The 5 Minute Urology Consult 3rd Ed.

PENIS, TRAUMA

Hunter Wessells, MD, FACS

Brad Figler, MD

 BASICS

DESCRIPTION

Acute traumatic injury to the penis may be due to blunt trauma (penile fracture to the erect penis), penetrating injury (stab wound, firearm, improvised explosive device [IED], or amputation), degloving (MVC, power takeoff injury), burns, human and animal bites, or constriction with reduced blood flow

EPIDEMIOLOGY

Incidence

• Penetrating trauma to genitals is relatively rare in civilian setting

• Gunshot wounds and penetrating injuries make up 40–60% of battlefield urologic injuries during times of war; likely due to lack of protection to external genitalia

• In the battlefield, use of fragmentation devices (mines, IED) and high-velocity missiles cause a significantly greater percentage of genitourinary injuries to involve the penis and genitalia

• Penile fracture infrequently seen in US, with incidence of 1 in 175,000 hospital admissions

• Penile fractures are common in Iran where it is a social practice (Taghaandan)

Prevalence

N/A

RISK FACTORS

• Occupational (military, farming, heavy machinery)

• Bicycling is leading sport associated with injury to the external genitalia

Genetics

N/A

PATHOPHYSIOLOGY

• Transfer of kinetic energy to the penis is most devastating due to penetrating mechanisms

• Blunt injuries to the flaccid phallus are much less likely to cause any damage

• Penis is very resistant to injury in flaccid state; in erect state, bending injury can lead to rupture of tunica albuginea (“penile fracture”)

– Typically results from impact with partner’s pubic symphysis or perineum

• Redundant blood supply to the penis (dorsal, cavernosal, and bulbourethral arteries and superficial skin vasculature) all protect from ischemic loss of the penis

• Penile strangulation

– Constricts blood flow, leading to edema, ischemia, constricted micturition

– Pediatric patients: Hair or string causes constriction

– Adult patients: Penile constricting devices designed for sexual enhancement

• Pelvic fracture can lead to avulsion of the crura of the corpora cavernosa with subsequent dysfunction

• Associated injuries are common due to the proximity to other pelvic organs

• Degloving injuries: Loss of superficial penile tissue (skin and Dartos fascia)

ASSOCIATED CONDITIONS

• Injury to scrotum, testicle, urethra, or rectum may accompany penile trauma

• Pelvic fracture

GENERAL PREVENTION

• Military services are developing devices for ballistic protection of the external genitalia

• Protective equipment during contact sports

• Proper safety training for industrial machinery

• Proper instruction in patients prescribed penile constriction devices for the management of erectile dysfunction

• Cautious sexual intercourse

 DIAGNOSIS

HISTORY

• Type of injury

• Magnitude of force transmitted

• Type of object in penetrating injury

• Determine species of animal in bite injuries

• In cases of amputation history of method of preservation of amputated portion if available

– Method of penile preservation

– Self-inflicted amputation may occur in psychotic states

• Timing, severity, progression of pain, swelling, discoloration of penis, scrotum, and genitalia

• Circumstances and timing of penile constriction device

• Intercourse-related trauma to the penis may be reported as a “pop” or “snap” associated with swelling and immediate penile detumescence

• Intercourse-related trauma with “pop,” swelling but no immediate penile detumescence is suspicious for rupture of superficial dorsal vein

• Associated abdominal pain, nausea, emesis

PHYSICAL EXAM

• Pattern of erythema, ecchymosis

• Assess for injuries of adjacent organs

• Blood at meatus concerning for urethral injury

• Size of laceration, if present

• Transilluminate any palpable scrotal mass

– Hydrocele will transilluminate

– Hematocele or tumor will not transilluminate

• Penile fracture:

– Penile swelling, ecchymosis with possible palpable defect in corpora cavernosa

– “Eggplant sign”: Hematoma deep to Buck’s fascia

• “Butterfly hematoma”: Hematoma deep to Colles’ fascia

• Penile strangulation:

– Penile edema, ischemic changes, gangrene

– Suprapubic fullness secondary to urethral constriction

• Gunshot wounds: Search for associated injuries especially injured femoral vessels, urethral injury, or rectal injury.

