History
Penile fracture
The clinical presentation of a penile fracture is often fairly straightforward. Diagnosis is based on history and physical examination findings. [15] Most affected patients report penile injury coincident with sexual intercourse. Patients usually report that the female partner was on top, straddling the penis, and that 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. Less severe penile injuries can be distinguished from penile fracture, as they are not usually associated with detumescence. [8] These patients may report minimal to severe sharp pain, depending on the severity of injury.
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.
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.
Physical Examination
Penile fracture
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.
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 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.
Presentation of superficial vascular injuries can be similar to penile fracture. Courtesy of Joel Gelman, MD.
Ligation of the injured superficial dorsal vein upon exploration. Courtesy of Joel Gelman, MD.
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
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. 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
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
-
Eggplant deformity.
-
Small penile fracture involving the right corpus cavernosum.
-
More severe penile fracture.
-
Gunshot wound to the penis.
-
Partial penile amputation.
-
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.
-
Presentation of superficial vascular injuries can be similar to penile fracture. Courtesy of Joel Gelman, MD.
-
Ligation of the injured superficial dorsal vein upon exploration. Courtesy of Joel Gelman, MD.
-
Concomitant urethral injury with visible Foley catheter.
