Penile Fracture and Trauma

Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS

http://emedicine.medscape.com/article/456305-overview#showall
Background
Traumatic penile injury can be due to multiple factors. Penile fracture, penile amputation, penetrating penile injuries, and penile soft tissue injuries are considered urologic emergencies and typically require surgical intervention. The goals of treatment for penile trauma are universal: preservation of penile length, erectile function, and maintenance of the ability to void while standing. Traumatic injury to the penis may concomitantly involve the urethra.[1] Urethral injury and repair is beyond the scope of this article but details can be found inUrethra, Trauma.

Penile fracture
Penile fracture is the traumatic rupture of the corpus cavernosum. Traumatic rupture of the penis is relatively uncommon and is considered a urologic emergency. Sudden blunt trauma or abrupt lateral bending of the penis in an erect state can break the markedly thinned and stiff tunica albuginea, resulting in a fractured penis. One or both corpora may be involved, and concomitant injury to the penile urethra may occur. Urethral trauma is more common when both corpora cavernosa are injured. Penile rupture can usually be diagnosed based solely on history and physical examination findings; however, in equivocal cases, diagnostic cavernosography or MRI should be performed. Concomitant urethral injury must be considered; therefore, preoperative retrograde urethrographic studies should generally be performed.

Small penile fracture involving the right corpus cavernosum.

More severe penile fracture.

Penile amputation
Penile amputation involves the complete or partial severing of the penis. A complete transection comprises severing of both corpora cavernosa and the urethra. Amputation of the penis may be accidental but is often self-inflicted, especially during psychotic episodes in individuals who are mentally ill.

Partial penile amputation.

Penetrating injury
Penetrating injury is the result of ballistic weapons, shrapnel, or stab injuries to the penis. Penetrating injuries are most commonly seen in wartime conflicts and are less common in civilian medicine. Penetrating injuries can involve one or both corpora, the urethra, or penile soft tissue alone.

Gunshot wound to the penis.

Penile soft tissue injury

Penile soft tissue injury can result through multiple mechanisms, including infection, burns, human or animal bites, and degloving injuries that involve machinery. The corpora, by definition, are not involved.

History of the Procedure

Penile fracture
Historically, conservative management was considered the treatment of choice for penile fractures. Conservative therapy consisted of cold compresses, pressure dressings, penile splinting, anti-inflammatory medications, fibrinolytics, and suprapubic urinary diversion with delayed repair of urethral injuries. This concept has fallen into disfavor because of the high complication rates (29-53%) of nonoperative therapy. Complications of conservative management included missed urethral injury, penile abscess, nodule formation at the site of rupture, permanent penile curvature, painful erection, painful coitus, erectile dysfunction, corporourethral fistula, arteriovenous fistula, and fibrotic plaque formation.[2] The primary goals of surgical repair are to expedite the relief of painful symptoms, to prevent erectile dysfunction, to allow normal voiding, and to minimize potential complications due to delay in diagnosis. Currently, the vast majority of authors favor immediate surgical repair, citing fewer complications, increased patient satisfaction, shorter hospital stays, and better outcomes.

Penile amputation
Ehrich et al[3] reported the first macroscopic reimplantation of a penile amputation, in which arterial anastomosis is not performed. Functional and cosmetic results were satisfactory, but penile skin necrosis was common. Tamai et al later modified the technique to include microsurgical reanastomosis of the penile blood vessels and nerves, thereby reducing the risk of penile skin necrosis. Reanastomosis requires the amputated penile remnant. In the case of distal penile loss, phallus reconstruction can be performed using a forearm free flap.

Epidemiology
Frequency
Penile fracture The frequency of penile fracture is likely underreported in the published literature. Trauma during sexual relations is responsible for approximately one third of all cases; the female-dominant position is most commonly reported. The mechanism of action may lead to embarrassment, causing patients to avoid seeking treatment and contributing to late presentation. As of 2001, 1331 cases were reported in the literature. The incidence of concomitant urethral injury in reported cases is 10-58%. Penile amputation Penile amputation is rare, with most cases being reported sporadically. Cases are typically associated with self-mutilation related to acute psychotic episodes or gender dysphoria. Felonious assaults account for the remainder of cases. Penetrating injury Gunshot wounds account for 35% of all genital injuries. In 25% of cases, the penis alone is involved. In another 25% of cases, both the penis and scrotum are involved. The frequency of stab wounds to the penis is relatively rare, accounting for only 4% of penetrating penile injuries. Penile soft tissue injury Soft tissue skin loss of the penis is a rare phenomenon. Fournier gangrene accounts for approximately 75% of cases that involve genital skin loss. This infectious process is beyond the scope of this article and can be found in Fournier Gangrene. The remainder of soft tissue loss cases are typically due to avulsion injuries, human or animal bites, and burns.

Etiology
Penile fracture
In the Western Hemisphere, penile fracture usually occurs during sexual intercourse when the penis slips out of the vagina and strikes the perineum or the pubic symphysis. Other potential causes include industrial accidents, masturbation, gunshot wounds, or any other mechanical trauma that causes forcible breaking of an erect penis. In Middle Eastern countries, the injury is usually due to penile manipulation to achieve detumescence. Additional rare etiologies include turning over in bed, a direct blow, forced bending, or hastily removing or applying clothing when the penis is erect.

