- Email: [email protected]
Dog Bites to the Male Genitalia: Characteristics, Management and Comparison with Human Bites
0022-534 7/93/1492-0286$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 149, 286-289, February 1993 Printed in U.S.A.
DOG BITES TO THE MALE GENITALIA: CHARACTERISTICS, MANAGEMENT AND COMPARISON WITH HUMAN BITES J. STUART WOLF, JR., CHARLES TURZAN, EUGENE V. CATTOLICA AND JACK W. MCANINCH* From the Departments of Urology, University of California School of Medicine and San Francisco General Hospital, San Francisco and Kaiser Permanente Medical Center, Oakland, California
ABSTRACT
Dog bites to the external male genitalia occur infrequently. We present 4 new cases and review 4 others described previously. Victims tend to seek medical care quickly. Thus, morbidity is directly related to the severity of the initial wound and delayed infectious complications appear to be minimal. Guidelines for management include irrigation, debridement as necessary, empiric anti biotics, consideration of tetanus and rabies immunization, and primary wound closure or surgical reconstruction. The differences between dog bites and human bites to the genitalia-primarily interval to presentation and subsequent likelihood of infection-are summarized. Measures to prevent dog bites are discussed. KEY WORDS: penis; wounds and injuries; bites and stings; genitalia, male
With an annual incidence of 1.5 to 2 million dog bites in the United States, 1 in 1 7 dogs bites someone every year,1' 2 account ing for almost 1 % of all emergency department visits.3 Despite these figures dog bite injuries to the male genitalia are rarely reported in the literature (table 1).4-6 Genital trauma secondary to dog bites involves somewhat different management princi ples from other types of genital trauma. We review 4 new and 4 previously reported cases, emphasizing the special aspects of the evaluation and treatment of these injuries. MATERIALS AND METHODS
Medical records at our institutions were searched, and 4 cases of dog bite injury to the male genitalia were identified. The records were reviewed with attention to mechanism, injury, dog characteristics, treatment, antibiotics and outcome. RESULTS
The ages of the 4 victims were 3 weeks, and 21, 32 and 42 years (table 2). In 3 cases the dog was known to the victim. The attack was believed to be unprovoked in all instances. The dog was reported to be a German shepherd in 2 cases, a Doberman pinscher in 1 and described as large in 1. All victims presented to the emergency department immediately after in jury. Of the cases 2 involved severe lacerations and punctures to the scrotum and penis, with loss of 1 or both testicles (fig. 1). Treatment in both cases entailed irrigation and debride ment, suture ligation of the amputated spermatic cord(s) and primary closure. One victim with a 2 cm. laceration on the scrotum was treated as an outpatient with primary closure after irrigation. One patient required only antibiotics and genital elevation for 2 puncture wounds to the penis (fig. 2). Wounds Accepted for publication May 29, 1992. * Requests for reprints: Department of Urology, U-575, University of California, San Francisco, California 94143-0738.
