Case Presentation: Penile degloving is a rare injury with few documented cases in literature. We present the case of a 41-year-old male with self-inflicted penile degloving while under the influence of cocaine.A 41-year-old male with PMH polysubstance abuse, MDD and bipolar disorder presented to the ED with five days of penile pain after prolonged masturbation while under the influence of cocaine. Approximately 2 days prior he noticed mid-shaft penile skin breakdown and a white, superficial skin ulcer which progressed to a greenish hue. The pain was constant, 3-4 out of 10, and worsened during urination. He denied using lubricants or pain medications. On initial exam, BP 104/60, HR 76, RR 16, T 98.1°F, 100% RA. Genital exam revealed a circumferential degloving of the midshaft of the penis extending proximal to the base, supple scrotum and normal urethral meatus. The remainder of the physical exam was unremarkable including absence of inguinal lymphadenopathy, ulceration and visible urethral discharge. Laboratory studies demonstrated WBC 6.3, AST 105, ALT 43, total bilirubin 1.5. Urinalysis showed trace leukocytes, 11-20 RBC/HPF, 30 mg/dL protein, no nitrites and no bacteria. Urine toxicology was positive for cocaine, opiate and THC. Hepatitis C antibody, Hepatitis B surface antigen, Hepatitis B core IgM antibody, N. gonorrhea nucleic acid PCR, Chlamydia nucleic acid PCR, HIV antigen/antibody, T. Pallidum antibody, ANA was negative. The patient was admitted for degloving circumferential injury of the penis and started on broad-spectrum antibiotics. On day 2, debridement revealed denuded penile skin with no evidence of infection, minimal necrotic areas of superficial skin and underlying healthy dermis without any urethral, scrotal or deep tissue involvement. Superficial wound culture revealed methicillin-sensitive S. aureus and S. pyogenes and antibiotics were narrowed to IV Cefazolin. On day 8, a split thickness skin graft harvested from the patient’s right thigh was placed. His clinical course improved and he was discharged home with outpatient urology and wound care follow up.
Discussion: Penile degloving injury, a rare occurrence, is defined by a separation of the superficial dartos fascia from deep fascia without involvement of underlying deep erectile tissue or the spermatic cord. Most penile degloving injuries are a result of “power take off” injuries involving an avulsion of skin from the penis. Incidents typically surround trauma, heavy machinery, animal bites and penile rings. Clinically diagnosed, history and physical findings are sufficient in establishing a diagnosis. Treatment entails exploration and debridement of non-viable tissue; more severe cases require reconstruction with skin grafting in which split-thickness grafts are preferred. Penile degloving injuries are typically non-painful and rarely life-threatening; however, they may carry severe psychological burden and can lead to secondary idiopathic Peyronie’s disease and erectile dysfunction.
Conclusions: Although penile degloving remains a rare occurrence, typically associated with trauma, it is important for clinicians to be aware of this soft-tissue injury in the setting of substance use.