Penile amputation
Penile amputation frequently occurs as a result of mental illness; in fact, most cases of penile amputation in the Western world are due to mental illness. The rate of mental illnessrelated penile amputation is as high as 87%. Most of these patients (51%) have acutely decompensated schizophrenia. The literature reports a high rate of associated gender identity in nonpsychotic occurrences; most of these amputations result from an attempt at gender conversion. Cases of assault are also reported. A rash of these attacks occurred in Thailand during the 1970s, when a large number of enraged wives amputated the penises of their adulterous husbands.

Penetrating injury
Most penetrating penile injuries occur during wartime. As solid-organ abdominal injuries and subsequent death rates have been reduced with the use of body armor in modern warfare, the frequency of penetrating genital injuries has increased. This is because of two factors. The first is that body armor does not traditionally cover the genitals. The second is that genital injuries were likely underreported in previous wars because unprotected individuals tended to die of massive abdominal injuries. Extraction of injured soldiers from the combat theater and improvements in the treatment of trauma patients have also increased survival rates, leading to increased reporting of injuries to the penis.

Penile soft tissue injury

Avulsion injuries to the penis are typically due to entrapment of the penile skin within the clothing. This clothing is caught on moving machinery, such as motorcycles or farm implements, which rends the soft tissue from the stronger underlayer of the tunica albuginea.

Pathophysiology
The penis is composed of 3 bodies of erectile tissue: the corpus cavernosum (left and right) and the corpus spongiosum. Both corpora cavernosa are contained by the tunica albuginea. All three corpora are surrounded individually by Buck fascia. All three corporal cylinders are capable of considerable enlargement with sanguineous engorgement during normal erection. The corpora cavernosa are composed of sinusoids that fill with arterial blood during erection. The internal pudendal arteries provide the blood supply to the penis and the urethra. Each artery divides into the dorsal penile artery, the cavernosal artery, and the bulbourethral artery. The cavernosal artery supplies the corpus cavernosum.

Penile fracture
In the flaccid state, injury to the penis is rare because of the mobility and flexibility of the organ. During an erection, the arterial inflow to the penis causes the erectile bodies to enlarge longitudinally and transversely. This causes the flaccid penis to become fully erect and less mobile. As the penis changes from a flaccid state to an erect state, the tunica albuginea thins from 2 mm to 0.25-0.5 mm, stiffens, and loses elasticity. The expansion and stiffness of the tunica albuginea impede venous return and are responsible for maintaining tumescence during male erection. Sudden direct trauma to the penis or an abnormal bending of the penis in an erect state can cause a 0.5-4 cm transverse tear of the tunica albuginea, with injury to the underlying corpus cavernosum. Oblique or irregular tears are less common, but reported. The injury typically results in injury to one corpus cavernosa, but both can be involved. This may result in penile laceration and urethral injury.

Penile amputation
Penile amputation is not a physiological process.

Penetrating injury
The penis is somewhat resistant to penetrating injury owing to its location and relative mobility. The penis is shielded by the surrounding bony pelvis posteriorly and upper thighs laterally, thereby preventing injury.

Penile soft tissue injury

The penis is particularly susceptible to avulsion injuries. The overlying skin of the penis is loose and elastic. The penile skin must be highly mobile to accommodate both the rigid and flaccid state of the penis. This loose base predisposes the skin to be ripped easily from the penis.

Presentation
Penile fracture
The clinical presentation of a penile fracture is often fairly straightforward. Diagnosis is made based on history and physical examination findings.[4] Most affected patients report penile injury coincident with sexual intercourse. Patients usually report that the female partner was on top, straddling the penis. During sexual relations, the penis slipped out, hitting the perineum or the pubis of the female partner. Patients sometimes report that they were having sexual relations on a desk (with the patient on top) and the penis slipped out, hitting the edge of the desk. Patients describe a popping, cracking, or snapping sound with immediate detumescence. They may report minimal to severe sharp pain, depending on the severity of injury. Upon physical examination, evidence of penile injury is self-evident. In a typical penile fracture, the normal external penile appearance is completely obliterated because of significant penile deformity, swelling, and ecchymosis (the so-called "eggplant" deformity).

Eggplant deformity.

Upon inspection, significant soft tissue swelling of the penile skin, penile ecchymosis, and hematoma formation are apparent. The penis is abnormally curved, often in an S shape. The penis is often deviated away from the site of the tear secondary to mass effect of the hematoma. If the urethra has also been damaged, blood is present at the meatus. If the Buck fascia is intact, penile ecchymosis is confined to the penile shaft. If the Buck fascia has been violated, the swelling and ecchymosis are contained within the Colles fascia. In this instance, a "butterfly-pattern" ecchymosis may be observed over the perineum, scrotum, and lower abdominal wall. The fractured penis is often quite tender to the touch. Because of the severity of pain, a comprehensive penile examination may not be possible. However, a "rolling sign" may be appreciated when a judicious examination is performed on a cooperative patient. A rolling sign is the palpation of the localized blood clot over the site of rupture. The clot may be felt as a discreet firm mass over which the penile skin may be rolled. Patients with a rupture of the deep dorsal vein of the penis can present with findings similar to those of a penile fracture. Associated swelling and ecchymosis of the penis ("eggplant" sign) is present. Injury commonly occurs during sexual intercourse. However, the patient does not typically hear a crack or popping sound. In addition, detumescence does not immediately occur. However, because of similar physical examination findings, a deep dorsal vein rupture should be surgical explored, as it is often difficult to differentiate from penile fracture. Patients with concomitant urethral trauma report hematuria upon postinjury voiding. Approximately 30% of men with penile fractures demonstrate blood at the meatus. Some patients may also report dysuria or experience acute urinary retention. Retention may be secondary to urethral injury or periurethral hematoma that is causing a bladder outlet obstruction. Urinary extravasation may be a late complication of unrecognized urethral

injury. Successful voiding does not exclude urethral injury; therefore, retrograde urethrography is required whenever urethral injury is suspected. Signs and symptoms of urethral injury are described below.

