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, 2] Urethral injury and
repair is beyond the scope of this article but details can be found in Urethral 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. [3]

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. [4]

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. See the images below.

Small penile fracture involving the

right corpus cavernosum.
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 More severe penile fracture.
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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. See the image below.

Partial penile amputation.

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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. See the image below.

Gunshot wound to the penis.

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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. [5, 6]

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 [7] 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. [8] 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). See the image.

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. [9]

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 10- and 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. [10] Patients with penile trauma require fluid resuscitation prior
to operative intervention.

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