Circumcision for penile deep burn with phimosis

Summary

In this case report, we present the management of an uncommon case of genital burns in a patient with pre-existing phimosis. Generally, a burn wound on the prepuce is ­treated with a standard burn wound care strategy; however, in this case, circumcision was performed to address both the phimosis and the genital burns simultaneously. To the best of our knowledge, no similar cases have been reported in the literature. Genital burns are not often encountered due to their protected anatomic location and the additional coverage provided by clothing. Thus, genital burns are usually associated with extensive total body surface area (TBSA) burn injuries. Currently, there is no available standardized algorithm or treatment guideline for genital burn injuries. The treatment of burns in this region is primarily conservative. In this case, a 55-year-old male patient presented with extensive scald burn injury, including genital burns. He was diagnosed with third-degree scald burns on both upper extremities and deep second-degree burns on the lower extremities, abdomen, perineum and genitals, covering 46% of the TBSA. However, his penis was protected by native phimosis. We performed fluid resuscitation and burn wound management, including circumcision. The use of circumcision as a simultaneous treatment for genital burns and phimosis led to a highly favorable outcome, including good wound healing, effective pain control, satisfactory prognosis, and excellent cosmetic appearance.

Keywords:

Circumcision – genital burn – extensive total body surface area burn – phimosis

Introduction

Genital burns (GBs) are uncommon and are usually associated with extensive total body surface area (TBSA) burn injuries. Isolated GBs seldom occur, as the vulva, penis, and scrotum are protected by clothing and by the thighs and abdomen [1]. The incidence of GBs was estimated to range from 2.8% to 13% in patients admitted to burn injury hospitals, according to a previous report by Michielsen et al. Flames (24–77%), hot liquids (15–64%), and chemical agents (8–16%) are the most frequent causes of burns in this region [2]. However, GBs not only cause physical damage but also psychological and reproductive consequences [3]. The American Burn Association classifies any burn involving the genitalia and perineum as a major burn injury [1,4]. GBs are classified into three groups according to the depth of the injury. First-degree lesions are limited to the epidermis; erythema is a characteristic feature. Second-degree are further divides into superficial and deep dermal burns. Superficial second-degree burns affect the entire epidermis and part of the underlying dermis; the appearance of blisters is a characteristic feature. Deep second-degree burns show no blanching signs and have a reddish appearance, while third-degree burns may have a white, waxy presentation and are accompanied by a lack of sensation in the affected skin [2,5]. Despite this classification, there is no standardized algorithm or treat­ment guideline for GB injuries or their complications. The common approach to treating burns in this region is primarily conservative [6]. Patients with deep second -⁠ or third-degree burns should be considered for surgical debridement and/or split-thickness skin grafts [1,7]. While prepuce burns are generally treated with a burn wound care strategy, in this case, we opted for a circumcision rather than split-thickness skin grafting to simultaneously address both the deep GBs and phimosis, which resulted in an excellent outcome.

Case report

A 55-year-old man was accidentally burned when hot soy milk was spilled on his abdomen and all four limbs. He was referred to the emergency department. Fluid resuscitation was initiated immediately according to Parkland’s formula, and hydrotherapy was coordinated. Upon initial physical examination, the patient presented with a white, waxy appearance without blanching signs on both upper extremities. Diffuse erythema and some blistering were observed on his lower extremities and abdomen. The genitalia exhibited some blister formation, with no signs of blanching (Fig. 1). The patient was diagnosed with third-degree scald burns on the bilateral upper extremities and deep second-degree burns on the bilateral lower extremities, abdomen, perineum and genitalia, covering 46% of the TBSA. He was ad­mitted to the burn center for further management.

Surgical debridement was conducted on day 3, and all non-viable or necrotic tissue was removed. The patient’s thighs and genitalia appeared white and waxy, without blanching signs (Fig. 2A). After sterile saline irrigation, the wounds were dressed with AQUACEL® (ConvaTec, Reading, United Kingdom) and gauze. However, by day 14, the patient’s thighs and genitalia became yellow, dry, and inelastic (Fig. 2B). Debridement was repeated 5× and the burn wound dressing were changed regularly. Hydrotherapy was performed once-to-twice per week, using chlorhexidine gluconate and sterile saline irrigation. The TBSA was re-evaluated at each hydrotherapy. In addition, the patient underwent 20 courses of hyperbaric oxygen therapy (HBO) to promote burn wound healing, which proved successful. The burn wounds on the extremities and abdomen healed progressively every day with the formation of good-quality granulation tissue and re-epithelialization, indicating excellent outcomes (Fig. 2). The prepuce also showed a good wound bed with no surrounding erythema, no signs of infection or inflammation, and granulation tissue formation (Fig. 3A). Despite this progress, the wound on the prepuce became chronic. The patient had a painful sensation on the penis due to the chronic wound and showed early signs of prepuce scar formation. In addition, phimosis made it difficult to maintain proper hygiene of the corona of the penis, leading to smegma buildup contributing unfavorable healing conditions (Fig. 3B). Therefore, circumcision was scheduled 6 weeks after admission to simultaneously treat the deep GB wound and the phimosis. First, we excised the chronic wound which lay on the prepuce and close the deep dermal penile burn. Following the circumcision, only a suture wound remained, which was much easier to manage (Fig. 3). The surgery was uneventful and there were no immediate complications. The operation achieved a satisfactory outcome, with resolution of the chronic wound from the deep GB as well as pre-existing phimosis.