Penile amputation
Diagnosis of the amputated penis is obvious on physical examination. A thorough history must be taken to determine the patient's mental state and if self-mutilation is responsible for the amputation. Many patients present to the hospital for evaluation because of the alarming, although seldom life-threatening, volume of blood loss. Determination of the psychiatric state helps with operative planning. The literature suggests that, in cases of self-amputation, resolution of the acute psychotic episode and treatment of the underlying mental illness typically results in a desire for penile preservation. The only exception may involve men who have repeatedly attempted amputation. The risks of future self-mutilation must be weighed against the effects of no penile replacement. Examination of the penis and remnant (if available) is important to determine the possible reconstructive options. The condition of the graft bed is closely inspected. Destruction of the amputated segment precludes reimplantation, and the patient should be prepared for future phallic reconstruction. Patients with adequate penile stumps may avoid reimplantation altogether, although this is typically a less desirable outcome. The cancer literature suggests that a penile length of 2-3 cm is necessary for directing the urinary stream while standing to void. The length required for sexual intercourse is likely longer but depends on body habitus and partner preference. Extensive physical examination should not delay operative intervention, as a better examination is likely to be obtained in the operating room with the patient under anesthesia.

Penetrating injury
Diagnosis of a penetrating penile injury is obvious based on both history and physical examination findings. Care must be paid to the patient's other associated injuries, which can be life-threatening and should take precedence over genital injuries. Significant associated injuries are present in 50-80% of cases. The patient must be medically stabilized prior to surgical repair of the injured penis. Blood in the meatus can indicate urethral injury and should be suspected in any penetrating trauma to the penis. The authors routinely perform retrograde urethrography to evaluate for urethral injury. Penetrating injuries to the corpora cavernosa often have a hematoma that overlies the defect and have a "rolling sign" similar to that of penile fracture.

Penile soft tissue injury

Examination of the penis reveals soft tissue loss. Those who have undergone laceration secondary to a human bite usually present in a delayed fashion because of embarrassment of the injury. This places them at increased risk for infection, which may be seen in the form of abscess, cellulitis, or tissue necrosis.

Urethral Injury
Signs and symptoms of urethral injury should be considered in all forms of penile trauma. The mechanism of penile injury and physical examination findings must be considered. The diagnostic test of choice is retrograde urethrography. The key indications of urethral injury are as follows:

Blood at the meatus Gross hematuria Microscopic hematuria (>5 RBCs per high-power field) Dysuria Urinary retention

Indications
Penile fracture
Indications for immediate surgical intervention include the presence of obvious clinical signs and symptoms of penile fracture. Diagnostic imaging studies are not normally required in this setting. Surgery is also warranted if diagnostic cavernosography or MRI findings are equivocal but clinical findings are consistent with penile fracture.[5]

Penile amputation
Penile amputation is a surgical emergency. Imaging studies are not necessary. The patient should be taken to the operating room for penile replantation or revision of the penile stump, with or without plans for future phallic reconstruction.

Penetrating injury
The signs of penetrating penile injury should be an indication for surgical exploration. The only contraindication to surgery is medial instability due to other associated injuries. In rare instances, penile trauma can be treated nonoperatively. In one series, 10 of 26 patients were managed without surgery. These patients had two factors that contributed to nonoperative treatment. One group (3 patients) had minimal injuries with a single shotgun pellet lodged in the penis. The other group had only superficial or isolated foreskin injuries.

Penile soft tissue injury

Surgical repair of soft tissue loss to the penis should be undertaken quickly. Prolonged exposure of the denuded penis increases the risk of secondary infection.

Relevant Anatomy
The penis is divided into 3 parts. The root lies under the pubic bone and provides stability when the penis is erect. The body comprises the major portion of the penis and is composed of 2 cavernosal bodies and a corpus spongiosum. The urethra traverses the corpus spongiosum to exit through the meatus. The 2 cavernosal bodies (ie, corpus cavernosa, erectile bodies) produce erections when filled with blood. The glans is the distal expansion of the corpus spongiosum. The loose skin of the prepuce normally covers the glans of an uncircumcised penis. The penis is innervated by the left and right dorsal nerves, which are the main sensory nerve supply. These nerves are typically located at the 10and 2-o'clock positions, but, in reality, their locations significantly vary. Care must be taken with surgical exploration of any penile injury to avoid iatrogenic injury to the dorsal nerves. The penis is also innervated by branches of the pudendal nerve.