in all patients healed well. Both adults with penile mJuries reported normal erections upon followup. There were no infec tious complications. DISCUSSION
The literature on dog bites in general is extensive. A careful assessment of this information, a review of our cases and others reported, and the application of the principles of genital trauma management allow us to elucidate guidelines for the evaluation and treatment of genital injuries by dog bite. Considering that the jaws of a biting dog can develop forces up to 400 pounds per square inch,3 it is surprising that injuries to the genitalia, serious as many of them have been, are not more severe. Of the 8 well described cases (including our 4) 2 included puncture wounds to the penile shaft and 2 involved at least partial amputation of the glans penis. In 5 patients skin loss or avulsion was significant, with 2 requiring skin grafting. In 3 patients at least 1 spermatic cord was amputated. Irrigation and debridement are the cornerstones of manage ment of any penetrating genital trauma. Dog bite lacerations can be sutured closed safely if there is no infection.7 Skin avulsion from the penis may require extensive debridement and skin grafts or flaps. After observation and dressing changes for a few days to be certain no infection is present, we recommend nonmeshed thick split-thickness grafts (16/1,000 inch) in the potent patient because such grafts have little contracture and yield excellent functional results.8 Scrotal wounds can usually be closed primarily, since any bite that removes a large amount of scrotal skin will likely amputate the spermatic cord as well. Thigh pouches or meshed split-thickness skin grafts are appro priate if testicular coverage is needed.8 The most controversial aspect of dog bite injuries is antimi crobial treatment. The typical pathogens include Staphylococ cus and Streptococcus species, aerobic rods such as Escherichia coli, Pasteurella multocida and Moraxella species, the anaero-
TABLE 1. Dog bites to the male genitalia-previously reported cases
Reference Kyriakidis et al' Donovan and Kaplan' (2 cases)
Piza-Katzer and Latal6
Injury Partial amputation of glans Amputation of glans, avul sion of penile skin Avulsion of penile and scrotal skin, amputation of 1 cord Avulsion of penile skin 286
Treatment Delayed, failed reconstruction Debridement and skin graft ing Debridement and skin graft ing Primary resuturing
287
DOG BITES TO GENITALIA TABLE 2.
Dog bites to the male genitalia-new cases Antibiotics
Pt.-Age 1-32 yrs.
2-3 wks.
Mechanism
Injury
Rt. scrotum macerated and spermatic cord amputated with loss of testis, 2 punctures to penis Family dog found chewing Neonatal circumcision site Intoxicated victim found in shower with family dog chewing on scrotum on victim ) s groin
3-42 yrs. Attack through shorts while jogging 4-21 yrs. Bite through pants by dog chained to bedpost
opened, entire scrotum
macerated, both testes lost 2 cm. laceration on scrotum 2 punctures to penis with hematoma, urethra normal
At Hospital Discharge
Initial
Treatment
Followup
Cefazolin
Cephradine
Irrigation and debridement, spermatic cord ligated, primary closure
Normal erections at 2 wks.
Cefazolin
None
Irrigation and debridement, spermatic cords ligated, primary closure
Healed at 1 mo., social investigation found no abuse
Amoxicillin clavulanate Ampicillin, gentamicin
Amoxicillin clavulanate Cephradine
Irrigation and primary closure Elevation of genitalia
Healed at 2 wks. Normal erections at 1 mo.
FIG. 2. Patient 4. Puncture wounds to penis with large hematoma
FIG. 1. Patient 1. A, puncture wound at base of penis. B, right hemiscrotum macerated with amputation of spermatic cord.
hie Bacteroides and Fusobacterium species, and the Centers for Disease Control alphanumeric species IIj, EF-4 and DF-2. 3 Many (25 to 36%) dog bite infections contain more than 1 pathogen9 and only 10 to 15% of bite wounds yield no bacterial growth. 10 Despite these ominous findings only 6 to 13% of all dog bite wounds become infected, although the rate does in crease to 20 to 25% for puncture wounds. 1 Callaham recom mends antimicrobial prophylaxis for dog bites only if certain risk factors are present, such as injuries to the hand, wrist or foot; over a major joint; involving punctures, or in a relatively immunocompromised person (elderly, diabetic, asplenic and so
