Taumatic Emergencies of the External Genital Organs

Background: The traumas of scrotum are often traumas caused by accidents on the public highway or in sport. However, fractures of the penis are secondary to a direct trauma to the penis with rupture of the albuginea causing hematoma, pain and deviation of the penis. Animal bites are rare. Purpose: To describe the management of traumatic emergencies of the external genital organs at the CHU Bouaké. Patients and Methods: Retrospective and descriptive study on the patients treated at Bouaké University Hospital for traumatic emergencies of the external genital organs during the period from January 01, 2012 to December 31, 2018. The parameters studied were epidemiological, clinical and therapeutic. Results: The study period registered 26 patients. The mean age was 34.5 years, Closed trauma to the scrotum was a frequent reason with 30.8%, the trauma sat on the scrotum in 53.8%, the penis in 42.3%, the vulva in 3.8% of cases. The circumstances of discovery of trauma to the penis were dominated by coitus missteps of the cases; two patients (7.7%) had complications such as testicular necrosis and atrophy which have been treated by orchidectomy. Conclusion: Traumatic emergencies of the external genitalia are rare but serious. Treatment is dominated by surgery.


Introduction
Traumatic emergencies of the external genitalia are relatively uncommon and affect young people [1]. These traumas represent less than 1% in Africa [1], 8% -10% in Europe [2], 2% -10% Asia [3], 1% America [4] and 1.9% in the Middle East [5]. The etiologies are multiple and the lesions may involve the penis and/or the scrotal contents (testicle, epididymides, cord) in men and the vulva in women. The diagnosis of these injuries is most often clinical in the case of open trauma or fracture of the penis, and may involve ultrasound in the case of a large posttraumatic bursa [2]. They may lead to urinary complications and sequela (erectile dysfunction, curvature of the penis during erection, urethral stricture, testicular atrophy) and serious psychological harm [2]. The management of external genitalia trauma is done in an emergency setting and may include trimming in case of a wound or surgical exploration of the traumatized bursa and finally cavernous suture for penile fractures [3]. This management strategy therefore requires a rigorous clinical evaluation with a precise and complete lesion assessment. Treatment must be early to minimize complications and sequela. The aim of our study was to describe the epidemiological, clinical and therapeutic aspects of traumatic emergencies of the external genitalia in the urology department of the University Hospital of Bouaké.

Patients and Methods
This is a retrospective and descriptive study which took place in the urology department of the university hospital of Bouaké. The study took place from January 1, 2012 to December 31, 2018, during which we collected all cases of traumatic External Genitalia Organs (EGO) emergencies that were treated in the department. The study period registered 26 patients. The study included male and female patients of all ages who were treated medically or surgically for EGO trauma emergencies. There were no exclusion criteria. The parameters studied included: socio-demographic data: (age, profession, sex), clinical: (circumstances of occurrence, aetiology, consultation time, site of injury, associated injuries), paraclinical (imaging), therapeutic (surgical procedure, evolution, postoperative complications, hospitalization time). The data were collected from the patients' files, a survey form and the register of surgical reports of patients operated on for traumatic emergencies at the EGO. All data were entered into the WORLD

Epidemiology
The average age of the patients is 34.5 years with extremes of 16 years to 52 years. Table 1 shows the epidemiological characteristics of the patients studied; the patients were predominantly male (96.23%) and almost half were over 30 years old. Most were Farmers with 38.46%. The majority was married (69.23%) and the illiterate ones were (46.23%).

Reason for Consultation
Closed scrotal trauma was the most frequent reason for consultation with 30.8%. Table 2 shows that closed trauma to the penis is the second reason for consultation with 26.9%. However, open traumatism of the scrotum and penis comes third (23.1%) and fourth (11.5%) respectively. Very few patients consult a doctor for scrotal sore (3.8%) or vulvar folds (3.8%).