At 75 days after the initial burn injury, the patient was discharged with instructions for self-care. At 1-year follow-up, all the burn wounds were completely healed (Fig. 4). The patient did not experience any painful sensation on the penis or erectile dysfunction, and was overall satisfied with excellent functional and cosmetic outcomes.

Discussion

According to the American Burn Association, burns that involve the genitalia or perineum are considered to be major burns and should be referred to a burn center [8–10]. Despite GBs are rare, they greatly affect physical, psychological and social wellbeing [3]. Nevertheless, no standard treat­ment has yet been established for GBs and to the best of our knowledge, no similar case of managing patient with a genital burn and pre-existing phimoses has been ever reported before.

Phimosis is the inability to completely retract the foreskin and expose the glans. Phimosis can be congenital (primary, without signs of scarring) or acquired (secondary and pathological); the latter is a consequence of local inflammation (recurrent balanitis or balanoposthitis) or infections due to poor hygiene, moreover is strongly associated with invasive penile cancer, due to chronic infections. It is mostly common in children in the first decade of life with a second peak of incidence occurring after the sixth decade of life [11]. The prevalence of phimoses in adults is ranging between 0.5 and 13% [12]. Conservative treatment is an option both in congenital and acquired phimosis. A circumcision remains the gold standard of surgical approach. Circumcision is considered a simple surgical procedure; however, an overall complication risk of 3.8% has been reported. The main and most frequently encountered complications of male circumcision are minor ones and are represented by wound infections, bleeding and incomplete or excessive removal of the foreskin [11].

In second-degree genital burns, a conservative approach with physiological dressings and topical antimicrobials is advised [13]. However, conservative treatments are notoriously inadequate for penile burns because secondary contractures and hypertrophic scarring are highly probable [14].

In the particular case we are presenting, conservative treatment was not sufficient. The wound of the penile burn did not heal even after 6 weeks of admission regardless of meticulous conservative care including 20 sessions in hyperbaric chambre due to its deep second-degree nature. Furthermore, the patient had a painful sensation on the penis due to the chronic wound and exhibited signs of prepuce scar formation. In this case, the native phimosis may have initially benefited the patient by protecting the underlying penile tissues from more severe burn injury. However, later it complicated hygiene of patient`s genitals, which might have contribute to chronicity of the wound.

Typically, deep GBs with chronic wounds are treated through serial surgical debridement and split-thickness skin grafting. This approach, though, may result in contractures in the penile shaft, skin tethering, shrinkage, abnormal curvature of the erect penis after surgery. Additionally, the patient would continue to experience consequences of persistent phimosis. Therefore, strategy addressing both the GBs and the phimoses was elected, and a circumcision was performed. This facilitated the wound care as well as genital hygiene, while reducing a risk of wound and genital inflammation and yielding a favorable outcome, eliminating the need for further surgical debridement or skin grafting in this area. In the literature, similar technique was published using reverse circumcision in four patients with severe burns in the genital area, leading to satisfactory the postoperative and aesthetic results with an uneventfully healing and with no long-term complications such as scarring or contractures on the glans or penile shaft after surgery [14].

Conclusions

GBs are uncommon and usually associated with extensive burn injuries. Burns to the genital and perineal areas lead to significant physical, functional, sexual, and psychological repercussions, directly impacting quality of life. Pa­tients with GBs are considered to have major burn injuries, and care should primarily include fluid resuscitation and burn wound management. In this particular case, the patient’s pre-existing phimosis initially played a protective role but later made the healing condition more challenging. Circumcision was used to successfully simultaneously treat the GB and phimosis. The surgery led to excellent outcomes, including good wound healing, efficient pain control, satisfactory prognosis, and acceptable cosmetic result.

However, there is currently no established standard treatment protocol or guideline for managing genital burn injuries. In many cases of superficial burns, the treatment of genital burns is conservative. For deep burns, the treatment can be more demanding. The wound care strategy for deep genital burns should encompass more than just surgical debridement and split-thickness skin grafts, taking into account possible later complications. A circumcision should be considered as an effective and standardized treatment for deep genital burns, with excellent outcomes minimizing a risk late complication of GBs, thus reducing protentional long-term impacts of patient`s quality of life.

Conflict of interests

The authors declare that they have no conflict of interest related to the creation of this article, and that this article has not been published in any other journal with access to congress abstracts.