Penile Fracture and Trauma Treatment & Management

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.