Managing Thermal Injuries of the Penis and Scrotum: A Narrative Review

Round 1

Reviewer 1 Report

In the section for "acute management in burns", Lines 107-109, I think citation should be placed for ABA guidelines for transfer to burn center or recommend transfer to burn center.

In the section for "flaps", Lines 228 to 229, I think minimal complications and their rates should be listed. 

 

Author Response

"In the section for "acute management in burns", Lines 107-109, I think citation should be placed for ABA guidelines for transfer to burn center or recommend transfer to burn center.

In the section for "flaps", Lines 228 to 229, I think minimal complications and their rates should be listed."

The authors thank this reviewer for their constructive feedback. A sentence describing the ABA guidelines with an appropriate citation has been added. Additionally, we described further complications/rates associated with gracilis flaps, scrotal flaps, and radial forearm flaps in the “Flaps” section.

Reviewer 2 Report

Minor comments: 

Line 31: sequela is misspelled

Line 72-73: The sentence beginning with "This severity may..." appears to be missing a word between "may" and "due". 

Line 181: The sentence beginning with "Specifically, skin...", grafting is misspelled. 

Line 220-222: What is the reference for this statement ("Some literature states that if<50% of the scrotum is affected...")? Is it reference 12 or reference 25? There needs to be a reference here to verify this statement. 

Major comments: 

The introduction does not mention frostbite but includes it in the abstract, materials and methods, and discussion. Please include the rationale for including frostbite and the similarities/differences between frostbite and typical thermal injuries. 

Please make it clear which studies are looking at pediatric populations versus adult populations or if they included both. This important distinction is only clear in a handful of places in the manuscript. 

A discussion of the limitations and differences between studies would be helpful in understanding this topic. 

 

 

Author Response

"Line 31: sequela is misspelled

Line 72-73: The sentence beginning with "This severity may..." appears to be missing a word between "may" and "due". 

Line 181: The sentence beginning with "Specifically, skin...", grafting is misspelled.

Line 220-222: What is the reference for this statement ("Some literature states that if<50% of the scrotum is affected...")? Is it reference 12 or reference 25? There needs to be a reference here to verify this statement."

-We appreciate this reviewer for catching these grammatical errors and statements without references. These changes are now reflected in the manuscript, and two additional references were added to support the claim about the surface area of the scrotum.

Major comments: 

"The introduction does not mention frostbite but includes it in the abstract, materials and methods, and discussion. Please include the rationale for including frostbite and the similarities/differences between frostbite and typical thermal injuries."

Thank you for these comments. We have added to the Introduction and Methods to include a discussion about frostbite and provide our rationale for including this topic in the manuscript. Some similarities between both types of injuries are described in the frostbite section. 

"Please make it clear which studies are looking at pediatric populations versus adult populations or if they included both. This important distinction is only clear in a handful of places in the manuscript."

We agree with the reviewer that this is unclear, especially in the epidemiology section. We have revised the epidemiology section to specify the epidemiology of genital burns according to age more specifically.

"A discussion of the limitations and differences between studies would be helpful in understanding this topic."

We agree that we hope to increase the understanding of this topic among our readers. We believe several limitations regarding studies listed in the manuscript have been described, but we are open to including more analysis if certain sections require it.

Reviewer 3 Report

 

This narrative review is very well written and scientifically sound and surely deserves to be published at EBJ.

 

 

There are only some minor remarks to be pointed:

 

1.       The title is written according to the American format (all words with first letter in capitals) and should be changed to the European format (only first letter of the first word in capitals; all the others in lower case.

 

2.       In the Epidemiology section, it is stated that genitalia burns are more common in men than women and most cases due to fire or open flames. As it was even recognized by the Authors, this data refers mostly (or only) to the United States and is probably linked with cultural and/idiosyncratic factors. It should be referred that, at least in Europe, the epidemiology is a little bit different, with more women than men admitted to Burn Units with this kind of burns, and hot liquids being its first cause.

 

3.       Paying attention to the typical readers of EBJ, perhaps a description of burn degree classification could be waived.

 

4.       The Authors do not refer the use of dermal matrices for scrotum and penis reconstruction, as well as the role for xenografts and synthetic skin substitutes.