The penis is a highly vascular organ and is supplied by the internal pudendal artery. The internal pudendal artery rises from the internal iliac artery (ie, hypogastric artery), which then branches into the deep artery of the penis, the bulbar artery, and the urethral artery. The deep artery of the penis becomes the cavernosal arteries, which supply the entire corpus cavernosum. The urethral artery supplies the glans penis and corpus spongiosum. The bulbar artery supplies the bulbar urethra and the bulbospongiosus muscle

Contraindications
Contraindications to surgical therapy include intolerance to general anesthesia and a history of penile trauma but completely normal physical examination findings. In patients with polytrauma, life-threatening injuries must be prioritized; delayed penile repair can be considered when the patient becomes medically stable.[6]Patients with penile trauma require fluid resuscitation prior to operative intervention

Laboratory Studies

Although no specific laboratory studies are required for penile trauma, a standard preoperative laboratory panel should be considered on a caseby-case basis in all patients. This includes the following: Electrolytes Complete blood count Coagulation studies Type and screen Urinalysis Microscopic hematuria should raise suspicion of a possible urethral injury. Urine culture should be considered in those with obvious signs of a urinary tract infection.

Imaging Studies
Imaging studies to assess penile trauma are not usually required and should be used with reservation. They increase medical costs and delay definitive therapy. The physical examination findings alone are often used to establish the diagnosis. When the diagnosis is equivocal, surgical exploration is warranted to assess the injury, diagnose the injury, and render appropriate surgical repair. Imaging studies of the penis can be considered when injury is not evident on physical examination; in this case, the radiologic test is used only to confirm a conservative course of nonoperative management. Retrograde urethrography is the only imaging study for which there should be a low threshold of use. Retrograde urethrography should be performed if urethral injury is suspected based on the presence of blood at the meatus, hematuria of any form, dysuria, or urinary retention. The test is easy to perform and inexpensive.

Retrograde urethrography: Retrograde urethrogram reveals the extravasation of contrast material from the urethra into the penile soft tissues, indicating urethral injury. It can be performed by insertion of a 12-14F Foley catheter into the fossa navicularis (distal urethra). The Foley balloon is inflated with 1-2 mL of sterile water. Contrast is injected from a 60-mL piston syringe with the penis placed on stretch. Oblique radiographs are taken and the continuity of the urethra is examined. An alternative technique is forgoing placement of a catheter with intubation of the urethral meatus with a piston syringe and injection of contrast directly into the urethra. Penile cavernosography: Penile cavernosography reveals extravasation of contrast material from the corpus cavernosum into the penile soft tissues, indicating an injury of the tunica albuginea. It can be performed by direct injection of 15-70 mL of quartertohalf-strength nonionic contrast into the uninjured corpora until penile tumescence is achieved. Fluoroscopic images during injection and 10 minutes postinjection reveal filling defects or extravasation. This technique is thought to cause corporal scarring and should be used with reservation. Cavernosography rarely precludes surgical exploration in both penetrating trauma and fracture of the penis. Its use should not delay definitive surgical treatment. Penile magnetic resonance imaging (MRI): An MRI of the penis provides excellent delineation of anatomy and thus can reveal tunical tears and urethral injury. The technique is expensive and time-consuming. Its availability is often limited depending on time of patient presentation and can cause undue delay in definitive surgical management. It is best reserved for patients in whom injury appears absent and who would support nonoperative treatment.

Medical Therapy
The medical management of penile trauma is limited and usually depends on surgical optimization of the patient in preparation for the operating room. Penile trauma is often accompanied by other associated injuries, some of which may be life-threatening. Fluid resuscitation and stabilization of the patient should be the focus. Administration of preoperative antibiotics should be considered in patients with open wounds. If penile reconstruction must be delayed in the setting of a urethral injury, suprapubic urinary diversion may be performed. If surgical therapy must be delayed, initial medical therapy consists of cold compresses, pressure dressings, and anti-inflammatory medications, followed by definitive surgical therapy.

Penile amputation
Pretreatment of the patient with an amputated penis has unique requirements. In the face of an acute psychotic episode, psychological stabilization is required, often with the aid of a psychiatrist. Management of the amputated penile remnant is imperative to a successful reimplantation. The severed penis should be cleaned of debris and wrapped in sterile, saline-soaked gauze. The wrapped penis should be placed into a sealed bag and placed inside a second container filled with an ice-slush mix. This helps to reduce the ischemic injury to the severed penis. Reimplantation should be performed as quickly as possible.

Penile soft tissue loss

Bite injuries to the penis require extra care, as they have the potential for infection with unique organisms. Dog bites, the most common animal bite, consist of multiple pathogens such as Staphylococcus and Streptococcus species,Escherichia coli, and Pasteurella multocida. Antibiotic treatment should generally include oral dicloxacillin or cephalexin. Patients with possible Pasteurellaresistance can be treated with penicillin V. Chloramphenicol has also been shown to have good efficacy. Human bites are considered infected by definition and should not be closed. They can be treated with antibiotics similar to those used in animal bites despite the fact that bacterial cultures may differ.

