primary skin closure as in the final step of formal partial penectomy Bilateral spermatic cord ligation, perineal urethrostomy + primary closure of the wound Irrigation, débridement, primary suturing of the wound in all cases

Not specified Primary closure Conservative treatment Internal preputial layer mobilization + scrotal skin flap Urethral+primary skin closure

Irrigation, débridement and skin grafting Irrigation, débridement, ligation of spermatic cords and primary suturing of the wound Delayed external anal sphincter and levator ani repair for incontinence Not Specified

Sharp débridement and skin grafting

Surgical procedure

Not specified antibiotics

Not specified antibiotics

Third generation cephalosporin

Ampicillin sodium and sulbactam sodium

Not specified antibiotics

First generation cephalosporine in all cases

Cloramphenicol + ampicillin

Cloramphenicol + ampicillin

Cephalexin

Cloramphenicol + ampicillin

Not specified Cloramphenicol Cloramphenicol Cloramphenicol

Not specified

Not specified

Cefazolin

Not Specified

Antibiotics

Immunization done but not specified Immunization done but not specified

Tetanus and antirabies vaccines

Tetanus prophylaxis, antirabies vaccine None

Tetanus prophylaxis in all cases

Not specified Not specified for all patients

Not specified

Not specified

Not specified

Tetanus prophylaxis

Prophylaxis

Bertozzi and Appignani: Management of genitalia injuries by dog bite

African Journal of Paediatric Surgery

Bertozzi and Appignani: Management of genitalia injuries by dog bite

In this review, 9/21 dog bite are produced by the family dog, in three cases by stray dogs and in the remaining nine cases the nature of dog was unknown.

INJURIES Even if, in literature a large variety of lesions is reported, in the most part of cases, genital injuries due to dog bite are catastrophic. Wolf et al.,[12] report a case of a newborn with the loss of both testes as in case of Redman’s patient. Budhiraja et al.,[7] report a case of loss of right testis. Mild injuries due to dog bites to the external genitalia such as wounds without involvement of scrotal contents are reported by Cummings et al.,[8] in 2000. The most important injuries in males are those described by Donovan et al.,[9] Gomes et al.,[10] and Bothra et al.,[14] Donovan et al., report a full thickness avulsion of skin from the ventral shaft of the penis and scrotum with left testis loss in an infant and an amputation of the glans in another one. Bothra et al.,[14] in one of their three patients describe the amputation of the glans together with both testes lost. The other two patients reported by Bothra et al., have had partial avulsion of the preputial skin and a wound at the root of penis respectively. Gomes et al.,[10] describe a partial penile amputation in a patient and a complete testicular and scrotal avulsion with penile amputation in another one; in the remaining patients of Gomes et al., a laceration of glans and urethral meatus, two penile degloving, a mild third penile laceration involving corpus spongiosum and urethra, and a penile puncture wound with ematoma are reported. Bertozzi et al., describe a 4-year-old male child attacked to the external genitalia by the family dog[13] and producing a traumatic resection of the right testicular vas deferens repaired by microsurgical vasoepididymal anastomosis. The only two females reported in Literature with injuries to the external genitalia due to dog bites are those described by Tuggle et al., in 1993.[6] The cases reported describe severe injuries to the perineal area as loss of external genitalia and anus and avulsion of the external anal sphincter and laceration of vagina.

POTENTIAL DOG BITE PATHOGENS Dog bites may harbour potential pathogens, but only 15-20% of dog bite wounds become infected. African Journal of Paediatric Surgery

Most infected dog bite wounds yield polymicrobial organisms. Pasteurella species was the most common isolate, followed by anaerobic organisms. Pasteurella multocida and Staphylococcus aureus are the most common aerobic organisms, occurring in 20-30% of infected dog bite wounds [15,16] Other possible aerobic pathogens include Streptococcus species, Cor ynebacterium species, Eikenella corrodens and Capnocytophaga canimorsus[15,17,18] Anaerobic organisms, have also been implicated in infected dog bites. (Bacteroides fragilis, Fuso-bacterium species and Veillonella parvula). It is generally accepted that superficial, easily cleaned dog bite wound will not require antibiotics if the patients is otherwise immonocompetent.

Rabies Nowadays the most common source of the rabies virus is wild animals. Nonetheless, there are still reported cases of rabies virus associated with a dog bite.[19] Rabies immunization must be considered when the bite is from a stray dog or in a country where the disease could be endemic.[7,14] In case of dog bite, when possible, observation of the dog for 10 days is advised in all cases, but it is appropriate when the vaccination status of the animal is unknown. During the observation, 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.[20,21] All forms seem to have equivalent safety and efficacy.[21,22] Once the vaccine series has begun, it is usually completed with the same vaccine type. Vaccine is administered on days 0, 3, 7, 14 and 28.