 

5.       The statement “most may recommend that urinary catheterization is not used for treating genital burns due to the inherent risk of nosocomial UTIs” is controversial and the respective references were published more than 10 years ago. Agreeing that urinary catheters soon become colonized and should be removed as soon as possible, the evolution from this colonization to real UTI will not happen every time and will depend mostly in the management of the catheters and on infection control. On the other hand, urinary catheters may be very useful to avoid burns contamination and pain at least in the first days. Moreover when extensive skins burns are associated the quantification of hourly urinary output is naturally mandatory.

 

6.       Adding a section on penile and testicular prosthesis indications will would enrich the manuscript

Author Response

      1. The title is written according to the American format (all words with first letter in capitals) and should be changed to the European format (only first letter of the first word in capitals; all the others in lower case.

Thank you for this observation. We have kept the original format of the title, as most articles on the EBJ website follow this format.

2. In the Epidemiology section, it is stated that genitalia burns are more common in men than women and most cases due to fire or open flames. As it was even recognized by the Authors, this data refers mostly (or only) to the United States and is probably linked with cultural and/idiosyncratic factors. It should be referred that, at least in Europe, the epidemiology is a little bit different, with more women than men admitted to Burn Units with this kind of burns, and hot liquids being its first cause.

We thank this reviewer for their comments about this discrepancy. We have included a sentence describing this difference in epidemiology for genital burns between regions but were unable to find sources specifically discussing the differences in the prevalence of genital burns between sexes in Europe. This is also briefly discussed.

3. Paying attention to the typical readers of EBJ, perhaps a description of burn degree classification could be waived.

Thank you for this comment. We hope that readers from all levels of medical training can understand and enjoy this article. For this reason, we hope to include these definitions in the article. No changes were made.

4. The Authors do not refer the use of dermal matrices for scrotum and penis reconstruction, as well as the role for xenografts and synthetic skin substitutes.

      We agree that this would enrich the manuscript. A paragraph in the graft section has been added to discuss synthetic skin substitute application in genital burns.

5. The statement “most may recommend that urinary catheterization is not used for treating genital burns due to the inherent risk of nosocomial UTIs” is controversial and the respective references were published more than 10 years ago. Agreeing that urinary catheters soon become colonized and should be removed as soon as possible, the evolution from this colonization to real UTI will not happen every time and will depend mostly in the management of the catheters and on infection control. On the other hand, urinary catheters may be very useful to avoid burns contamination and pain at least in the first days. Moreover when extensive skins burns are associated the quantification of hourly urinary output is naturally mandatory.

      The authors agree with the recommendations this reviewer has provided. This sentence has been modified to reflect the current paucity of information that still remains regarding this issue.

6. Adding a section on penile and testicular prosthesis indications will enrich the manuscript

      We believe that this is an interesting topic to discuss. While there are surely individualized case studies of prostheses being used, penile and testicular implants are not commonly used in genital burn injuries, and there is scant literature discussing their use in these types of genital injuries. Because of this, we believe this may be beyond the scope of this review. No changes were made.  

Reviewer 4 Report

This is an overall nice summary of options for perineal burns. One important change is to remove references to "debridement" and change to excision. These are two very different procedures. The article refers to a thick graft of 0.04 mm for these burns, which is reasonable. However, given that dermatomes are set in inches, not millimeters, would be more useful if they included the equivalent depth in inches. The section on split thickness skin grafting should differentiate between penis (and regions within the penis) and scrotum. There is a paucity of discussion on the indications for a flap. 

The article overall would benefit from the addition of an indications section and an algorithm for management of these burns (and a separate algorithm for frostbite).

Author Response

"This is an overall nice summary of options for perineal burns. One important change is to remove references to "debridement" and change to excision. These are two very different procedures."

We thank the reviewer for this suggestion. Based on our literature review, we have seen that both debridement and excision are used interchangeably in the U.S. Because of this, no changes were made.

"The article refers to a thick graft of 0.04 mm for these burns, which is reasonable. However, given that dermatomes are set in inches, not millimeters, would be more useful if they included the equivalent depth in inches. The section on split thickness skin grafting should differentiate between penis (and regions within the penis) and scrotum."

The authors agree with this reviewer’s comments. We have revised this paragraph to specify the graft thickness and location.

"There is a paucity of discussion on the indications for a flap."

We agree with this reviewer’s observation. A sentence has been added about the main indications for using flaps for penile and scrotal reconstruction.