Surgical Therapy
No matter the form of penile trauma, the goals of surgery for the traumatized penis are universal: restore the penis to its preinjury state, prevent erectile dysfunction, maintain penile length, and allow normal voiding.[7, 8, 9]

Penile fracture
In the reported literature, surgical therapy has consistently resulted in fewer complications. Muentener et al reported good outcomes in 92% of patients treated surgically versus only 59% in those treated conservatively. In addition, surgery provides good outcomes after varying timing of presentation after injury. A study by El-Assmy et al found no substantial difference in recovery based on early or delayed presentation of penile fracture with subsequent surgery. Patients were divided into group I early presentation (1-24 hours after injury) and group II delayed presentation (30 hours to 7 days after injury). Mean follow-up was 105 months for group I and 113 months for group II.[10] Principles of surgical therapy are as follows:

Optimize the surgical exposure. Evacuate the hematoma. Identify the site of injury. Correct the defect in the tunica albuginea. Repair the urethral injury. Three types of incisions are generally used to repair penile fracture: incision directly over the defect, circumscribing-degloving incision, and inguinal-scrotal incision. An incision directly over the identified defect in the corpus cavernosum allows minimal dissection of neurovascular bundles but does not afford complete evaluation of both the corpora cavernosa and the corpus spongiosum. The authors do not advocate this type of entry. A circumferentialdegloving incision begins 1 cm proximal to the coronal sulcus and affords excellent exposure. However, decreased penile sensation has been reported with this type of incision. The inguinal-scrotal incision provides excellent exposure of the base, root, and dorsal surfaces of the penis. If necessary, the entire penis may be averted inside out to maximize surgical exposure. At the authors' institution, a circumferential-degloving incision is routinely used with excellent results. On occasion, the authors have also used an inguinal-scrotal incision for more complex injuries located near the base of penis.

Penile amputation
An amputated penis should be immediately and expeditiously repaired to prevent further ischemic injury to the penile remnant. This should be undertaken at a center of excellence, and the patient should be stabilized and transferred if a reconstructive urologist or plastic surgeon is not available at the presenting institution. Principles of surgical therapy are as follows:

Optimize the surgical exposure. Judiciously debride necrotic tissue. Anastomose the severed urethra over a Foley catheter to provide stabilization. Repair the tunica albuginea. Use microsurgery to repair the dorsal nerves, arteries, and veins of the penis.

Penetrating injury
Expeditious surgical repair of the penis should be undertaken as soon as possible. Principles of surgical therapy are as follows:

Optimize the surgical exposure. Judiciously debride necrotic tissue. Repair injured urethra. Repair tunica albuginea injuries.

Penile soft tissue injury

Surgical repair should be initiated as soon as possible in soft tissue injuries. This prevents colonization of the wound. The only exception is that of the human bite because of the high risk of polymicrobial infection. Principles of surgical therapy are as follows:

Debridement of necrotic tissue Copious irrigation of wound with Povidine and antibiotic solution Closure of injury with exception of human bites Skin grafting and harvest to cover large defects

Preoperative Details
The use of perioperative antibiotics varies among authors, with no clear consensus. The authors routinely administer broad-spectrum intravenous antibiotics (cefazolin) 1 hour before surgery. Informed consent that outlines the risks is obtained. Risks include but are not limited to bleeding, infection, erectile dysfunction, penile curvature, decrease in penile sensation, and the possible need for circumcision. The patient must be informed that erectile dysfunction may result because of the nature of injury rather than the operation itself.

Intraoperative Details
Penile fracture
The patient is placed in a supine position. The lower abdomen and genitalia are prepared and draped in a sterile fashion. A circumferential incision is made. The incision is carried through the dartos fascia and down to the Buck fascia. The penis is degloved to the base of the penis, taking care not to injure the dorsal neurovascular bundle. Both corpora cavernosa and the corpus spongiosum are thoroughly inspected. If both corpora are injured, the corpus spongiosum must be carefully inspected because of the high associated incidence of urethral injury. If the corpus spongiosum is involved, both corpora cavernosa must be thoroughly examined for possible injury.

The presence of corporal hematoma strongly suggests an injury to the tunica. Upon encountering a corporal hematoma, the Buck fascia is opened and the hematoma is evacuated. Upon evacuating the hematoma, a defect in the tunica will be apparent. A recent series by Shaeer revealed that intraoperative injection of methylene blue into the corpora helped reveal the tunical injury and thereby reduced unnecessary tissue dissection and operative time and simplified the repair. [11] Freshen the edges of the tunica albuginea. The type and method of suture repair of the tunica albuginea varies widely, but all authors insist on a watertight closure. The authors use 1-0 braided nonabsorbable suture in an interrupted fashion. Invert the sutures so the knots will not be palpable. Alternatively, a 2-0 delayed absorbable suture such as polydioxanone may be used. At this juncture, an artificial saline-induced erection may be induced to test for watertight integrity. Close the fascia. Suture the penile shaft skin to the coronal skin with 3-0 chromic sutures in an interrupted fashion. Typically, drains are not required. Partial and complete urethral transections that are clean require a primary anastomosis over a catheter. Additionally, urinary diversion via a suprapubic tube may be considered. Close the urethral defect with 4-0 chromic or 5-0 polydioxanone sutures in an interrupted fashion, and leave an indwelling urethral catheter for 2-3 weeks. If a devitalized urethral segment is identified, minimal judicious debridement may be performed. If a complete tear is noted, mobilize the urethra proximally and distally. Spatulate the proximal and distal ends of the urethra and insert a urethral catheter. Approximate the urethral margins with 5-0 polydioxanone sutures in an interrupted fashion.