Tetanus Tetanus is a severe systemic disease that can be transmitted through animal bites. Tetanus immunoglobulin and tetanus toxoid should be administered to patients with two or fewer primary immunizations. Tetanus toxoid only should be given to those who previously completed the primary July-September 2013 / Vol 10 / Issue 3

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Bertozzi and Appignani: Management of genitalia injuries by dog bite

immunization series, but who have not received a booster for more than 5 years.[23] All authors of this review talk about these diseases in their published manuscript, nevertheless only five authors specified the choice to administer tetanus prophilaxis and antirabies vaccine or not.[7-9,13,14]

ANTIBIOTIC TREATMENT The risk of wound infection resulting from an uncomplicated dog bite was reported to be 6-29%;[24] this percentage can decrease from 59% to only 12% if good irrigation is performed.[25] The administration and choice of antibiotics are controversial because only a few evidence-based guidelines are available regarding the risk of infection from a dog bite.[20,23,25-27] Cummings 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.[27] Although antibiotics have not been clearly shown to prevent infection after an animal bite, most physicians suggest antibiotic prophylaxis for moderate or severe wounds. Such wounds include bites to the hand, head, neck and genital region. No standard guidelines are available regarding the length of antibiotic therapy. Usually, prophylactic oral therapy is 5-7 days; in the case of established infection, it is 7-14 days. Based on the microflora of canine oral cavity and isolates obtained from bite wounds the first choice for prophylaxis after a dog bite should be amoxicillin with a b-lactamase inhibitor.[20,28,29] For patients who are allergic to penicillin, doxycycline is an acceptable alternative, except for children younger than 8 years and pregnant women. Erythromycin can also be used, but the risk of treatment failure is greater because of antimicrobial resistance.[17,29] Other acceptable combinations include clindamycin and a fluoroquinolone in adults or clindamycin and trimethoprim-sulfamethoxazole in the children.[30] When compliance is a concern, daily intramuscular injections of ceftriaxone are appropriate.[17] In the analysis of the Literature three authors doesn’t specifies the administration of antibiotics for their patients[6,8,11] the remaining six authors used different 208

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antibiotic prophylaxes: Wolf et al.,[12] used cefazolin, but the length of therapy is not reported; Gomes et al.,[10] administrated cloramphenicol in 3 cases, cloramphenicol associated with an ampicillin in other three cases and cephalexin in the last one, all these patients received antibiotics for a minimum of 10 days, but the choice of different antimicrobials is not explicated; Cummings et al.,[8] covered patients prophylactically with first generation cephalosporine; Budhiraja et al.,[7] treated the unique patient with a not specified antibiotic. Bertozzi et al., administered intravenous ampicillin sodium and sulbactam sodium for 7 days. Bothra et al., when specified the use of antibiotic report a third generation cephalosporin.

SURGICAL MANAGEMENT Depending on lesion, surgical intervention may be different. According to all authors, the management of simple wound of external genitalia include copious irrigation, débridment and primary closure. Copious irrigation with normal saline or Ringer’s lactate solution may reduce the rate of infection. Injection of the tissue with irrigant solution should be avoided because this can spread the infection.[15,17] Necrotic or devitalized tissues should be removed, but care must be taken not to débride so much tissue as to cause problems with wound closure and appearance. Cultures are usually not helpful unless the wound appears infected or is unresponsive to appropriate antibiotic therapy. When a culture is necessary, aerobic and anaerobic cultures should be obtained and observed for a minimum of 7 to 10 days to allow for slow-growing pathogens.[17] In case of skin avulsion, mobilisation of skin layers, skin flaps or skin grafting may be necessary. In some cases, a dog bite to the external genitalia can result in unilateral or bilateral loss of the testis.[7,9,10,12,14] When testis is lost, ligation of the spermatic cord is necessary. When doubt exists regarding testis parenchymal involvement or in the presence of haematocele, surgical exploration must be carried out. In the case of paediatric spermatic injury, microsurgical reconstruction is mandatory even if, the fertility can only be demonstrated once the child has reached adulthood. When macroscopic signs of urethral involvement are absent, urethral injuries must be always excluded by examination of urine and eventually by urethral endoscopy. African Journal of Paediatric Surgery

Bertozzi and Appignani: Management of genitalia injuries by dog bite

In case of penile injuries, when a macroscopic lesion of the urethra is clearly visible, surgeon must proceed with its repair. Major injuries of the penis such as partial or total penile amputation may be treated by corpora cavernosa and urethral trimming and in some cases perineal urethrostomy must be considered. In one case of complete testicular and scrotal avulsion with penile amputation Gomes et al., after a psychological evaluation of the patient and family, performed a surgical procedure for feminization of the genitalia 1 year after trauma. Bothra et al., propose the feminizing genitoplasty in one of their patients with bilateral testes loss, glans amputation and avulsion of more than half of the shaft of penis, but parents refused this procedure.

be catastrophic. Males are attacked to external genitalia more frequently than females, but if that occurs, we can have more severe injuries.