DIAGNOSTIC TESTS & INTERPRETATION

Lab

• Urinalysis

• Urine culture if infection suspected

• CBC

• For delayed presentation with abscess formation, culture abscess

Imaging

• Suspicion of urethral injury warrants evaluation with retrograde urethrography to evaluate for the presence of injury and injury location.

• Penile fracture:

– MRI or US useful if rupture of superficial dorsal vein suspected

– Cavernosography historically described

• Scrotal ultrasound or CT scan may be useful if suspicious for associated injuries

Diagnostic Procedures/Surgery

Cystoscopy: Used to assess for urethral injury

Pathologic Findings

N/A

DIFFERENTIAL DIAGNOSIS

• Burn

• Constriction injury (band or other device placed around base of penis) can include medically approved devices

• Fournier gangrene

• Human or animal bite

• Laceration

• Penetrating injury

• Penile “fracture”

• Rupture of superficial dorsal vein

• Penile amputation

 TREATMENT

GENERAL MEASURES

• Ensure the overall stability of the patient (1)

• Recognize and appropriately manage injuries to the external genitalia

• Maintain high index of suspicion for urethral injury and assess with retrograde urethrogram or cystoscopy

• Association for the Surgery of Trauma (AAST) organ injury scale classification (2):

– I: Cutaneous laceration/contusion

– II: Buck’s fascia (cavernosum) laceration without tissue loss

– III: Cutaneous avulsion; laceration through glans/meatus; cavernosal/urethral defect <2 cm

– IV: Partial penectomy; cavernosal or urethral defect >2 cm

– V Total penectomy

• For burns see section on “Burns, External Genitalia, and Perineum”

MEDICATION

First Line

• Appropriate fluid resuscitation based on severity of injury

• Broad-spectrum antibiotic prophylaxis for all penetrating genital injuries

• See section on Bites to penis (animal and human) for appropriate antibiotic coverage

• Tetanus prophylaxis for all penetrating injuries

Second Line

N/A

SURGERY/OTHER PROCEDURES

• Surgical exploration is required in almost all cases of penile injury (3 – 5)

– Exploration typically performed through a circumferential skin incision at coronal margin

– Deeper injuries require penoscrotal or perineal incisions

• Hemostasis is achieved by closure of corporal defects due to fracture, gunshot, or stab wound

• The urethra should be directly inspected for appropriate identification of any urethral injuries which need to be identified and repaired

• Glans injuries are repaired by debridement and reduction in the size of the glans while maintaining its overall configuration

• Primary skin closure is appropriate unless significant contamination of wound is noted

• Penile amputation

– Preservation of the amputated phallus

– “2-bag method” (penis wrapped in saline gauze in inner bag; ice in the outer bag)

– Cold ischemia >24 hr is acceptable if it allows transfer to a specialized center for microvascular replantation

– Even at normal temperatures, replantation 16 hr after injury has been successful

– Technique for microvascular replantation:

 Single-layer urethral repair over catheter

 Tunica albuginea reanastomosis (5-0 PDS)

 Dorsal vein and dorsal artery microvascular reanastomosis (to preserve skin perfusion and venous drainage; 0-0 nylon)

 Dorsal nerve reanastomosis for sensation, 10-0 nylon

– If amputated segment cannot be reattached:

 Close corporal bodies with 4-0 PDS

 Spatulate urethral meatus to tunica

 Can gain penile length later by cutting suspensory ligament, defatting pubis, or considering reconstruction with free flap

• Penile fracture:

– Circumcising incision via subcoronal approach with evacuation of hematoma

– Close cavernosal injuries with absorbable suture (5-0 PDS)

– Explore for urethral injuries and, if present, repair (5-0 PDS)

• Penile strangulation:

– Incision of offending agent if possible (cut hair, string, bands, soft rings with scissors)

– Solid constricting devices: Attempt removal with lubrication; distal penile compression with manual pressure may decrease tissue edema long enough to remove foreign body

– Some devices may require ring cutters, operative drills, industrial drills, various saws; protect phallus with tongue depressors, malleable retractors

– Suprapubic tube may be needed for bladder decompression

• Avulsions (degloving injury):