Penile amputation
The patient is placed in a supine position. The lower abdomen and genitalia are prepared and draped in a sterile fashion. Bleeding from the penile stump is controlled by wrapping the base of the penis circumferentially with a small Penrose drain and securing with a hemostat. Minimal debridement of any necrotic tissue is performed. The penile remnant should be cleaned and irrigated with antibiotic solution and minimally dbrided, as necessary. Under loupe or microscopic magnification, the penile skin from both the stump and amputated shaft should be undermined for 1 cm. This allows exposure and identification of the dorsal veins, artery, and nerves. The urethra should be spatulated opposite of each other. A Foley catheter is then used to bridge and stabilize the amputated segment. The urethral mucosa is reapproximated using 5-0 polydioxanone sutures on the mucosa and a second layer on the spongiosum. The deep cavernosal arteries do not need to be anastomosed unless the amputation is very proximal and the erectile tissue will be minimally injured. This remains somewhat controversial and often depends on the author. If the deep cavernosal arteries are repaired, 11-0 nylon should be used. The tunica albuginea of each corporal body should be reapproximated with 2-0 slowly absorbing suture. Once the main shaft of the penis and urethra are reanastomosed, attention can be turned to repairing the dorsal neurovascular bundles of the penis. The dorsal arteries are anastomosed with 11-0 monofilament nylon; 10-0 monofilament nylon is used for the dorsal nerves. The epineurium of the dorsal nerve is reapproximated with 10-0 nylon. Once the dorsal neurovascular bundles are microsurgically repaired, the dartos fascia can be closed with interrupted 2-0 self-absorbable sutures. The skin is then closed with running 4-0 cat gut. Some authors elect to leave a small Penrose drain to prevent hematoma accumulation. Most authors choose to leave a suprapubic cystotomy drain. The penis is wrapped in loose circumferential gauze. If microsurgical reanastomosis is not possible, penile stump advancement should be performed by dividing the suspensory ligament of the penis from the pubic symphysis. Free lateral forearm flap phalloplasty can be performed as a staged procedure once the patient has recovered from his initial insult. This is a highly specialized procedure and fraught with complications. As a result, only highly trained specialized surgeons should perform the procedure.

Repair of partial penile amputation after primary closure (without replantation of penile remnant).

Penile amputation in the initial stage of replantation. Penile amputation after replantation.

Penetrating injury
The technique for repair of penetrating injuries to the penis is similar to that used in penile fracture. Incisions can be made directly over the site of injury, as an inguinal-scrotal approach, or as a circumferential degloving of the penis. The authors prefer a circumferential degloving incision as described above.

When the underlying Buck fascia is exposed, the corpora cavernosa and spongiosum are examined. The hematoma is evacuated and the injury site inspected. Necrotic areas should be dbrided. Caution should be used to avoid overdebridement, as hematoma can be confused with dead tissue. Small corporal injuries of the tunica albuginea are repaired via primary closure using 1-0 braided nonabsorbable sutures or 2-0 delayed absorbable sutures such as polydioxanone. Larger defects may require placement of xenograft material such as Tutoplast cadaveric dermis or small intestinal submucosa (SIS). Urethral transactions are completed with primary anastomosis over a Foley catheter. Defects can be closed using 4-0 polydioxanone. Large defects that cannot be closed primarily can be diverted with a suprapubic cystotomy with delayed repair. An indwelling urethral catheter should be left in place for 2 weeks.

Penile soft tissue injury

No standard approach is used to treat soft tissue injuries to the penis, as the mechanism of injury is quite varied. Individualized approaches should be used for each patient. Standard treatment includes debridement of necrotic tissue. The wound must be copiously irrigated with povidine and antibiotic solution. Bite injuries with puncture type wounds to the corpora cavernosa and urethra can be repaired in a similar fashion to that of penetrating injuries of the penis. Care should be used to avoid closure of skin and subcutaneous tissues in the case of a human bite and injuries with signs of gross infection. Primary closure of animal bites can be performed, as infection is rare. Lacerations of the penis can be closed primarily if they are small. Larger avulsion injuries often require skin grafting. The two methods typically used for grafting are controversial: meshed versus unmeshed split-thickness skin grafts.

Postoperative Details
Penile fracture
The patient is discharged with pain medications and oral antibiotics 1-3 days after the operation. If no urethral injury was detected intraoperatively, the Foley catheter is removed prior to discharge. Light compressive dressings are applied for one week. Some authors advocate formal suppression of spontaneous erections with diazepam or stilboestrol. Others believe that the painful stimuli are sufficient control to prevent spontaneous erections, and the sedating effects of the medication may be avoided. In the authors' clinical experience, troublesome spontaneous erections are not encountered after this type of penile reconstruction.

Penile amputation
An area of controversy is the use of anticoagulation in the immediate postoperative period. If anticoagulation is desired, some authors recommend 500 mL of low molecular dextran for 72 hours. The patient should be kept on intravenous antibiotics until the remnant appears to be taking appropriately. The patient can then be switched to oral therapy for one week.

Penetrating injury
The postoperative care for penetrating injury to the penis is similar to that of penile fracture.