"The article overall would benefit from the addition of an indications section and an algorithm for the management of these burns (and a separate algorithm for frostbite)."

We agree with this reviewer that the manuscript would benefit from a figure highlighting an algorithm for managing genital thermal injuries for the penis and scrotum. We have included a conceptual diagram at the end of the manuscript to highlight several concepts to consider when managing a genital thermal injury. We have kept the algorithm broad as there is still a paucity of literature recommending concrete interventions for genital thermal injuries.

Reviewer 5 Report

An interesting review of genital burns

Language wise good, only a few minor mishaps (eg page 4, line 18 “…skin grating…”), page 2, line 72 lacks a “be”?.

The fairly rarely seen genital burns are reviewed and the literature can be summed up in scant. Maybe not that high of a scientific impact but most certainly important information and suggestive.

The paper is worth publication however, numerous major shortcomings need to be addressed

Abstract – “…are uncommon…” I’m not sure I agree with uncommon, especially in the light of the numbers the authors themselves present in the introduction “…1.7%-16.9%” and “…8% of all skin grafts applied…”. Furthermore, I can’t locate the figure 1.7% in reference #2?

 Abstract and throughout. There seems to be a whole lot of mixing of terms/definitions and varying focus -genitals, penis/scrotum, perineum. Eg, the numbers above relate to perineal burns – not to penile/scrotal burns.

I think the manuscript would highly gain from being more strict. Ie either write about perineal burns, or male genital burns and/or female genital burns. It’s quite confusing now.

 Introduction

Ref#1 was not accessible to me.

Page 1, line 25-26 – maybe also add the ”hidden/protected” location of genitals in the list of reasons why genital burns are few. I can not really see how the “…region’s limited surface area…” affects the incidence rate?

You write approx. 500000 annually seeking medical attention for burn injuries. If I read correctly you then base numbers on ref#2 BMS report containing >6,700 patients (over 25 somewhat years)? BMS also seems to have restrictions, eg: “To be included in the database, the burn injuries of participants must meet several criteria (as of 2015):

• More than 10% total body surface area (TBSA) burned, 65 years of age and older with burn surgery for wound closure;

• More than 20% TBSA burned, 0–64 years of age with burn surgery for wound closure” thereby missing a great number of patients"

Which likely distort data?

 

Materials & Methods

I think it’s a pity that you don’t take the oportunity to also include female genital burns, especially in the light of the incidence figures above.

 

Epidemiology

Again, the manuscript needs to be more strict regarding what you are actually writing about children/adults? – is the epidemiology the same?

Page 2, line 50 – 70% (actually 70.8%) of all burns in that reference are males (adults and children) and then you continue the sentence of stating that risk of genital burns is 3 times greater in males (children) no reference to whether this is true also in adults, especially when it is not certain whether you compare perineal or strict genital burns.

Page 2, line 53 – again the surface area of the pubic region is considered as reason for increased prevalence. No discussion whether the somewhat more protruding male genital organs could have something to do with it?

Page 2, line 57-60 – “The leading mechanisms of injury to the penis and scrotum include fire/flame burns, scalds, and grease injuries, accounting for 58.1%, 16.1%, and 7.7% of the total burn injuries reported, respectively [2].” As I read ref#2 – the numbers come from Table 13 – these numbers refer to the total burn population in the report and not specifically penis and scrotum!

Page 2, line 65-67 – I cannot find, in ref#2, where I find pediatric genital burns numbers.

Page 2, line 67-68 – just a few lines above you write that fire or open flames are the leading course of burns overall (all ages and with restrictions) then you refer to ref#4 with scalds being the most common reason for genital burns (in children)?

More could be written of the mixing of apples and pears in terms of numbers and definitions in this manuscript.

 

Page 4, line 18. It may be that ref#18 prefer full-thickness grafts, however, I’m not convinced that the literature agrees completely. Would be good with more refs to support this. STSG is otherwise often considered gold standard for traumatized penis/scrotum.

Page 4, line 20-page 5, line 20 – CCA, DHCAM, etc can be useful in preparing/enhancing wound healing but is not an alternative as final wound closure. As of now I read this passage as CCA, DHCAM can be used in FT burns – need to reflect about what these materials actually do.

