Penile Fracture and Trauma

History of the Procedure

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 the following[5, 6] :

• 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
• Fibrotic plaque formation

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.

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 the 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 erect penis 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 have been reported. The trauma usually results in injury to one corpus cavernosa (usually at the ventrolateral location), but both can be involved. Urethral injurymay also occur.

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, which helps prevent injury.

Penile soft tissue injury

The penis is particularly susceptible to avulsion injuries. The overlying skin of the penis is loose and elastic, as it 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.

Penile fracture

A meta-analysis on penile fractures showed that the most common causes are sexual intercourse (46%), forced flexion (taqaandan) (21%), masturbation (18%) and rolling over (8.2%).[7]  The most common mechanism of injury is when the penis slips out of the vagina and strikes against the symphysis pubis or perineum. Penile fracture is more likely when the partner is on top but can occur in any coital position.[8]

Penile amputation

Penile amputation is frequently self-inflicted, as a result of mental illness. In the Western world, as many as 87% of penile amputations are due to mental illness. 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. The 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.

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 is 20%.[8]  

An emerging trend is penile fracture following the use of collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie disease. The rate of penile fracture associated with CCH is reported to range from 0.5% to 4.9%, with a small fraction occurring spontaneously, in the absence of sexual activity.[9, 10]  

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. Penetrating penile injury with concomitant urethral injury has been reported in 11–29% of cases. The frequency of stab wounds to the penis is relatively rare, accounting for only 4% of penetrating penile injuries.

Historically, wounds to the GU structures have been less common than extremity and penetrating abdominal trauma in combat operations. The use of improvised explosive devices (IEDs) has resulted in a significant increase in genitourinary (GU) wounds since 2001. Studies report that 20-31% of GU injuries involved the penis.[11, 12]

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 discussed in Fournier Gangrene. The remainder of soft tissue loss cases are typically due to avulsion injuries, human or animal bites, and burns.

Pubic hair grooming–related injuries, including lacerations and burns, have been reported, with the penis the second most common site of injury (34.8%).  A cross-sectional study of US adults found 66.5% of men reporting a history of pubic hair grooming, with 23.7% having sustained an injury. Although most injuries reported were minor, 1.4% required medical attention. Men who removed all their pubic hair had an increased risk for grooming injury.[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.[14]  Patients treated with conservative management have a significantly higher incidence of complications compared with those treated with prompt surgical therapy.

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.

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. 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.

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. 

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.

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 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. If the graft does not take in patients who undergo split-thickness skin grafting, the consequences can be devastating. Penile sensation is decreased in those with significant penile skin loss.

The most frequent complication of soft tissue injury is postoperative infection; complications such as erectile dysfunction, curvature, and fistula are associated risks.

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. 

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.

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

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 sufficient to establish the diagnosis. Some debate surrounds the usefulness of imaging studies in diagnosing cavernosal injury. 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.[16]

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).

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.[8] The test is easy to perform and inexpensive.

 

 

Although no specific laboratory studies are required for penile trauma, a standard preoperative laboratory panel should be considered on a case-by-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.

On a retrograde urethrogram, the extravasation of contrast material from the urethra into the penile soft tissues indicates urethral injury. The procedure can be performed by inserting a "Christmas tree" adaptor into the fossa navicularis (distal urethra) and injecting contrast from a 60-mL piston syringe with the penis placed on stretch. Oblique radiographs are taken and the continuity of the urethra is examined. 

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 quarter–to–half-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.

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.[17]

Penile fracture

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. 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.[18]

Penile amputation

Penile amputation is a surgical emergency. Imaging studies are not necessary. Reanastomosis requires the amputated penile remnant. In the case of distal penile loss, phallus reconstruction can be performed using a forearm free flap. 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.

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 and that repair adds more operative time and results in damage to the erectile tissue.

Anticoagulation remains problematic. 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.

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.

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

Acute management involves resuscitation of the patient, who may be compromised from massive blood loss, and preparation for surgical re-implantation of the penis if it has been recovered and is not too badly damaged. 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.[8] 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.

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.[19, 20, 21]

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. [22]   Patients with penile trauma require fluid resuscitation prior to operative intervention. Although there is no clear consensus on the use of preoperative antibiotice, broad-spectrum intravenous antibiotics (cefazolin) 1 hour before surgery should be considered.

Informed consent that outlines the risks must be 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.

Penile fracture

In the 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.[23] 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.[24]  However, the results of a meta-analysis of 58 studies involving 3213 patients found early surgery preferable to delayed surgery, with significantly fewer complication reported, although there was no significant difference in the rates of erectile dysfunction.[25]

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 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:

• 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 povidone iodine and antibiotic solution
• Closure of injury with exception of human bites
• Skin grafting and harvest to cover large defects

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. An alternative technique is incision along the palpable hematoma or a midline raphe when the location of the corporal injury is obvious on examination.

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 series by Shaeer showed 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.[26]

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 2-0 delayed absorbable (such as polydioxanone) suture in an interrupted fashion. Invert the sutures so the knots will not be palpable. Other suture materials have been described by other authors. 

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 debrided, 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. See the images below.

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 povidone iodine 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.

Split-thickness skin grafting is routine in the repair of penile skin loss.  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 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.

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.

The American Urology Association (AUA) guidelines for diagnosis and management of genitourinary injuries were amended in 2017 and 2020 to reflect literature that was released since the original publication in 2014. Key recommendations for genital trauma include the following[27] :

• Penile fracture should be suspected in a patient who presents with penile ecchymosis, swelling, and pain following a cracking or snapping sound during intercourse or manipulation and immediate detumescence.
• Surgeons should perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture.
• Ultrasound may be performed in patients with equivocal signs and symptoms of penile fracture.
• Evaluation for concomitant urethral injury should be performed in patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria, or inability to void.
• Surgical exploration and limited debridement of non-viable tissue should be performed in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical).
• Prompt penile replantation should be performed in patients with traumatic penile amputation, with the amputated appendage wrapped in saline-soaked gauze, put in a plastic bag, and placed on ice during transport.
• Initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated.

The European Association of Urology guidelines for urologic trauma were first published in 2003 and have undergone annual assessment of newly published literature in the field to guide updates. As of 2021, key recommendations include the following[8] :

• Penile fracture is associated with a sudden cracking or popping sound, pain, immediate detumescence, and local swelling.
• Magnetic resonance imaging (MRI) is the preferred imaging modality for the diagnosis of penile fracture.
• If a concomitant urethral injury is suspected, flexible cystoscopy is preferred over retrograde urethrography.
• Surgical closure of the tunica should be carried out using absorbable sutures within 24 hours of presentation.
• Nonoperative management is recommended for small superficial penetrating injuries with intact Buck’s fascia.
• In more significant penetrating penile injuries, surgical exploration and debridement of necrotic tissue should be performed.
• Surgical re-implantation should be considered and performed within 24 hours of amputation.
• If the severed penis cannot be found, or is unsuitable for re-attachment, then the end should be closed as it is done in partial penectomy.