In the last two decades, there has been an increase in student cultism and gun violence in campuses of tertiary institutions in our country. This injury is a direct consequence of such violence. It is an interesting case of assailant turned victim. There is no report in the literature of civilian accidental self-inflicted gunshot injury to the male external genitalia but several cases of military [1, 3, 4] and civilian [2, 7, 12] gunshot injuries of the external genitalia have been documented. The age of our patient falls within the age range and is close to the mean ages of 29.0 years and 30.4 years, respectively, reported by previous authors for civilian gunshot wounds [2, 7].
Injury severity in gunshot wounds is determined by kinetic energy (KE) transferred by the bullet which in turn is directly proportional to the mass and velocity of the bullet [13].We could not ascertain the type of gun used by our patient but he obviously sustained the maximum impact from the bullet since he accidentally shot himself from his trouser pocket. This is evidenced by the high AAST scores documented.
Successful treatment of gunshot wounds of the external genitalia depends on early surgical exploration, broad spectrum antibiotic cover, anti-tetanus prophylaxis, debridement of the wounded structures and primary repair of lesions that can be repaired primarily [1,2,3,4,5]. The preservation of potency, normal micturition, fertility and a cosmetically acceptable phallus are major treatment goals [2,3,4,5,6,7]. Debridement should be cautious because marginally viable tissues may eventually survive due to the rich blood supply of the perineum [5]. Majority of patients will need surgical exploration [1,2,3, 10] as in our index case with only a very small percentage being managed non-operatively [5, 10]. Non-operative management of external genitalia injuries is controversial and should be reserved only for the most superficial of injuries [5, 10]. Extra genital organ injuries may be present. They should be sought for, evaluated and treated on their own merit. The extra genital organ injuries are usually more life threatening than the external genitalia injuries and should therefore be given priority attention [4]. Our index patient had extra genital organ injury to the upper thigh that did not involve major vessels or bone.
The penis is injured in 8–9.5% of all genitourinary trauma [1, 2]. The evaluation of penile injuries may require ultrasonography to detect occult corporal injuries. Our index case did not have ultrasonography done. Injuries to the corpora carvenosa should be repaired with non-absorbable sutures as was done in this index case while avoiding exploration of the cavernous tissue as this may cause more damage and result in impotence [8]. The urethra may be affected in 11–29% of penetrating penile injuries [5, 10, 14]. Urethral injuries can vary from mild contusions, urethral lacerations to major urethral disruptions [6, 8, 10, 11]. Our index patient had a greater than 2 cm urethral defect (AAST grade IV penile injury). A retrograde urethrogram is recommended for evaluation of urethral integrity in all patients with penetrating GSW of the penis [5, 8, 10]. However, some authors have relied on the triad of absence of blood at the meatus, spontaneous voiding or easy catheterization and absence of haematuria as sufficient evidence of urethral integrity [8]. Our index patient did not have a urethrogram. He had a very obvious urethral injury and there was easy urethral catheterization. Management of minor urethral lacerations is controversial. Some authors have documented good results with urethral stenting catheter and suprapubic urinary diversion alone [11], while others recommend primary repair or end to end anastomosis [4, 6, 10]. For major urethral disruptions, there is a consensus of opinion that staged urethroplasty gives the best outcome [4, 8]. However, there is scanty evidence on the types and outcome of staged urethroplasty done. Our index patient had an AAST grade V urethral injury that was managed by staged buccal mucosal graft urethroplasty with satisfactory outcome even though the authors are non-reconstructive urologists. Buccal mucosa is readily available, easy to harvest, hairless, accustomed to a wet environment and resilient to infection. It is also a thick epithelium with a thin lamina propria that allows for early inosculation [15].
The scrotum and testes are commonly injured along with the penis. Phonsombat et al. [5] documented 39% testicular involvement in 54 patients with gunshot injury to the external genitalia. Penetrating scrotal wounds often require exploration to assess the extent of testicular damage as was done in our index case. In doubtful cases a scrotal ultrasound may be done to determine the viability of the underlying testis [10]. Attempt should be made to preserve the testes but shattered and obviously non-viable testis should be removed [10].Our index patient had a shattered and devitalized left testis that obviously had to be removed. Orchidectomy rates vary from study to study and may be as high as 61% [10].
Substantial penile skin loss may occur with severe gunshot injuries to the external genitalia as documented in our case. Our patient had almost 80% penile skin loss (Fig. 1) that was successfully covered with thick split thickness skin graft (Fig. 4). The need for proper coverage of the penile shaft with sensate, stable, supple and aesthetically acceptable skin cannot be over-emphasized. The split thickness skin graft is a desirable option as it requires less than ideal condition for survival conferring a major advantage over the full thickness skin graft [16] however it shows more secondary contracture [17]. Fortunately, our index patient recovered fully without contractures.
The upper thigh is the most commonly injured extra genital organ associated with gunshot injury to the external genitalia [2, 5, 8]. The degree of involvement may range from soft tissue injury alone to bony or major vessel involvement [2, 8]. Our index patient had only soft tissue injury to the upper thigh that was sutured at the referral hospital. It healed primarily and did not need further attention.