Page 5 – very long, quite detailed, passage of different flaps. Could probably be shortened to “flaps can be used” (a bit overexaggerated).

Page 5, line 25 – need more refs to support that ‘radial forearm flap can give an aesthetic, sensate phallus with which one can void standing, or have intercourse with’

 Urinary diversion – please expand a bit on the fact(?) that urinary catheters can help in preventing urethral strictures.

 

Frostbite – page 6, line 31 – I’m not sure that frostbite injuries are lesser known, however, they are quite rare. In the list of causes nitrous oxide could probably be added.

Author Response

"An interesting review of genital burns

Language wise good, only a few minor mishaps (eg page 4, line 18 “…skin grating…”), page 2, line 72 lacks a “be”?."

We appreciate this reviewer for catching these grammatical errors. These changes are now reflected in the manuscript.

"The fairly rarely seen genital burns are reviewed and the literature can be summed up in scant. Maybe not that high of a scientific impact but most certainly important information and suggestive.

The paper is worth publication however, numerous major shortcomings need to be addressed

Abstract – “…are uncommon…” I’m not sure I agree with uncommon, especially in the light of the numbers the authors themselves present in the introduction “…1.7%-16.9%” and “…8% of all skin grafts applied…”. Furthermore, I can’t locate the figure 1.7% in reference #2?"

The authors agree. The wording in the abstract has been changed. The 1.7% statistic comes from the many referenced sources following that statistic. Specifically, it is found in reference #3.

"Abstract and throughout. There seems to be a whole lot of mixing of terms/definitions and varying focus -genitals, penis/scrotum, perineum. Eg, the numbers above relate to perineal burns – not to penile/scrotal burns.

I think the manuscript would highly gain from being more strict. Ie either write about perineal burns, or male genital burns and/or female genital burns. It’s quite confusing now."

We agree that this terminology can be confusing in the manuscript. Reference two is from a reputable burn center source, and “perineum” burns were interpreted to serve as a proxy for genital burns, as the prevalence is relatively the same compared to other studies, and they do not specify the definition of the perineum. These statistics were then used to describe genital burns overall, not specifically burns to the penis or scrotum. Additionally, it is not uncommon for these terms to be used interchangeably when discussing the epidemiology of genital burns (see an introduction in reference 9). 

"Introduction

Ref#1 was not accessible to me."

Thank you for checking this reference. We also can no longer access this information because the website appears to be under maintenance. We expect this reference to reappear following these changes. No changes were made.

"Page 1, line 25-26 – maybe also add the ”hidden/protected” location of genitals in the list of reasons why genital burns are few. I can not really see how the “…region’s limited surface area…” affects the incidence rate?"

We agree with the reviewer. Our statements were attempting to suggest the same conclusion that you have made. We have added a small statement regarding this.

"You write approx. 500000 annually seeking medical attention for burn injuries. If I read correctly you then base numbers on ref#2 BMS report containing >6,700 patients (over 25 somewhat years)? BMS also seems to have restrictions, eg: “To be included in the database, the burn injuries of participants must meet several criteria (as of 2015):

• More than 10% total body surface area (TBSA) burned, 65 years of age and older with burn surgery for wound closure;
• More than 20% TBSA burned, 0–64 years of age with burn surgery for wound closure” thereby missing a great number of patients"

Which likely distort data?"

We agree with this reviewer’s findings about reference #2 that their criteria may distort data. We also respect their original study's methodology and only attempt to paraphrase their findings. A small phrase related to this has been added on line 28.

"Materials & Methods

I think it’s a pity that you don’t take the opportunity to also include female genital burns, especially in the light of the incidence figures above."

The authors agree with this reviewer's suggestions that female genital burns should be discussed, and we will consider this as another potential idea to write about for a future publication. Ultimately though, we believe this falls outside this current manuscript's scope.

"Epidemiology

Again, the manuscript needs to be more strict regarding what you are actually writing about children/adults? – is the epidemiology the same?

Page 2, line 50 – 70% (actually 70.8%) of all burns in that reference are males (adults and children) and then you continue the sentence of stating that risk of genital burns is 3 times greater in males (children) no reference to whether this is true also in adults, especially when it is not certain whether you compare perineal or strict genital burns."

We agree with the reviewer that this section is unclear. We have revised this section to specify the ages more appropriately. Specifically, we have corrected the sources from where this information was obtained.