Penile soft tissue injury

Circumferential compressive dressings to the penis may be required until the graft takes if skin grafting has been performed. Antibiotic treatment should be continued as described above. In general, patients should abstain from sexual relations for 6-8 weeks following most penile trauma.

Follow-up
For patients with urethral reconstruction, the urethral catheter may be removed in 2 weeks. After removal of the urethral catheter, retrograde urethrography should be performed in a gentle fashion. Alternatively, voiding cystourethrography may be performed via the suprapubic tube. The cystotomy tube can be removed after normal voiding no leak is present. If extravasation from the urethra is present, the cystotomy should be continued for an additional 2 weeks or the Foley catheter replaced if cystotomy tube was not used in the original repair.

Complications
Penile fracture
Potential complications of penile fracture include erectile dysfunction (which may result from a cavernosospongiosal fistula), abnormal penile curvature, painful erections, formation of fibrotic plaques, penile abscess, urethrocutaneous fistula, corporourethral fistula, and painful nodules along the site of injury. Patients treated with conservative management have a significantly higher incidence of complications compared with those treated with prompt surgical therapy.

Penile amputation
Similar to the possible complications following correction of penile fracture, penile amputation can be associated with penile curvature, erectile dysfunction, hematoma, abscess formation, urethrocutaneous fistula, and corporourethral fistula. In addition, urethral stricture can occur. Penile skin necrosis was more common prior to microvascular anastomosis of the dorsal neurovascular complexes. The necrosis that typically occurs is less frequent and often superficial.

Penetrating injury
Similar to the possible complications following correction of penile fracture, penetrating corpora cavernosal injuries carry with them complications of erectile dysfunction, penile curvature, fibrotic plaques, abscess, and painful erections. Patients with urethral injuries risk corporourethral fistula, urethral stricture, and urethrocutaneous fistula

Penile soft tissue injury

The most frequent complication of soft tissue injury is postoperative infection. If the graft does not take in patients who undergo split-thickness skin grafting, the consequences can be devastating. As described above, complications such as erectile dysfunction, curvature, and fistula are associated risks.

Outcome and Prognosis

Penile fracture
Penile fracture is a urologic emergency that may have devastating physiologic and psychologic consequences. However, with prompt diagnosis and expedient surgical management, outcomes remain excellent and complications are minimal.[12]

Penile amputation
Erectile function remains in up to 86% of patients who undergo microvascular reanastomosis of the dorsal arteries. Penile sensation is maintained in up to 82% of patients, although this may be diminished when compared with preinjury. Urethral strictures develop in up to 20% of patients. Skin loss occurs in approximately half of all patients but is often superficial.

Penetrating injury
Patients who undergo exploration and primary repair of penetrating penile injury have good outcomes. Potency is maintained in up to 80-100% of patients in some series. This depends on the degree and severity of injury. Some authors anecdotally report that patients who have suffered close-range shotgun blasts have poorer outcomes secondary to massive tissue destruction.

Penile soft tissue injury

The long-term results of soft tissue injury to the penis are somewhat limited. Outcomes depend on the mechanism of injury and volume of tissue loss. Wound contracture and cosmesis is a concern in those who undergo skin grafting. Penile sensation is decreased in those with significant penile skin loss.

Future and Controversies

Penile fracture
Some debate surrounds the usefulness of imaging studies in diagnosing cavernosal injury. Most authors report accurate diagnoses without any imaging studies. Imaging studies have a limited role in the detection of penile fractures and should be reserved for cases in which clinical history does not correlate with examination findings or for those in which no injury is apparent and imaging would confirm nonoperative management. MRI provides excellent anatomic images of the penis and has been shown to be highly accurate in the detection of penile fractures. However, it appears to minimally affect treatment outcomes, is expensive, and is subject to limited availability in some institutions, especially after-hours. Penile ultrasonography, although widely available and inexpensive, heavily depends on the operator and requires specific expertise in the technique. False-negative rates are common. The most recent debate surrounds the use of penile cavernosography. False-negative findings are common, tissue reaction to the contrast material and increased corporal fibrosis are risks. Most authors report using penile cavernosography if physical examination findings are equivocal but the history indicates a possible injury. In most cases, prompt surgical exploration should be accomplished in lieu of preliminary penile imaging (other than urethrography).

Penile amputation
Cavernosal artery repair remains controversial. Some authors always attempt repair, especially when injury is more proximal, where the arteries may be larger, more easily sutured, and necessary to survival of the amputated stump. Other authors contend that the arteries do not provide a significant amount of vascular flow, add more operative time, and result in damage to the erectile tissue. Anticoagulation remains problematic. Most authors agree that anticoagulation leads to excessive bleeding and hematoma formation. Some contend that this prevents vascular occlusion of the freshly sutured dorsal artery and vein. To date, no studies have compared postoperative outcomes of penile amputation with or without anticoagulation.

Penile soft tissue injury

Split-thickness skin grafting is routine in the repair of penile skin loss. The choice of graft is largely up to the surgeon. Many authors have traditionally used unmeshed sheet grafts. This can be problematic because of fluid accumulation beneath the graft and infection of the graft bed. A recent series by Black et al showed that meshed unexpanded grafts achieved excellent cosmetic and functional results. However, a randomized controlled trial has not been undertaken to compare results.

