You are in: eMedicine Specialties > Urology > Trauma Penile Fracture and TraumaArticle Last Updated: Aug 14, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 13
  Author: Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction Richard A Santucci is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology) Coauthor(s): Marlou Heiland, MD, Consulting Staff, Mesa Urologists and Incontinence Center; Joshua A Broghammer, MD, Resident Physician, Department of Urology, Wayne State University Editors: Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center; Stephen W Leslie, MD, FACS, Founder and Medical Director of the Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio Author and Editor Disclosure Synonyms and related keywords: penile trauma, penile fracture, erection, fractured penis, penile rupture, traumatic rupture of corpus cavernosum, traumatic rupture of tunica albuginea, urethral injury, urethral trauma, erectile dysfunction, ED, penile amputation, penile avulsion, penile soft tissue loss, penetrating penile trauma INTRODUCTIONSection 2 of 13
  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. Urethral injury and repair is beyond the scope of this article but details can be found in Urethra, 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. 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. 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. 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 ProcedurePenile 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. 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 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. FrequencyPenile 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. EtiologyPenile 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 illness–related 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. PathophysiologyThe 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. ClinicalPenile fracture The clinical presentation of a penile fracture is often fairly straightforward. Diagnosis is made based on history and physical examination findings. 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). 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, the physician may appreciate a "rolling sign" 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:
INDICATIONSSection 3 of 13
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. 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 ANATOMYSection 4 of 13
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 CONTRAINDICATIONSSection 5 of 13
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. Patients with penile trauma require fluid resuscitation prior to operative intervention. WORKUPSection 6 of 13
Lab Studies
Imaging Studies
TREATMENTSection 7 of 13
Medical therapyThe 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 Pasteurella resistance 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 therapyNo 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. Penile fracture In the reported literature, surgical therapy has consistently resulted in fewer complications. A recent series from Muentener et al reported good outcomes in 92% of patients treated surgically versus only 59% in those treated conservatively. Principles of surgical therapy are as follows:
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 circumferential-degloving 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:
Penetrating injury Expeditious surgical repair of the penis should be undertaken as soon as possible. Principles of surgical therapy are as follows:
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:
Preoperative detailsThe 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 detailsPenile 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.1 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 débrided, 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. 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 débrided. 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 detailsPenile 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-upFor 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. COMPLICATIONSSection 8 of 13
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 PROGNOSISSection 9 of 13
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. 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 CONTROVERSIESSection 10 of 13
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. ACKNOWLEDGMENTSSection 11 of 13
The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Jong M. Choe, MD, FACS, to the development and writing of this article MULTIMEDIASection 12 of 13
REFERENCESSection 13 of 13
Penile Fracture and Trauma excerpt Article Last Updated: Aug 14, 2006 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
