Brad Figler, MD
Hunter Wessells, MD, FACS
BASICS
DESCRIPTION
• Burns to the external genitalia and perineum can damage skin, subcutaneous tissue, and surrounding organs and can be due to thermal, electrical, or chemical contact
• Thermal (most common): Includes scalding and immersion injuries, direct contact with flames or hot objects
• Electrical: Passage of an electrical current from 1 point to another through the body
• Chemical: Corrosive and alkali substances found in household and industrial chemicals
EPIDEMIOLOGY
Incidence
• Genital/perineal burns are rarely isolated
• Genitals/perineum involved in 5–13% of burns treated at major burn centers
• Abuse or neglect in 10–15% of childhood burn injuries (higher if <2 yr of age)
RISK FACTORS
• Age: Very young (scald burns common in abused children) and very old
• Employment: Exposure to flames or caustic substances
• Gender: Women are less likely to experience genital or perineal burns (less exposed)
Genetics
N/A
PATHOPHYSIOLOGY
• Classification (1)
– 1st-degree (superficial): Epidermis
– 2nd-degree (partial thickness): Dermis
Superficial (involving the superficial, papillary dermis)
Deep (involving reticular dermis)
– 3rd-degree: Underlying subcutaneous tissue
Typically not painful due to nerve damage
– 4th-degree: Bone and muscle
Can lead to compartment syndrome
Often fatal
ASSOCIATED CONDITIONS
• Child and spousal abuse
• Sexual abuse
• Myoglobinuria (electrical burns)
GENERAL PREVENTION
• Follow occupational-specific safety precautions.
• Handle caustic chemicals with care.
DIAGNOSIS
HISTORY
• Type of burn (thermal, chemical, or electrical)
• Causative agent or heat source (eg, flame vs. water, noxious substance)
• Location and areas involved (Rule of 9s): External genitalia and perineum usually accounts for 1% of body surface area when using “Rule of 9s".
• Possibility of other injuries (eg, fractures from motor vehicle accidents, shrapnel)
• Pediatric considerations
– Evaluate for scald and immersion injuries
PHYSICAL EXAM
• Complete assessment including ABCD’s of Advanced Trauma Life Support (ATLS). Often associated with concomitant injuries or further burns
– with electrical burns determine any other entry/exit site of current
• Rule of 9s: Based on total body surface involved. Genitalia/perineum accounts for 1% of body area
• Vital signs (patients with electrical burns will require cardiac monitoring for at least 24 hr)
• Neurologic exam: Evaluate for compartment syndrome, peripheral pulses
• GU: Examine for involvement of phallus, meatus, glans, and scrotum
• Classification:
– 1st-degree: Characterized by erythema, white plaques, and mild pain
– 2nd-degree: Characterized by erythema, pain, superficial blisters
– 3rd/4th-degree: Characterized by eschars, blistering, and absence of pain due to loss of nerve fibers
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Electrolytes: Treatment of burns generally requires large amount of fluid resuscitation
• With electrical burns, monitor creatine kinase and urine myoglobin
Imaging
As indicated by history or physical findings
Diagnostic Procedures/Surgery
N/A
Pathologic Findings
• 3 zones of burns:
– Zone of coagulation: Occurs at point of maximum damage. In this zone, there is irreversible tissue loss due to coagulation of the constituent proteins.
– Zone of stasis: Surrounding zone of stasis is characterized by decreased tissue perfusion. The tissue in this zone is potentially salvageable. The main aim of burn resuscitation is to increase tissue perfusion here and prevent any damage from becoming irreversible. Additional insults – such as prolonged hypotension, infection, or edema – can convert this zone into an area of complete tissue loss.
• Zone of hyperemia: In this outermost zone, tissue perfusion is increased. The tissue here will invariably recover unless there is severe sepsis or prolonged hypoperfusion.
DIFFERENTIAL DIAGNOSIS
• Diagnosis is usually apparent based on history and examination
ALERT
Treat any-life-threatening conditions (ABCD’s). IVF: Resuscitation is critical if patient has severe burns.