"Page 2, line 53 – again the surface area of the pubic region is considered as reason for increased prevalence. No discussion whether the somewhat more protruding male genital organs could have something to do with it?"

We agree with the reviewer. Our statements were attempting to suggest the same conclusion that you have made. We have added a statement regarding this.

"Page 2, line 57-60 – “The leading mechanisms of injury to the penis and scrotum include fire/flame burns, scalds, and grease injuries, accounting for 58.1%, 16.1%, and 7.7% of the total burn injuries reported, respectively [2].” As I read ref#2 – the numbers come from Table 13 – these numbers refer to the total burn population in the report and not specifically penis and scrotum!

Page 2, line 65-67 – I cannot find, in ref#2, where I find pediatric genital burns numbers."

We agree with the observations of this reviewer for both the statistic and referencing the breakdown of the mechanism of the burns reported. This was incorrectly reported and has been revised.

"Page 2, line 67-68 – just a few lines above you write that fire or open flames are the leading course of burns overall (all ages and with restrictions) then you refer to ref#4 with scalds being the most common reason for genital burns (in children)?

More could be written of the mixing of apples and pears in terms of numbers and definitions in this manuscript."

 We agree with the reviewer that the original epidemiology section was difficult to understand. We have revised this section to more appropriately describe the breakdown of the epidemiology of burns related to region, sex, mechanism, and age.  

"Page 4, line 18. It may be that ref#18 prefer full-thickness grafts, however, I’m not convinced that the literature agrees completely. Would be good with more refs to support this. STSG is otherwise often considered gold standard for traumatized penis/scrotum."

The authors agree. This section has been rewritten to reflect these changes, and a paragraph has been added to further discuss this topic further.

"Page 4, line 20-page 5, line 20 – CCA, DHCAM, etc can be useful in preparing/enhancing wound healing but is not an alternative as final wound closure. As of now I read this passage as CCA, DHCAM can be used in FT burns – need to reflect about what these materials actually do."

We agree that this was not written clearly and that DHCAM is not supported as an alternative to CCA. We have added a phrase on line 296 discussing this further.

"Page 5 – very long, quite detailed, passage of different flaps. Could probably be shortened to “flaps can be used” (a bit overexaggerated)."

We thank the reviewer for this comment. While this section could be summarized further, we aimed to describe current literature about choosing a flap for penile and scrotal defects for burn-related injuries. Different flaps have different outcomes depending on patient preferences. Because of this, we believe this is important to discuss in detail.

"Page 5, line 25 – need more refs to support that ‘radial forearm flap can give an aesthetic, sensate phallus with which one can void standing, or have intercourse with’"

We agree with bolstering these references. We added a citation about a systematic review and meta-analysis regarding radial forearm phalloplasty outcomes.

"Urinary diversion – please expand a bit on the fact(?) that urinary catheters can help in preventing urethral strictures."

Based on our review, the literature for urinary catheterization focuses more on urinary catheters being a cause of urethral strictures as opposed to preventing urethral strictures (though there may be some useful application of this that literature has not fully assessed). A sentence was added on line 389.

"Frostbite – page 6, line 31 – I’m not sure that frostbite injuries are lesser known, however, they are quite rare. In the list of causes nitrous oxide could probably be added."

Thank you for this suggestion. We have reworded the first sentence. Unfortunately, we could not find extensive literature about nitrous oxide causing frostbite of the genitalia, so this was not included.

Round 2

Reviewer 4 Report

ok

Author Response

We appreciate the time and energy this reviewer took to edit and offer suggestions to this manuscript. No changes were made. 

Reviewer 5 Report

Revised manuscript. Several improvements have been done in a manuscript worthy of publishing.

However, I still have some issues already mentioned in the previous review regarding wording and numbers.

Manuscript still not really strict regarding 1) wording genital/perineal burns, 2) data referred to; eg ref #4 describes genital AND perineal burns, hence not really fair to take these data and call it genital burns. I can’t figure out, in ref #4, how many are isolated genital and how many are perineal.

