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CASE REPORT
Year : 2006  |  Volume : 22  |  Issue : 4  |  Page : 370-371
 

A costly sting! Preputial gangrene following a wasp sting


1 Department of Urology, Leighton Hospital, Crewe, United Kingdom
2 Department of Urology, Wexham Park Hospital, Slough, United Kingdom

Correspondence Address:
Vishwanath S Hanchanale
Research Fellow, Urology, Leighton Hospital, Crewe, Cheshire, CW1 4QJ
United Kingdom
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-1591.29129

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   Abstract 

Penile injuries due to bites and stings are under-reported. The extent of injury depends not only on the initial trauma but also on the secondary injuries due to toxins and bacterial infections transmitted by the bite. Wasp bites are on the increase worldwide as humans encroach on their habitat. We report a case of wasp bite to the preputial skin of the penis leading to severe phimosis, difficulty in micturition and localized gangrene requiring emergency circumcision. Analysis of such cases can provide important information on the determinants of severe morbidity that may then be used in injury prevention.


Keywords: Emergency circumcision, prepuce, wasp sting


How to cite this article:
Hanchanale VS, Rao AR, Motiwala HG. A costly sting! Preputial gangrene following a wasp sting. Indian J Urol 2006;22:370-1

How to cite this URL:
Hanchanale VS, Rao AR, Motiwala HG. A costly sting! Preputial gangrene following a wasp sting. Indian J Urol [serial online] 2006 [cited 2017 Mar 30];22:370-1. Available from: http://www.indianjurol.com/text.asp?2006/22/4/370/29129



   Introduction Top


The human penis is an organ that has somehow attracted the wrath of a variety of animals and arthropods. It is estimated that one in two Americans is bitten by an animal, arthropod or human in their lifetime. In the United States such bites account for yearly 800,000 injuries requiring medical attention.[1] The reported animals include dogs, horses, donkeys, cats, bees, ants, wasps, spiders, ticks, snakes, scorpions and not to mention the most vicious of all, the humans.[2] Bee and wasp bites are becoming more common and it is estimated that for one person in 100, the sting of the insect can be fatal and it is indeed the overall leading cause of death due to bites and stings. We report an unusual case of wasp bite to the penis in a child leading to localized ulceration and gangrene requiring emergency circumcision.


   Case Report Top


A three-year-old boy attended the accident and emergency department two hours after a wasp bite on the penis. The sting occurred when the boy was passing urine in an open environment in a garden. He presented with redness, minimal edema and pain over the prepuce that settled down within one hour. General examination revealed normal vital signs and local examination showed preputial edema with no other demonstrable injuries. The boy was discharged with antihistamines and analgesics. However, three days later, the boy presented with increasing preputial swelling, difficulty in passing urine and severe pain. Examination now revealed gross edema of the preputial skin, severe phimosis, ulceration and discoloration suggesting gangrenous change surrounding the sting site. Underlying condition of the glans could not be examined. Therefore, an emergency circumcision was carried out. Dorsal slit revealed that the gangrene had extended onto the glanular surface of the prepuce [Figure - 1]. There was erythema of the glans but there was no evidence of any ulceration [Figure - 2]. Circumcision was completed and antibiotics were prescribed. Histology of the preputial skin showed severe gangrenous changes with surrounding necrosis. At follow-up, the cosmetic result was satisfactory and the boy was referred to immunologist for sensitivity testing and further advice.


   Discussion Top


Bite wounds account for approximately 1% of all emergency department visits in the United States, of which the majority involve children. These attacks may cause significant morbidity, especially with regard to immediate soft tissue injury or as late squeal, infection and necrosis.[1] The vast majority of deaths from Hymenoptera stings are caused by immediate hypersensitivity reactions to venom. The three families of stinging insects in the order hymenoptera are Vespidae (wasps, yellow jackets, hornets) , Apidae (honeybees and bumblebees) and Formicidae (stinging ants). The most medically significant wasps belong to the family Vespidae. The genera Vespula , Polistes and Ropalidia , comprise the most important subfamily of vespids, the Vespinae.[3] Wasp bites to the genital region are rare and therefore urologists are not aware of its consequences and its management.

Wasp stings can cause generalized and/or local reaction due to its venom. Generalized reactions can be severe and death due to anaphylaxis or envenomation has been reported.[4] Local reaction can be as mild as swelling, urticaria, blisters but can be severe as to cause necrosis and gangrene. As demonstrated in our case, swelling is an initial reaction, but may progress to necrosis and gangrene. Therefore, repeated examination is required till the swelling completely subsides.

Acute management includes treatment of shock and anaphylaxis. Local reaction includes careful removal of the sting, which may release more venom. It is interesting to note that bees leave behind the sting and not wasps. Wasp bites are more dangerous as they are known to sting repeatedly. Antihistamines should be administered to decrease the allergic reaction and severe cases may need steroid. Delayed manifestations such as necrosis and gangrene require surgical debridement as it may predispose to spreading infection. McGain et al reported prior histories of wasp or bee venom allergy or both in five of the seven victims, but none carried injectable adrenalin. They concluded that all patients with a history of systemic Hymenoptera sting allergy should undergo assessment for immunotherapy and carry adrenalin and information on bites and stings should therefore be incorporated within injury prevention programs.[3] Wearing protective clothing is a simple preventable measure in wasp infestation areas.

Principles of management of stings to the external genitalia are similar to other regions of the body. Loss of tissue should be prevented, as deformity resulting from it may be devastating. Infection should be prevented as perineal tissues are prone for Fournier's gangrene. Venomous bites to the external genitalia presenting as an unusual cause of acute scrotum has also been reported.[5]

In conclusion, bites to the penis are under-reported as it may be cause of embarrassment. Repeated examination of the bite area may be necessary to rule out delayed infection or necrosis of the skin as in our case.

 
   References Top

1.Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51-3.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Gomes CM, Ribeiro-Filho L, Giron AM, Mitre AI, Figueira ER, Arap S. Genital trauma due to animal bites. J Urol 2001;165:80-3.  Back to cited text no. 2  [PUBMED]  
3.McGain F, Harrison J, Winkel KD. Wasp sting mortality in Australia Med J Aust 2000;173:198-200.  Back to cited text no. 3    
4.Barr SE. Allergy to Hymenoptera stings: Review of world literature: 1953-1970. Ann Allergy 1971;29:49-66.  Back to cited text no. 4  [PUBMED]  
5.Moran ME, Ehreth JT, Drach GW. Venomous bites to the external genitalia: An unusual cause of acute scrotum. J Urol 1992;147:1085-6.  Back to cited text no. 5  [PUBMED]  


    Figures

  [Figure - 1], [Figure - 2]



 

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    Abstract
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    Case Report
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    References
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