TREATMENT
GENERAL MEASURES
• Treat any life-threatening conditions (ABCD)
– Do not attempt to cool wound as this may cause more extensive injury
• Shock may occur; IVF critical
– >20% total body surface area (TBSA), use modified Brooke formula:
2 mL/kg/TBSA
• Most chemical burns should be copiously irrigated. If agent is known use guidelines:
– Hydrofluoric acid: Irrigate with calcium gluconate
– Hydrochloric acid or sulfuric acid: Use bicarbonate irrigation
– Phenol: No irrigation
MEDICATION
First Line
• Silver sulfadiazine 1%: Apply to affected area
– Does not penetrate eschar
• Mafenide acetate (Sulfamylon) 11.1%
– Penetrates eschar
• Pain control
– Narcotics
– Anti-inflammatories
• Fluid resuscitation
• Electrolytes as needed
• Tetanus prophylaxis
• Antibiotic prophylaxis not necessary
– Treat specific infections as they arise.
SURGERY/OTHER PROCEDURES (2,3)
• Most burns, particularly in children, should be managed with conservative treatment and require no surgical intervention.
• Foley catheter or suprapubic drainage may be used, but are often not necessary
• Mainstay of surgical treatment, if needed, is careful debridement.
• Affected areas may require skin coverage:
– Granulation indicates acceptable graft bed
– Split-thickness skin grafts have reliable graft take and excellent cosmesis
– Skin grafts can be meshed or unmeshed
– If graft bed health is questionable, can use temporary xenograft
• Wound contractures are not uncommon; treat with z-plasty
• Urethral stricture may develop; should be treated in a delayed fashion (4)
– Catheter drainage may be required in the interim
ONGOING CARE
PROGNOSIS
• Based on degree and extent of burn
• Most burns have matured by 6–12 mo; additional reconstruction may be required at that time
COMPLICATIONS
• Erectile dysfunction
• Scarring/disfigurement
• Urethral strictures
FOLLOW-UP
Patient Monitoring
• Follow-up as indicated
Patient Resources
• American Burn Association
www.ameriburn.org
• Phoenix Society for Burn Survivors
www.phoenix-society.org
REFERENCES
1. Hettiaratchy, Dziewulski. ABC’s of burns. Br Med J. 2004;328:1427–1429.
2. Black PC, Friedrich JB, Engrav LH, et al. Meshed unexpanded split-thickness skin grafting for reconstruction of penile skin loss. J Urol. 2004;172(3):976–979.
3. Angel C, Shu T, French D, et al. Genital and perineal burns in children: 10 years of experience at a major burn center. J Pediatr Surg. 2002;37(1):99–103.
4. Michielsen D, Van Hee R, Neetens C, et al. Burns to genitalia and perineum. J Urol. 1998;159(2):418–419.
ADDITIONAL READING
• Michielsen DP, Lafaire C. Management of genital burns: A review. Int J Urol. 2010;17(9):755–758.
• Peck MD, Boileau MA, Grube BJ, et al. The management of burns to the perineum and genitals. J Burn Care Rehabilitation. 1990;11(1):54–56.
• Vanni AJ. Trauma to the external genitalia. In: Wessells, ed. Urological Emergencies. Totowa NJ: Humana Press, 2013.
See Also (Topic, Algorithm, Media)
• Burns, External Genitalia and Perineum Image 
• Penis, Trauma
• Scrotum and Testicle, Trauma
CODES
ICD9
• 942.05 Burn of unspecified degree of genitalia
• 942.15 Erythema [first degree] of genitalia
• 942.25 Blisters, epidermal loss [second degree] of genitalia
ICD10
• T21.06XA Burn of unsp degree of male genital region, init encntr
• T21.07XA Burn of unsp degree of female genital region, init encntr
• T21.16XA Burn of first degree of male genital region, init encntr
CLINICAL/SURGICAL PEARLS
• Genital/perineal burns are rarely isolated.
• Favor conservative management initially.
• Excellent functional and cosmetic results are possible with split-thickness skin grafting.