Occurred Circumstances 1) Penis
The circumstances in which penile injuries occurred were dominated by coital slips with 45.5% (n = 5; Table 3).
2) Bursa The circumstances of occurrence of trauma to the bursa are dominated by road traffic accidents with 60% (n = 6; Table 4).

3) Vulva
Only one case of trauma to the vulva due to a road accident was noted (n = 1; 3.84%).

Delay of Consultation
The majority of patients consulted within 24 hours of the trauma (n = 23; 88.5%).

Site of Trauma
Trauma was predominantly to the scrotum with 53.8% in men (n = 14).

Type of Treatment
The majority of patients received surgical treatment with 92.30% (n = 24).

Type of Anaesthesia
Loco-regional anaesthesia was the main route of anaesthesia with 91.66 (n = 22).

Per-Operative Lesions
Intraoperatively, non-expansive scrotal haematoma accounted for 29.16%, fracture of the corpora cavernosa accounted for 20.83% and superficial wounds of the penis and scrotum accounted for 20.83% (Table 6).

Surgical Procedures
Exploratory scrototomy associated with evacuation of scrotal hematoma were the most common surgical procedures performed on patients with 29.16%. Table 7 shows that simple trimming and evacuation of the hematoma followed   A patient underwent a trimming associated with a right orchiectomy (4.16%). The only woman benefited from a trimming associated with a suture of the vulva (4.16%).

Post-Operative Treatment of Associated Lesions
Post-operatively, all patients who had undergone suture of the corpora cavernosa received oral medication based on diazepam at a dose of 10 mg per day for a fortnight, and non-steroidal anti-inflammatory drugs for a week. They also received probabilistic antibiotic therapy with cephalosporin until the eighth day.
The dog-bitten patient had received rabies prevention, tetanus sero-vaccination and broad-spectrum antibiotic therapy.
Two patients had associated injuries.
There was a traumatic rupture of the urethra and a fracture of the pelvis (7.69%) (n = 2). The treatment consisted of an end-to-end suture of the urethra on a catheter and an orthopaedic treatment for the pelvic fracture.

Duration of Hospitalization
More than half of the patients had a hospital stay between [0 and 5 days] after IV-7-Follow-up of the treatment.
One trophic complication (testicular atrophy) and one infectious complication (testicular necrosis) were observed post-operatively. Orchidectomy was performed to treat the testicular necrosis as well as the testicular atrophy in both patients.