– Exposed surface should be immediately covered with sterile saline-soaked gauze and area re-examined in 24 hr to assess extent of injury

– Penile shaft can be covered with split-thickness skin graft

– Scrotum can be covered with meshed split-thickness skin graft

• Gunshot wounds:

– If wound contaminated, then conservatively débride and allow healing by secondary intention

– If wound clean, tunical margins can be reapproximated with absorbable suture; urethral injuries should be identified and repaired

• Human bites:

– Should not be closed; antibiotic therapy includes oral dicloxacillin or cephalexin

ADDITIONAL TREATMENT

Radiation Therapy

N/A

Additional Therapies

N/A

Complementary & Alternative Therapies

N/A

 ONGOING CARE

PROGNOSIS

• Most penile injuries can be successfully repaired with low rate of erectile dysfunction when immediate reconstruction is performed.

• Delayed repair or nonoperative approach to penile injuries may lead to penile curvature and erectile dysfunction.

• Even after penile amputation, with successful replantation patients can have sensation with erectile function.

COMPLICATIONS

• Decreased sensation

• Impotence

• Penile curvature

• Skin loss (particularly with nonmicrovascular penile replantation)

• Urethral stricture

• Urethral stricture or fistula

• Wound infections

FOLLOW-UP

Patient Monitoring

• Patient monitoring is required for detection for complications.

• Traumatic injury may result in erectile dysfunction requiring additional therapy.

Patient Resources

Urology Care Foundation. http://www.urologyhealth.org/urology/index.cfm?article=12

REFERENCES

1. Morey AF, Metro MJ, Carney KJ, et al. Consensus on genitourinary trauma: External genitalia. BJU Int. 2009;94:507–515.

2. American Association for the Surgery of Trauma. http://www.aast.org/library/traumatools/injuryscoringscales.aspx#penis (Assessed August 21, 2014)

3. Waxman S, Beekley A, Morey A, et al. Penetrating trauma to the external genitalia and Operation Iraqi Freedom. Int J Impot Res. 2009;21:145–148.

4. Wessells H, Long L. Penile and genital injuries. Urol Clin North Am. 2006;33:117–126.

5. Lewis EA, Pigott MA, Randall A, et al. The development and introduction of ballistic protection of the external genitalia and perineum. J R Army Med Corps. 2013;159(suppl 1):i15–i17.

ADDITIONAL READING

• Avery LL, Scheinfeld MH. Imaging of penile and scrotal emergencies. Radiographics. 2013;33(3):721–740.

• García Gómez B, Romero J, Villacampa F, et al. Early treatment of penile fractures: Our experience. Arch Esp Urol. 2012;65(7):684–688.

• Morey AF, Brandes S, Dugi DD, et al. Urotrauma: AUA Guideline (https://www.auanet.org/common/pdf/education/clinical-guidance/Urotrauma.pdf Accessed August 21, 2014)

See Also (Topic, Algorithm, Media)

• Bites to Penis (Animal and Human)

• Burns, External Genitalia and Perineum

• Penis, Strangulation

• Penis, Trauma Algorithm 

• Penis, Trauma Images 

• Scrotum and Testicle, Trauma

• Taghaandan

• Urethra, Trauma (Anterior and Posterior)

 CODES

ICD9

• 878.0 Open wound of penis, without mention of complication

• 959.13 Fracture of corpus cavernosum penis

• 959.14 Other injury of external genitals

ICD10

• S31.20XA Unspecified open wound of penis, initial encounter

• S39.840A Fracture of corpus cavernosum penis, initial encounter

• S39.94XA Unspecified injury of external genitals, initial encounter

 CLINICAL/SURGICAL PEARLS

• Penile injuries have high likelihood of associated injuries to the external and internal pelvic organs.

• Urethral injury must be excluded.

• With penile fracture there is 10–22% associated urethral injury; surgical repair is associated with lower rates of erectile dysfunction or curvature.

• Early surgical exploration and repair allows excellent preservation of function and cosmesis.

• Penile fracture characteristically causes ecchymosis, swelling, an associated popping or cracking sound during intercourse followed by immediate detumescence.



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