forth). 9 Although well vascularized, the male external genitalia possess loose subcutaneous tissues that could easily permit spread of a bacterial inoculum. Given the minimal experience with dog bites to the genitalia and the serious morbidity that can accompany infections of the external genitalia, genital bites should be considered high risk wounds and empiric antibiotics should be administered in all cases until a larger study can show them to be unnecessary. Pertaining to the choice of antibiotics, common as well as serious pathogens must be considered. Oral dicloxacillin or cephalexin (both 500 mg. 4 times daily) is the antibiotic of choice. Some investigators express concern that P. multocida, present in 20 to 25% of all dog bite wounds, may be resistant to these agents. 10 Others dispute these findings and argue that dicloxacillin or cephalexin alone is usually adequate. 8• 11 The oral agents penicillin, ampicillin, amoxicillin clavulanate and cefuroxime axetil are consistently active against P. multocida. 12 The addition of penicillin V (500 mg. 4 times daily) to diclox acillin or cephalexin, costing only pennies a day more, would
288
WOLF AND ASSOCIATES TABLE
Characteristic Frequency of bites Mechanism Injury Interval to presentation Bacterial infection Morbidity Tetanus immunization Rabies prophylaxis Initial management Laboratory tests
Primary wound closure Systemic diseases potentially transmitted
3. Comparison of human and dog bite wounds to the male genitalia Human"
Dog
Minor injury probably common Sexual activity Penile Delayed Often if seeking medical care Related to delayed presentation Yes No Irrigation and debridement Complete blood count, cultures, veneral disease serology, hep atitis B virology, human im munodeficiency virus Never Syphilis, hepatitis B, hepatitis C, acquired immunodefi ciency syndrome, tetanus, tu berculosis, actinomycosis, herpes simplex, toxic shock syndrome
Rare Attack Any genital Immediate Rare Related to initial injury Yes Possibly Irrigation and debridement Complete blood count, cultures if infected
Important bacterial pathogens
Staphylococcus and Streptococ cus species, anaerobic strep tococci, Haemophilus species, Neisseria species, Eikenella corrodens, Bacteroides spe cies, Fusobacterium species
Oral antibiotics (in order of preference)
Dicloxacillin and penicillin V, cephalexin and penicillin V, cefuroxime axetil, amoxicillin clavulanate
offer assured protection against this pathogen. Alternatively, cefuroxime axetil (250 mg. twice daily) or amoxicillin clavulan ate (500 mg. 3 times daily) is effective against most dog bite pathogens, including P. multocida. The former is preferred because of better activity and fewer adverse effects.9 Either agent might be considered if a simpler and less frequently dosed regimen is desired. The cost of these agents is 6 to 8 times more than penicillin V plus either dicloxacillin or cephalexin. Sepsis secondary to numerous organisms has been docu mented after dog bite. In addition, systemic diseases may be transmitted, including brucellosis, melioidosis, pasteurellosis, yersiniosis, tularemia, tetanus, erysipeloid, leptospirosis, rabies, cat scratch disease, lymphocytic choriomeningitis and blasto mycosis.1 Appropriate steps regarding tetanus and rabies must be taken. Briefly, tetanus toxoid should be administered to those with questionable immunization history. Rabies precau tions require observation of the dog for 10 days or, if the animal is unavailable, consultation with public health officials knowl edgeable about local conditions. Both protocols are summarized in texts present in most emergency departments.1· 3• 11 As with any traumatic injury, the best measure is prevention. Knowledge of the characteristics of biting dogs and their vic tims is helpful in this regard. The most likely dog to bite would be a young male animal of a large working or sporting breed that is not a stray.13 All of the dogs in our series were large and at least 3 were owned by the victim or a person known to him. The most likely person to be bitten is a boy wh6 knows the dog ( 4 of the 8 patients were children).13 Whether attacks are more frequently provoked or unprovoked is unknown. Strategies for preventing dog bites include animal control laws, effective breeding programs, education of dog owners and their families, and identification of overly aggressive dogs.13 Table 3 lists certain characteristics of genital bite injuries and their treatment, comparing dog bites with human bites.14 Several management points vary between the 2 types and the urologist should be aware of these differences. Most significant is the fact that victims of human bites often seek medical care only after a substantial delay but dog bite victims do so im mediately after injury. Embarrassment about the former injury and fright regarding the latter probably have a role in this
