A Toddler with an Injured Penis

A 27-month-old boy sustained superficial lacerations to his penis when he was voiding directly into the toilet bowl and the toilet seat fell onto the external genitalia. Bruising at the distal end of the penis with a linear proximal border was consistent with the mode injury described by the caretaker. The child recovered spontaneously without any signs of urethral injury or obstruction. Pediatric penile injury associated with toilet training may be preventable with increased parental awareness and substitution of hard wooden and ceramic toilet seats with lighter materials or slow-close technology.


Introduction
Crush penile injury is a developmental hazard to male toddlers during toilet training.The incidence appears on the rise in recent years (Glass et al, 2013).Clinicians looking after young children should be aware of this kind of genital trauma and be able to distinguish it from abusive injuries.The following case report of a non-witnessed genital injury is illustrative.

Case Report
A 27-month-old boy was left alone in the toilet to urinate.All of a sudden, his father heard a scream from outside.He rushed in and found the toddler crying beside the toilet bowl with his pants down.The penis was bruised with blood oozing from the preputial opening.The toilet seat was down and some urine was spilled on the floor.
The child was taken by his parents to the hospital.The child's growth parameters were normal with no significant signs of injury outside the perineum.The distal part of the penis was swollen and covered with a bruise marked by a linear proximal border.A superficial laceration was found in the prepuce, and stale blood was noticed around the preputial opening (Fig. 1).______________________________________________________________________________________________________________  These signs were consistent with the parents' notion that the injury might have occurred when the wooden toilet seat fell and impaled onto the external genitalia while the child was passing urine directly into the toilet.

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The child was able to continue to pass urine without obstruction or gross hematuria.
The injuries resolved spontaneously without any specific treatment.

Discussion
Pediatric penile injuries may be accidental (Widni et al, 2011), iatrogenic and are often associated with circumcision (El-Bahnasawy and El-Sherbiny, 2002), or abusive (Hobbs and Osman, 2007) in nature.Unintentional injuries to the male external genitalia may occur from falls, during playful activities, sports, and motor vehicle or motorbike accidents (Widni et al, 2011).Male toddlers or preschool children tend to sustain genital injuries at home.The bathtub appears to be a dangerous spot when young children presenting with severe impalement injuries to the perineum are investigated (Sugar and Feldman, 2007).The toilet seat may be a hazard for the toddler graduating from toilet training (Glass et al, 2013).
The pattern of injury associated with toilet seat impalement as opposed to other kinds of genital trauma has not been described in the literature.The present case report may provide a helpful clue for the emergency physician to evaluate pediatric patients presenting with acute penile injuries.Injury largely limited to the distal part of the penis with a linear proximal border is consistent with an unintentional trauma due to a falling toilet seat.
Children suffering from toilet seat injury generally do not require specific treatment and the condition will recover invariably (Glass et al, 2013;Widni et al, 2011).Parents are instructed to observe for urinary obstruction, gross hematuria, and skin infection as potential complications, though no urethral complications have so far been reported.
It has been suggested that families with young male toddlers should avoid using toilet seats made from hard solid materials such as wood or ceramic (Philip et al, 2008), and toilet seats should be left in the lift-up position when it is not in use.Slowclose toilet seat technology will be another safety alternative (Glass et al, 2013).Epidemiologic data are needed to back up these recommendations although there is very little, if any, harms to implement such changes in most households.

Figure 1 :
Figure 1: Bruises and superficial laceration limited to the distal half of the penis with stale blood at the preputial opening.Note the linear proximal border of the bruise.The scrotum and the perineum were healthy