The development of high-speed machines and an advanced building industry has changed the presentation of trauma patients and it leads to associated industrial accidents as well as traffic accidents. Such trauma can involve every part of the body, including the penoscrotal area. Owing to their concealed anatomical locations, such injuries can go easily undetected, further delaying treatment. There are few comments on the mechanism of development of penoscrotal injuries in a trauma patient, besides a direct injury of the perineal area from the trauma. In rotation machines, the capturing force of the machine creates torsion and leads to traction of the area.15,16 In falls, direct trauma to the falling side causes friction burns which lead to soft tissue injuries. If the scrotal skin loss is less than 50%, it can often be closed immediately after the trauma.16 The depth of injury can involve damage to the cavernous bodies, spongy body, or testes.17 Following blood loss, infection and lymphedema can lead to the development of an irreversible wound.
In this study, our final proposal was an assessment algorithm for trauma-related penoscrotal avulsion injury (Figure 4). We composed a five-category algorithm, based on our multivariate clinical risk evaluation. The categories were patient severity, respiration, hemodynamic status, comorbidities, and immobilization. In this algorithm, the main factors that contribute to advanced penoscrotal injury are composed of patient stability, immobilization, and oxygen insufficiency. Orthopedic injury and restrain contribute to immobilization, and this can lead to delayed wound healing and wound deepening. Insufficient respiration and blood loss contribute to oxygen insufficiency, which leads to wound necrosis and aggravation of the edema.
The details of the treatment algorithm are described below. Firstly, in multiple trauma patients, the initial hemodynamic status should be assessed. Various laboratory findings and hemodynamic indicators help us decide whether resuscitation treatments should be started immediately or later. Hemodynamic instability should be considered first; if the patient is persistently unstable, stabilization without active wound management should be considered. Massive blood loss usually requires transfusion; thus, integration of transfusion management should be considered. The next step is the severity of the patient’s condition, which should be considered with respect to their age. Respiratory care with intubation, in our experience, increased the risk of penoscrotal injury with a highly advanced wound status; thus, active surgical management should be considered. In multiple trauma patients, their additive injury status leads to further problems. Thus, a categorized evaluation is needed. In particular, combined orthopedic injuries were associated with high rates of advanced penoscrotal wounds which required special attention. Moreover, intraorgan injuries and extensive soft tissue injuries are often associated with advanced penoscrotal wounds; however, no statistical significance was noted in our study. Finally, based on these five categories of evaluation in trauma patients, we aim to detect penoscrotal wounds earlier and start active interventions.
Why is the early diagnosis of surgical prone penoscrotal defects in trauma patients important for reconstruction? Extensive penoscrotal defects ultimately require surgical reconstruction. However, anatomically the lesion penoscrotal area, there is a presence of circumferential muscle and its flexible skin texture has to be dealt with in a very particular attention. Especially erectile function should be reproduced via functional reconstruction. These days, sensate flap reconstruction is possible, hence one should not delay a referral. In our study, the most common surgical option was a local flap. The range of local flaps includes skin advancement using inguinal to upper thigh skin, local fasciocutaneous flaps, and musculocutaneous flaps. Functionally and aesthetically pleasing reconstructions are now possible. However, while choosing an appropriate method of surgical reconstruction, we need to take the patient’s overall status into consideration
The limitations of our research are as follows. Owing to the nature of a level I trauma center, the severity of the patients’ condition is relatively high, which could have contributed to the higher mortality seen in our study compared to those in other studies. The resuscitation rates such as respiratory resuscitation and transfusion rates were also very high. However, the mortality itself was not directly associated with the severity of the penoscrotal injury. Therefore, there was a limitation in the association between the nature of the trauma center itself with the severity of the wounds. Through this study, we hope that the discovery algorithm used to detect penoscrotal injuries in traumatic patients, will now include more than just an assessment of wound complexity.