Recommended if uninfected Brucellosis, melioidosis, rabies, pasteurellosis, yersiniosis, tularemia, tetanus, erysipe loid, leptospirosis, blastomy cosis, cat scratch disease, lymphocytic choriomeningi tis Staphylococcus and Strepto coccus species, E. coli, Mor axella species, P. multocida, Centers for Disease Control series-Ilj, EF-4, DF-2, Bac teroides species, Fusobacter ium species Same as for human bites
distinction. This difference in presentation time undoubtedly is part of the reason why, at the time of initial medical assess ment, human bite wounds are often infected but dog bite wounds are clinically without gross infection. Although the bacteriology of the wounds differs, the recommendation for antibiotics is the same. In summary, dog bites to the genitalia occur infrequently. Initial evaluation should include a directed history and physical examination. A complete blood count is the only suggested laboratory test, although cultures are reasonable in the unusual case of infection at presentation. Infection does not appear to be a problem in general but empiric antibiotics are nonetheless indicated. Evaluation for tetanus or rabies immunization is necessary. After irrigation, wounds should be debrided if there is any question of tissue viability. Primary closure is preferred if there is no infection. Further surgical management follows the usual guidelines for genital trauma. Hospitalization is in dicated if the patient is debilitated, suffers from immuno suppression, requires surgery or is unreliable for self-assess ment. Dr. Laurence S. Baskin supplied figure 2. REFERENCES
1. Callaham, M. L.: Domestic and feral mammalian bites. In: Man agement of Wilderness and Environmental Emergencies. Edited by P. S. Auerbach and E. C. Geehr. New York: Macmillan & Co., chapt. 11, pp. 310-351, 1983. 2. Pinckney, L. E. and Kennedy, L. A.: Traumatic deaths from dog attacks in the United States. Pediatrics, 69: 193, 1982. 3. Doan-Wiggins, L.: Animal bites and rabies. In: Emergency Medi cine: Concepts and Clinical Practice, 2nd ed. Edited by P. Rosen, F. J. Baker, II, R. M. Barkin, G. R. Braen, R.H. Dailey and R. C. Levy. St. Louis: The C. V. Mosby Co., chapt. 52, pp. 965-980, 1988. 4. Kyriakidis, A., Karydis, G. and Yannopoulos, P.: An unusual trauma of the glans penis. Brit. J. Urol., 51: 161, 1979. 5. Donovan, J. F. and Kaplan, W. E.: The therapy of genital trauma by dog bite. J. Urol., 141: 1163, 1989. 6. Piza-Katzer,H. and Latal, D.: Late results following avulsion injury of the shaft of the penis. Unfallchirurgie, 15: 208, 1989.
DOG BITES TO GENITALIA 7. Maimaris, C. and Quinton, D. N.: Dog-bite lacerations: a controlled trial of primary wound closure. Arch. Emerg. Med., 5: 156, 1988. 8. McAninch, J. W.: Management of genital skin loss. Urol. Clin. N. Amer., 16: 387, 1989. 9. Callaham, M.: Controversies in antibiotic choices for bite wounds. Ann. Emerg. Med., 17: 1321, 1988. 10. Goldstein, E. J.C.: Management of human and animal bite wounds. J. Amer. Acad. Dermatol., 21: 1275, 1989. 11. Jorden, R. C.: Bites and stings. In: Emergency Medicine: A Com prehensive Review, 2nd ed. Edited by T. C. Kravis and C. G.
289
Warner. Rockville, Maryland: Aspen Publishers, Inc., chapt. 43, pp. 605-628, 1987. 12. Goldstein, E. J., Citron, D. M. and Richwald, G. A.: Lack of in vitro efficacy of oral forms of certain cephalosporins, erythro mycin, and oxacillin against Pasteurella multocida. Antimicrob. Agents Chemother., 32: 213, 1988. 13. Wright, J.C.: Canine aggression toward people: bite scenarios and prevention. Vet. Clin. N. Amer., 21: 299, 1991. 14. Wolf, J. S., Jr., Gomez, R. and McAninch, J. W.: Human bites to the penis. J. Urol., 147: 1265, 1992.