PENILE TRAUMA
While the penis is one of the least injured organs, it too is occasionally injured. What can put it at risk? And how is it repaired? The following information should tell you when it is imperative to see your doctor about problems. How does the penis normally function? The two main functions of the penis are urinary and reproductive. Inside the penis there are three tubes. One is called the urethra. It is hollow and allows urine to flow from the bladder through the penis and to the outside. The two other tubes are called the corpora cavernosa, spongy tubes that are soft until filled with blood during an erection. The three tubes are wrapped together by a very tough

fibrous sheath called the tunica albuginea. At the time of sexual activity the erection of the penis allows it to be inserted into the woman's vagina. In this situation, the urethra acts as a channel for semen to be ejaculated into the vagina to allow conception and pregnancy. What are the causes and symptoms of penile injury? The penis is injured much less frequently than other parts of the body such as the abdomen, legs, arms and head. However, it can be wounded as a result of various injuries, including automobile accidents, gunshot wounds, burns, or sexual activity. Perhaps the most common injury to the penis occurs during sexual activity. When not erect, injury to the penis is rare because of the mobility and flexibility of the organ. During an erection, arterial blood flow causes the penis to become rigid. During vigorous thrusting, the erect penis may accidentally slip out of the vagina. The penis may accidentally strike the outside of the woman instead of being reinserted into the vagina. The penis may then bend sharply despite the erection. A typical sign of this problem is a sharp pain in the penis possibly a "popping" sound, and frequently a rapid loss of the erection. The pain and sound are produced by a tear of the tunica albuginea, which is stretched tightly during the time of an erection. Although there is no bone in the penis, urologists frequently refer to the injury as a penile "fracture." The pain may last for a short time or it may continue. The penis develops a collection of blood under the skin called a hematoma, and the penis may become quite swollen and badly bruised. Blood seen at the tip of the penis or in the urine is a sign of a serious injury to the urethra. Further injuries can occur if a man places a rubber tube or other constricting device around the base of the penis that is too tight or on for too long. Rings or other objects made of rigid material such as plastic or metal should never be placed around the penis as they become stuck if the penis swells further. Cutting off the blood supply, these items can cause permanent damage to the penis if the blood supply is blocked for too long.. Also, the urethra and/or penis may be damaged if objects are put into the tip of the penis. How are injuries to the penis treated? If a person sustains a penile injury, a urologist will take a thorough medical history and complete a physical examination along with blood and urine tests. The focus of any initial examination is to diagnose the injury and assess the damage to the penis. If the doctor suspects an injury to the urethra, he/she may perform a procedure to view the urethra with a fiber optic camera. Another study might be an X-ray study call a "retrograde urethrogram" performed by injecting a special solution used with X-ray studies through the opening at the top of the penis and then taking X-rays. If the X-ray shows any leakage outside the urethra, it may indicate damage to that part of the urinary tract. Additional imaging techniques might include an ultrasound of the penis or an MRI. Historically, treatment for a penis "fractured" during sexual activity was non-surgical management (e.g., cold compresses, pressure dressings, penile splinting and anti-inflammatory medications). Today, the treatment of choice is usually surgery since it has lower rates of infection, erectile dysfunction, and penile scarring and curvature. The most common surgical technique is to make an incision around the shaft near the head of the penis and pull back the skin to the base to examine the inner surface. The surgeon will then remove blood clots to help find any tears in the tunica albuginea. If tears exist, they are repaired before the skin is sewn back into position. A catheter may be placed through the penile urethra into the bladder to drain urine and allow the penis to heal. With the entire penis bandaged, the patient may remain in the hospital for one or two days, and go home with or without the catheter. They may be given antibiotics and pain medication and will probably be asked to make a follow-up office visit with their doctor. For the rare injury of a traumatic amputation of the penis, the amputated portion should be wrapped in gauze soaked in sterile saline solution and placed in a plastic bag. The plastic bag should then be put into a second bag or cooler with an ice water slush. Under no circumstances should any amputated organ be placed directly into ice water. The water and direct contact with ice is harmful to tissue. If reattachment of the penis is possible, the lower temperature produced by the slush will increase the likelihood of successful reattachment. Penile reattachment even after 16 hours may be possible.

For massive injuries to the penis, major reconstruction is frequently possible by urologists experienced with this difficult surgery. How closely the reconstructed penis can return to normal urinary or sexual function varies greatly. What can be expected after treatment for injuries to the penis? Most cases of fractured penis caused by sexual activity and most other minor penile injuries will heal without problems if treated promptly. However, complications can and do occur. Possible complications include: infection, erectile dysfunction due to blockage of the nerve or blood supply to the penis, priapism in which the penis becomes erect and stays erect to the point of pain, or curvature of the penis after the injury has healed.. Failure of return of sufficient sexual function is rare but depends upon the degree of injury to the arteries, nerves and corpora cavernosum and whether the patient was experiencing erectile dysfunction just prior to the injury. Frequently asked questions: Although uncommon, large hospitals may see several penile injuries each year. How do I prevent penile injury? Penile injuries related to sexual intercourse can be prevented in most cases if your partner is simply aware of the possibility. Classically, penile "fractures" occur with the female partner on top. If your penis is erect and inadvertently slips from the vagina of your partner, stop the thrusting immediately. For other injuries, caution on the job, especially near machinery, defensive driving and gun safety are obvious precautions for the other types of injuries.

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

Reviewed January 2011