 Ref #1 not accessible to me

 Ref #2 is still used as base for epidemiological numbers of burns. I again want to stress that, if I read correctly, the BMS report contains >6,700 patients (over 25 somewhat years)? And BMS seems to have restrictions, eg: “To be included in the database, the burn injuries of participants must meet several criteria (as of 2015): • More than 10% total body surface area (TBSA) burned, 65 years of age and older with burn surgery for wound closure; • More than 20% TBSA burned, 0–64 years of age with burn surgery for wound closure” thereby missing a great number of patients. Hence, probably quite skewed data. Why not use eg ABA’s national burn repository for these numbers?

Lines 78-79 “In children (1 month – 17 years), scalds accounted for the majority of genital burns (64.1%), then followed by flames (29.5%) [4].” In ref #4 “They found the most common cause of GBs were scalding injuries in both males (58.1%) and females (70.7%) with males comprising 64.4% of their study population [8].” I find the figure 64.4% in the ref but not your stated 64.1% furthermore I can not identify the figure 29.5% (however, I have not checked ref #4’s #8 reference that is referred to. Also in ref #4: “In alignment with our study, a ten year (1991–2000) retrospective review of genital and perineal burns in children by Angel et al., found that 64% of GBs in children were caused by scalds [13]” Also in ref #4: “When comparing burns to the male and female genitalia, we found burns to the penis and scrotum alone comprise 48.6% of burns to the genitalia. For females however, burns to the vulva/vagina alone comprise only 22.1% of burns to the genitalia.” These are numbers used in current manuscript. However, to me, unclear whether ref #4 in this case refers all ages or as the title of that ref pediatric.

Furthermore regarding Lines 78-79 “In children (1 month – 17 years)… by flames (29.5%) [4].” I do not find anywhere in ref #4 the age group 1 month-17 years. (Age was categorized into the following groups: 0–1, 2–5, 6–12, 13–17, 18–30, 31–45, 46–65 and 66+…. Children ages 0–12 comprised 37.1% of the study population… For children age group 01, 36.7% of hot water bathroom scalds occurred when infants kicked the hot water on or cold water off. In age groups 0–5, majority of burns were caused by hot water in the bathroom, whereas in age groups 6–12, the…)

Still Page 5, lines 223-243 – CCA, DHCAM, Integra etc can be useful in preparing/enhancing wound healing but is not an alternative as final wound closure. As of now I read this passage as CCA, DHCAM, Integra can be used in FT burns – need to reflect about what these materials actually do. They are not an alternative for final wound closure on their own. This needs to be added! Putting CCA on a wound can surely prime the wound and enhance wound healing but it will not be a final solution (except the odd case out and then it was not a FT burn or a very small one).

Still long and detailed section on flaps. Since the paper (probably) is not intended as a surgical manual this could probably be shortened to “flaps can be used” (a bit overexaggerated).

 

Author Response

Manuscript still not really strict regarding 1) wording genital/perineal burns, 2) data referred to; eg ref #4 describes genital AND perineal burns, hence not really fair to take these data and call it genital burns. I can’t figure out, in ref #4, how many are isolated genital and how many are perineal.

Reference #2 (BMS report that reported only on burns to the perineum) has been removed from the manuscript. Regarding confusion for how ref #4 (ref #2 now) is used to describe genital burns in our manuscript, this is actually discussed in reference #9, where they report on isolated genital burns, not the perineum. A direct quote from their manuscript is as follows: "Burns to the penis and scrotum alone comprised 48.6% of male burns whereas burns to the vulva/vagina alone comprised 22.1% of female burns." Additionally, ref #9 specifies in their methodology, "Injuries were categorized by an atomic location of each sex: penis, scrotum, perianal and multiple areas for males and vulva/vagina, perianal and multiple areas for females." Because of this, we believe ref #9 is specifically discussing burns of the penis and scrotum and not the perineum. Due to this, we believe we have become more stringent in discussing only genital burns. 

 Ref #1 not accessible to me

The citation referenced has been updated and includes a link to the report where this statistic comes from. The statistic has also become more specific in the manuscript to reflect this report.

 Ref #2 is still used as base for epidemiological numbers of burns. I again want to stress that, if I read correctly, the BMS report contains >6,700 patients (over 25 somewhat years)? And BMS seems to have restrictions, eg: “To be included in the database, the burn injuries of participants must meet several criteria (as of 2015): • More than 10% total body surface area (TBSA) burned, 65 years of age and older with burn surgery for wound closure; • More than 20% TBSA burned, 0–64 years of age with burn surgery for wound closure” thereby missing a great number of patients. Hence, probably quite skewed data. Why not use eg ABA’s national burn repository for these numbers?