Vol. 149, 286-289, February 1993 Printed in U.S.A.
DOG BITES TO THE MALE GENITALIA: CHARACTERISTICS, MANAGEMENT AND COMPARISON WITH HUMAN BITES J. STUART WOLF, JR., CHARLES TURZAN, EUGENE V. CATTOLICA AND JACK W. MCANINCH* From the Departments of Urology, University of California School of Medicine and San Francisco General Hospital, San Francisco and Kaiser Permanente Medical Center, Oakland, California
ABSTRACT
Dog bites to the external male genitalia occur infrequently. We present 4 new cases and review 4 others described previously. Victims tend to seek medical care quickly. Thus, morbidity is directly related to the severity of the initial wound and delayed infectious complications appear to be minimal. Guidelines for management include irrigation, debridement as necessary, empiric anti biotics, consideration of tetanus and rabies immunization, and primary wound closure or surgical reconstruction. The differences between dog bites and human bites to the genitalia-primarily interval to presentation and subsequent likelihood of infection-are summarized. Measures to prevent dog bites are discussed. KEY WORDS: penis; wounds and injuries; bites and stings; genitalia, male
With an annual incidence of 1.5 to 2 million dog bites in the United States, 1 in 1 7 dogs bites someone every year,1' 2 account ing for almost 1 % of all emergency department visits.3 Despite these figures dog bite injuries to the male genitalia are rarely reported in the literature (table 1).4-6 Genital trauma secondary to dog bites involves somewhat different management princi ples from other types of genital trauma. We review 4 new and 4 previously reported cases, emphasizing the special aspects of the evaluation and treatment of these injuries. MATERIALS AND METHODS
Medical records at our institutions were searched, and 4 cases of dog bite injury to the male genitalia were identified. The records were reviewed with attention to mechanism, injury, dog characteristics, treatment, antibiotics and outcome. RESULTS
The ages of the 4 victims were 3 weeks, and 21, 32 and 42 years (table 2). In 3 cases the dog was known to the victim. The attack was believed to be unprovoked in all instances. The dog was reported to be a German shepherd in 2 cases, a Doberman pinscher in 1 and described as large in 1. All victims presented to the emergency department immediately after in jury. Of the cases 2 involved severe lacerations and punctures to the scrotum and penis, with loss of 1 or both testicles (fig. 1). Treatment in both cases entailed irrigation and debride ment, suture ligation of the amputated spermatic cord(s) and primary closure. One victim with a 2 cm. laceration on the scrotum was treated as an outpatient with primary closure after irrigation. One patient required only antibiotics and genital elevation for 2 puncture wounds to the penis (fig. 2). Wounds Accepted for publication May 29, 1992. * Requests for reprints: Department of Urology, U-575, University of California, San Francisco, California 94143-0738.