Discussion
In our study, the minimal age of the patients was 34.5 years with extremes of 16 and 52 years. The young age has been reported by several authors in the literature.
Bah in Senegal reported in his study an average age of 37 years [6]. Ouattara in A haematocele which is clinically expressed as an enlarged, normally colored; A scrotal haematoma which is characterized by an enlarged, ecchymotic, dark red bursa on pale skin. Sometimes it is a localized deformity.
In our series, the clinical symptomatology was dominated by scrotal swelling in 26.9% followed by penile swelling in 23.1%.
Our results corroborate those of Coulibaly in Mali [9] and Andry in Switzerland [14]. The increase in the volume of the scrotum could be explained by the violence of the trauma on the scrotum on the one hand, and by the presence of a scrotal haematocele or haematoma on the other. As for the swelling of the penis, it can be explained by the presence of a haematoma opposite the fracture site of rupture of the albuginea [6]. However, its specificity is not perfect, sometimes leading to surgical exploration to make a complete assessment of the lesion [15].
In our work, the diagnosis was mainly made on the basis of clinical findings followed by an emergency operation. Ultrasound was not systematic. Six patients (23.07%) underwent scrotal ultrasound. Our attitude is in line with that of several authors, notably Djè [8] and Coulibaly [9], who recommend emergency surgical exploration except in cases of moderate trauma. This management would reduce the risks of complications and sequela. The therapeutic attitude to bursal trauma is variable and depends above all on the presence or absence of a haematocele on clinical examination [10]. Thus, in the absence of a haematocele and in the presence of an intact testicle on ultrasound, the medical treatment consists of analgesics, non-steroidal anti-inflammatory drugs in the absence of contraindication of gastro duodenal ulcers, antibiotic coverage, anti-tetanus sero-vaccination associated with suspension of bursaries [10], as was the case for two (2) of our patients, i.e. 7.7%. In our series, we used local-regional anaesthesia in 91.66% of cases. We chose spinal anaesthesia because of its advantages, which allow surgery to be performed with ease and comfort [16]. Our management consisted of trimming and suturing of the labia minor and major with 3/0 Vicryl. This reconstructive surgery was performed in collaboration with gynaecologists. Trauma to the external genitalia involving the vulva is extremely rare [19]. The only case reported in seven years of practice confirms this rarity. Animal bites are rare as evidenced by our study but potentially serious [20]. Wolf et al. report four cases of dog bites [19]. Cummings and Boullier reported eight (8) cases treated for scrotal dog bites [20]. However, in the largest series in the literature, Gomes et al. report ten (10) new cases: eight (8) cases were attacked by dogs, one by a horse and one by a donkey [21]. The morbidity is directly related to the severity of the bite and the delay in consultation. These animal bites carry a triple infectious risk: bacterial, tetanic and rabies [15]. Broad spectrum antibiotic therapy should be administered. In our series, one case of dog bite was observed. The bite involved the body of the penis. Wound trimming combined with anti-rabies prevention and anti-tetanus sero-vaccination were carried out according to the vaccine recommendations [21]. The most common bacteria isolated in animal bites are streptococci and staphylococci, Escherichia coli, associated with anaerobic germs. In our case, no germ was identified, hence the choice of broad-spectrum antibiotic therapy. In our series, two patients had associated lesions. It was a traumatic rupture of the urethra and a fracture of the obturator frame, i.e. 7.69%. The bone lesion was managed by orthopaedic surgeons. The urethral injury was not treated as an emergency. It was done as a delayed emergency as recommended by Leguillou in Bordeaux and Gueye in Dakar between the 8th and 10th day [22] [23] and Diallo in Conakry [24]. Our patient was operated on as a delayed emergency after organization of the lesions and at a distance from the inflammatory and infectious processes. This approach of management at a distance from the trauma was that adopted by Dje and Fall [8] [25]. In our series, more than 60% of patients had a hospital stay of less than five days after treatment. Our duration is in line with that of Coulibaly in Mali [9]. However, some authors such as Kambou [26]. The mechanisms of occurrence of testicular atrophy are not well known: post-traumatic lesions of the micro-vascularization of the testis; ischaemia by compression due to oedema and haematoma and autoimmune mechanisms are mentioned in the literature [27]. However, this study has limitations which must be taken into account when interpreting the results. As this is the retrospective nature with significant loss of information, its relatively small size does not give it sufficient statistical power.

Conclusion
Taumatic emergencies of the external genital organs are uncommon, but it is potentially serious because it can lead to urinary or sexual complications with major consequences for fertility. These injuries are rare in women and very frequent in men. The diagnosis is most often based on clinical examination. However, clinical examination is often difficult because of pain and/or swelling, hence the importance of ultrasound. Trauma to the bursa is most often encountered in road accidents. As for penile trauma, it is secondary to a false step in the coitus and emergency treatment is surgical in most cases. In women, surgical management must be carried out in a multidisciplinary context involving urologists, gynaecologists and psychologists of both sexes. Animal bites of external genital organs are rare but serious and carry a significant infectious risk. Morbidity is related to the severity of the bite and the delay in consultation. Surgical treatment must always be combined with medical treatment and vaccination. Complications and sequela of EGO trauma are formidable. These complications must be explained to the patient before treatment in order to reduce the medico-legal problems associated with trauma.

Ethical Clearance
The patients were informed and agreed to participate in the study, and their anonymity was preserved.

Conflicts of Interest
The authors declare that they have no ties of interest.