Feminisation of external genitalia and female gender assignment in boys may result in subsequent gender dysphoria. Nowadays, modern techniques of phalloplasty for the treatment of congenital penile agenesis might resolve the problem of complete avulsion of testes and scrotum associated to penile amputation due to dog bite, with reconstruction of external genitalia even in the 1st months of life. Prenatal and postnatal effects of the androgens on the brain and sexual orientation cannot be modified later in patients with congenital penile agenesis as well as in patient with traumatic loss of external genitalia. Definitive forearm flap phalloplasty is generally not recommended before puberty, but in adults may achieve good results even if, it is not easily available everywhere. To the contrary De Castro et al., [31] describe a palliative preliminary phalloplasty and urethroplasty technique in infants using an abdominal skin flap and a bladder/buccal mucosa free graft. Therefore, we believe that social and psychological concerns justified this type of phalloplasty and we consider feminisation of external genitalia in boys as the last surgical chance.

Investigations to verify the absence of urethral injuries must be performed, and surgical exploration of the scrotum, if necessary, will show the conditions of the testes, vas deferens, and spermatic vessels. In the case of paediatric spermatic injury, microsurgical reconstruction is mandatory even if, fertility can only be demonstrated once the child has reached adulthood. Orchiectomy is sometimes necessary, and parents must be warned about this possibility. In case of loss of testis due to dog bite, the vas must to be individuated and ligated.

Injuries of external genitalia in females need an accurate examination of all perineal area including therefore investigations about urethra, vagina, clitoris, anus and rectum. Tuggle et al.,[6] describe a case of delayed external anal sphincter and levator ani repair for persistent incontinence due to dog bite injuries occurred 8 years before.

CONCLUSION

Management of the wound includes irrigation and débridement of devitalized tissue and they should always be performed because they are often the only treatment required. Primary closure is possible in most cases and usually achieves good functional and cosmetic results. Sometimes severe injuries of the external genitalia can happen and a paediatric surgeon or paediatric urologist is necessary to preserve functions of genital and perineal area because for several lesions of genital dog injuries due to dog bite a reconstructive surgery is necessary.

In case of catastrophic avulsion of the scrotum and its content with penile amputation, a delayed palliative preliminary phalloplasty and urethroplasty technique using an abdominal skin flap and a bladder/buccal mucosa free graft must be considered. Feminisation of external genitalia and gender re-assignment must be procrastinate as the last surgical chance. Antibiotic prophylaxis is empirical, but advised in all cases based on the flora commonly present in dog bite wounds. Rabies and tetanus potentially transmitted by a dog bite must be considered especially rabies if the dog is not a family dog and prophylaxis should be administered according to vaccine protocols.

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Dog bites to the external genitalia are rare, but potentially serious. A large variety of lesions is reported in Literature, but genital injuries due to dog bite may African Journal of Paediatric Surgery

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22. Human rabies prevention – United States, 1999. Recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 1999;48:1-21. [Published erratum appears in MMWR Morb Mortal Wkly Rep 1999;48:16]. 23. Dreesen DW, Hanlon CA. Current recommendations for the prophylaxis and treatment of rabies. Drugs 1998;56:801-9. Brakenbury PH, Muwanga C. A comparative double blind study of amoxycillin/clavulanate vs placebo in the prevention of infection after animal bites. Arch Emerg Med 1989;6:251-6. 24. Douglas LG. Bite wounds. Am Fam Physician 1975;11:93-9. 25. Callaham ML. Treatment of common dog bites: Infection risk factors. JACEP 1978;7:83-7. 26. Callaham M. Controversies in antibiotic choices for bite wounds. Ann Emerg Med 1988;17:1321-30. 27. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: A meta-analysis of randomized trials. Ann Emerg Med 1994;23:535-40. 28. Goldstein EJ. Bites. In: Mandell GL, Bennett JE, Dolin R, editors. Principles and Practice of Infectious Diseases. Philadelphia: Churchill Livingstone; 2000. p. 3202. 29. Talan DA, Citron DM, Abrahamian FM, Moran GJ, Goldstein EJ. Bacteriologic analysis of infected dog and cat bites. Emergency medicine animal bite infection study group. N Engl J Med 1999;340:85-92. 30. Centers for Disease Control and Prevention (CDC). Human rabies – Washington, 1995. MMWR Morb Mortal Wkly Rep 1995;44:625-7.-: 31. De Castro R, Merlini E, Rigamonti W, Macedo A Jr. Phalloplasty and urethroplasty in children with penile agenesis: Preliminary report. J Urol 2007;177:1112-6.

Cite this article as: Bertozzi M, Appignani A. The management of dog bite injuries of genitalia in paediatric age. Afr J Paediatr Surg 2013;10:205-10.

Source of Support: Nil. Conflict of Interest: None declared.

African Journal of Paediatric Surgery