in all patients healed well. Both adults with penile mJuries reported normal erections upon followup. There were no infec tious complications. DISCUSSION
The literature on dog bites in general is extensive. A careful assessment of this information, a review of our cases and others reported, and the application of the principles of genital trauma management allow us to elucidate guidelines for the evaluation and treatment of genital injuries by dog bite. Considering that the jaws of a biting dog can develop forces up to 400 pounds per square inch,3 it is surprising that injuries to the genitalia, serious as many of them have been, are not more severe. Of the 8 well described cases (including our 4) 2 included puncture wounds to the penile shaft and 2 involved at least partial amputation of the glans penis. In 5 patients skin loss or avulsion was significant, with 2 requiring skin grafting. In 3 patients at least 1 spermatic cord was amputated. Irrigation and debridement are the cornerstones of manage ment of any penetrating genital trauma. Dog bite lacerations can be sutured closed safely if there is no infection.7 Skin avulsion from the penis may require extensive debridement and skin grafts or flaps. After observation and dressing changes for a few days to be certain no infection is present, we recommend nonmeshed thick split-thickness grafts (16/1,000 inch) in the potent patient because such grafts have little contracture and yield excellent functional results.8 Scrotal wounds can usually be closed primarily, since any bite that removes a large amount of scrotal skin will likely amputate the spermatic cord as well. Thigh pouches or meshed split-thickness skin grafts are appro priate if testicular coverage is needed.8 The most controversial aspect of dog bite injuries is antimi crobial treatment. The typical pathogens include Staphylococ cus and Streptococcus species, aerobic rods such as Escherichia coli, Pasteurella multocida and Moraxella species, the anaero-
TABLE 1. Dog bites to the male genitalia-previously reported cases
Reference Kyriakidis et al' Donovan and Kaplan' (2 cases)
Piza-Katzer and Latal6
Injury Partial amputation of glans Amputation of glans, avul sion of penile skin Avulsion of penile and scrotal skin, amputation of 1 cord Avulsion of penile skin 286
Treatment Delayed, failed reconstruction Debridement and skin graft ing Debridement and skin graft ing Primary resuturing
287
DOG BITES TO GENITALIA TABLE 2.
Dog bites to the male genitalia-new cases Antibiotics
Pt.-Age 1-32 yrs.
2-3 wks.
Mechanism
Injury
Rt. scrotum macerated and spermatic cord amputated with loss of testis, 2 punctures to penis Family dog found chewing Neonatal circumcision site Intoxicated victim found in shower with family dog chewing on scrotum on victim ) s groin
3-42 yrs. Attack through shorts while jogging 4-21 yrs. Bite through pants by dog chained to bedpost
opened, entire scrotum
macerated, both testes lost 2 cm. laceration on scrotum 2 punctures to penis with hematoma, urethra normal
At Hospital Discharge
Initial
Treatment
Followup
Cefazolin
Cephradine
Irrigation and debridement, spermatic cord ligated, primary closure
Normal erections at 2 wks.
Cefazolin
None
Irrigation and debridement, spermatic cords ligated, primary closure
Healed at 1 mo., social investigation found no abuse
Amoxicillin clavulanate Ampicillin, gentamicin
Amoxicillin clavulanate Cephradine
Irrigation and primary closure Elevation of genitalia
Healed at 2 wks. Normal erections at 1 mo.
FIG. 2. Patient 4. Puncture wounds to penis with large hematoma
FIG. 1. Patient 1. A, puncture wound at base of penis. B, right hemiscrotum macerated with amputation of spermatic cord.
hie Bacteroides and Fusobacterium species, and the Centers for Disease Control alphanumeric species IIj, EF-4 and DF-2. 3 Many (25 to 36%) dog bite infections contain more than 1 pathogen9 and only 10 to 15% of bite wounds yield no bacterial growth. 10 Despite these ominous findings only 6 to 13% of all dog bite wounds become infected, although the rate does in crease to 20 to 25% for puncture wounds. 1 Callaham recom mends antimicrobial prophylaxis for dog bites only if certain risk factors are present, such as injuries to the hand, wrist or foot; over a major joint; involving punctures, or in a relatively immunocompromised person (elderly, diabetic, asplenic and so