We are very thankful for this suggestion. The authors now use the ABA’s 2016 Report, Version 16 to cite statistics for the first paragraph of the Epidemiology section. The statistics have been updated to reflect this data. The original reference #2 (BMS Report) has been removed from the manuscript.

Lines 78-79 “In children (1 month – 17 years), scalds accounted for the majority of genital burns (64.1%), then followed by flames (29.5%) [4].” In ref #4 “They found the most common cause of GBs were scalding injuries in both males (58.1%) and females (70.7%) with males comprising 64.4% of their study population [8].”

A direct quote from reference #4 (now reference #2), as the reviewer has stated, is as follows, “A total of 64.1% were caused by hot liquids (scalds), 29.5% were flame burns, 3.8% contact burns, and 2.6% electrical burns.” This was used to describe their study where they assessed genital burns in children aged 1 month to 17 years. We believe this is appropriately reported in the manuscript. No changes were made.

 I find the figure 64.4% in the ref but not your stated 64.1% furthermore I can not identify the figure 29.5% (however, I have not checked ref #4’s #8 reference that is referred to. Also in ref #4: “In alignment with our study, a ten year (1991–2000) retrospective review of genital and perineal burns in children by Angel et al., found that 64% of GBs in children were caused by scalds [13]”

The reviewer may be referring to ref #9 regarding the 64.4% figure, which is where that statistic can be found, not reference #4 (now #2) as stated. 64.1% is the statistic found in reference #4 (now #2). Additionally, as previously discussed, a reference to the 29.5% statistic is found in reference #4 (now #2). No changes were made.

Also in ref #4: “When comparing burns to the male and female genitalia, we found burns to the penis and scrotum alone comprise 48.6% of burns to the genitalia. For females, however, burns to the vulva/vagina alone comprise only 22.1% of burns to the genitalia.” These are numbers used in current manuscript. However, to me, unclear whether ref #4 in this case refers all ages or as the title of that ref pediatric.

We agree that the statistics in the paper this reviewer mentions are vague. Based on the context clues in reference #9, it appears that they are referencing all ages, which is appropriately described in our manuscript. No changes were made.

Furthermore regarding Lines 78-79 “In children (1 month – 17 years)… by flames (29.5%) [4].” I do not find anywhere in ref #4 the age group 1 month-17 years. (Age was categorized into the following groups: 0–1, 2–5, 6–12, 13–17, 18–30, 31–45, 46–65 and 66+…. Children ages 0–12 comprised 37.1% of the study population… For children age group 01, 36.7% of hot water bathroom scalds occurred when infants kicked the hot water on or cold water off. In age groups 0–5, majority of burns were caused by hot water in the bathroom, whereas in age groups 6–12, the…)

The reviewer may be referring to ref #9 regarding age groups, not reference #4 (now reference #2), as the reviewer has stated. In ref #9, age groups were described as the reviewer has described, but in ref #4 (now reference #2), the age ranges for all their participants ranged from 1 month to 17 years. We believe this is appropriately reported and cited in the manuscript. No changes were made.

Still Page 5, lines 223-243 – CCA, DHCAM, Integra etc can be useful in preparing/enhancing wound healing but is not an alternative as final wound closure. As of now I read this passage as CCA, DHCAM, Integra can be used in FT burns – need to reflect about what these materials actually do. They are not an alternative for final wound closure on their own. This needs to be added! Putting CCA on a wound can surely prime the wound and enhance wound healing but it will not be a final solution (except the odd case out and then it was not a FT burn or a very small one).

We agree with this reviewer's comments. We have added two sentences following this section describing this issue as to why they are not considered as alternatives to final wound closures.

Still long and detailed section on flaps. Since the paper (probably) is not intended as a surgical manual this could probably be shortened to “flaps can be used” (a bit overexaggerated).

While we agree that this section may be long, our review aims to assess the management of genital thermal injuries of the penis and scrotum. Flaps are sometimes integral to managing severe burns and physical defects, so we believe this section is warranted for those interested in reading about this management.

Overall, we deeply appreciate this reviewer for their thoroughness and for taking the time and energy to help elevate this review.