forth). 9 Although well vascularized, the male external genitalia possess loose subcutaneous tissues that could easily permit spread of a bacterial inoculum. Given the minimal experience with dog bites to the genitalia and the serious morbidity that can accompany infections of the external genitalia, genital bites should be considered high risk wounds and empiric antibiotics should be administered in all cases until a larger study can show them to be unnecessary. Pertaining to the choice of antibiotics, common as well as serious pathogens must be considered. Oral dicloxacillin or cephalexin (both 500 mg. 4 times daily) is the antibiotic of choice. Some investigators express concern that P. multocida, present in 20 to 25% of all dog bite wounds, may be resistant to these agents. 10 Others dispute these findings and argue that dicloxacillin or cephalexin alone is usually adequate. 8• 11 The oral agents penicillin, ampicillin, amoxicillin clavulanate and cefuroxime axetil are consistently active against P. multocida. 12 The addition of penicillin V (500 mg. 4 times daily) to diclox acillin or cephalexin, costing only pennies a day more, would
288
WOLF AND ASSOCIATES TABLE
Characteristic Frequency of bites Mechanism Injury Interval to presentation Bacterial infection Morbidity Tetanus immunization Rabies prophylaxis Initial management Laboratory tests
Primary wound closure Systemic diseases potentially transmitted
3. Comparison of human and dog bite wounds to the male genitalia Human"
Dog
Minor injury probably common Sexual activity Penile Delayed Often if seeking medical care Related to delayed presentation Yes No Irrigation and debridement Complete blood count, cultures, veneral disease serology, hep atitis B virology, human im munodeficiency virus Never Syphilis, hepatitis B, hepatitis C, acquired immunodefi ciency syndrome, tetanus, tu berculosis, actinomycosis, herpes simplex, toxic shock syndrome
Rare Attack Any genital Immediate Rare Related to initial injury Yes Possibly Irrigation and debridement Complete blood count, cultures if infected
Important bacterial pathogens
Staphylococcus and Streptococ cus species, anaerobic strep tococci, Haemophilus species, Neisseria species, Eikenella corrodens, Bacteroides spe cies, Fusobacterium species
Oral antibiotics (in order of preference)
Dicloxacillin and penicillin V, cephalexin and penicillin V, cefuroxime axetil, amoxicillin clavulanate
offer assured protection against this pathogen. Alternatively, cefuroxime axetil (250 mg. twice daily) or amoxicillin clavulan ate (500 mg. 3 times daily) is effective against most dog bite pathogens, including P. multocida. The former is preferred because of better activity and fewer adverse effects.9 Either agent might be considered if a simpler and less frequently dosed regimen is desired. The cost of these agents is 6 to 8 times more than penicillin V plus either dicloxacillin or cephalexin. Sepsis secondary to numerous organisms has been docu mented after dog bite. In addition, systemic diseases may be transmitted, including brucellosis, melioidosis, pasteurellosis, yersiniosis, tularemia, tetanus, erysipeloid, leptospirosis, rabies, cat scratch disease, lymphocytic choriomeningitis and blasto mycosis.1 Appropriate steps regarding tetanus and rabies must be taken. Briefly, tetanus toxoid should be administered to those with questionable immunization history. Rabies precau tions require observation of the dog for 10 days or, if the animal is unavailable, consultation with public health officials knowl edgeable about local conditions. Both protocols are summarized in texts present in most emergency departments.1· 3• 11 As with any traumatic injury, the best measure is prevention. Knowledge of the characteristics of biting dogs and their vic tims is helpful in this regard. The most likely dog to bite would be a young male animal of a large working or sporting breed that is not a stray.13 All of the dogs in our series were large and at least 3 were owned by the victim or a person known to him. The most likely person to be bitten is a boy wh6 knows the dog ( 4 of the 8 patients were children).13 Whether attacks are more frequently provoked or unprovoked is unknown. Strategies for preventing dog bites include animal control laws, effective breeding programs, education of dog owners and their families, and identification of overly aggressive dogs.13 Table 3 lists certain characteristics of genital bite injuries and their treatment, comparing dog bites with human bites.14 Several management points vary between the 2 types and the urologist should be aware of these differences. Most significant is the fact that victims of human bites often seek medical care only after a substantial delay but dog bite victims do so im mediately after injury. Embarrassment about the former injury and fright regarding the latter probably have a role in this
Recommended if uninfected Brucellosis, melioidosis, rabies, pasteurellosis, yersiniosis, tularemia, tetanus, erysipe loid, leptospirosis, blastomy cosis, cat scratch disease, lymphocytic choriomeningi tis Staphylococcus and Strepto coccus species, E. coli, Mor axella species, P. multocida, Centers for Disease Control series-Ilj, EF-4, DF-2, Bac teroides species, Fusobacter ium species Same as for human bites
distinction. This difference in presentation time undoubtedly is part of the reason why, at the time of initial medical assess ment, human bite wounds are often infected but dog bite wounds are clinically without gross infection. Although the bacteriology of the wounds differs, the recommendation for antibiotics is the same. In summary, dog bites to the genitalia occur infrequently. Initial evaluation should include a directed history and physical examination. A complete blood count is the only suggested laboratory test, although cultures are reasonable in the unusual case of infection at presentation. Infection does not appear to be a problem in general but empiric antibiotics are nonetheless indicated. Evaluation for tetanus or rabies immunization is necessary. After irrigation, wounds should be debrided if there is any question of tissue viability. Primary closure is preferred if there is no infection. Further surgical management follows the usual guidelines for genital trauma. Hospitalization is in dicated if the patient is debilitated, suffers from immuno suppression, requires surgery or is unreliable for self-assess ment. Dr. Laurence S. Baskin supplied figure 2. REFERENCES
1. Callaham, M. L.: Domestic and feral mammalian bites. In: Man agement of Wilderness and Environmental Emergencies. Edited by P. S. Auerbach and E. C. Geehr. New York: Macmillan & Co., chapt. 11, pp. 310-351, 1983. 2. Pinckney, L. E. and Kennedy, L. A.: Traumatic deaths from dog attacks in the United States. Pediatrics, 69: 193, 1982. 3. Doan-Wiggins, L.: Animal bites and rabies. In: Emergency Medi cine: Concepts and Clinical Practice, 2nd ed. Edited by P. Rosen, F. J. Baker, II, R. M. Barkin, G. R. Braen, R.H. Dailey and R. C. Levy. St. Louis: The C. V. Mosby Co., chapt. 52, pp. 965-980, 1988. 4. Kyriakidis, A., Karydis, G. and Yannopoulos, P.: An unusual trauma of the glans penis. Brit. J. Urol., 51: 161, 1979. 5. Donovan, J. F. and Kaplan, W. E.: The therapy of genital trauma by dog bite. J. Urol., 141: 1163, 1989. 6. Piza-Katzer,H. and Latal, D.: Late results following avulsion injury of the shaft of the penis. Unfallchirurgie, 15: 208, 1989.
DOG BITES TO GENITALIA 7. Maimaris, C. and Quinton, D. N.: Dog-bite lacerations: a controlled trial of primary wound closure. Arch. Emerg. Med., 5: 156, 1988. 8. McAninch, J. W.: Management of genital skin loss. Urol. Clin. N. Amer., 16: 387, 1989. 9. Callaham, M.: Controversies in antibiotic choices for bite wounds. Ann. Emerg. Med., 17: 1321, 1988. 10. Goldstein, E. J.C.: Management of human and animal bite wounds. J. Amer. Acad. Dermatol., 21: 1275, 1989. 11. Jorden, R. C.: Bites and stings. In: Emergency Medicine: A Com prehensive Review, 2nd ed. Edited by T. C. Kravis and C. G.
289
Warner. Rockville, Maryland: Aspen Publishers, Inc., chapt. 43, pp. 605-628, 1987. 12. Goldstein, E. J., Citron, D. M. and Richwald, G. A.: Lack of in vitro efficacy of oral forms of certain cephalosporins, erythro mycin, and oxacillin against Pasteurella multocida. Antimicrob. Agents Chemother., 32: 213, 1988. 13. Wright, J.C.: Canine aggression toward people: bite scenarios and prevention. Vet. Clin. N. Amer., 21: 299, 1991. 14. Wolf, J. S., Jr., Gomez, R. and McAninch, J. W.: Human bites to the penis. J. Urol., 147: 1265, 1992.