Penile Trauma

JUDITH C. HAGEDORN

DANIEL I. ROSENSTEIN

Trauma to the penis is an uncommon event. Because of the relatively protected position of the penis between the thighs and pubic bone, it is usually able to avoid direct injury from external forces. Nonetheless, penile trauma may arise from both blunt and penetrating injuries. Such injuries present unique and difficult management problems to the urologic surgeon, in particular regarding long-term cosmesis, voiding function, and future potency. Major blunt penile injuries include penile rupture and skin loss from strangulation or degloving injuries. Penetrating penile trauma is usually secondary to stab or gunshot wounds and thus seldom occurs in the absence of associated genital, urethral, or major organ injury, except in the event of bites and self-inflicted wounds. Due to the wide disparity in the causes, diagnosis, and treatment, this chapter is divided into three parts: penile rupture, penile skin loss, and penetrating penile trauma.

PENILE RUPTURE (PENILE FRACTURE)

The most common blunt injury involving the penis is rupture of the corpora cavernosa, or penile fracture. This almost invariably occurs when the erect penis is forced to bend in an irregular fashion, such as when it accidentally impinges on the
pubis or perineum during sexual intercourse (1). The remainder of cases is caused by falls out of bed with an erect penis, masturbation, or manipulation of the erect penis. Recently, penile crush injury due to the accidental fall of a toilet seat has been described as an uncommon cause of genitourinary trauma (2). The patient often reports a cracking or popping noise at the time of injury, leading to immediate detumescence and rapid onset of discoloration and swelling over the site of injury. There is frequently a delay in presentation to the hospital—presumably secondary to patient embarrassment.

Diagnosis

The diagnosis of penile rupture is easily made by physical examination along with the appropriate history. Swelling and discoloration may or may not be limited to the penis, depending on the integrity of Buck fascia. If Buck fascia is intact, the hematoma will be contained and will not usually spread below the base of the penis, resulting in the typical “eggplant” deformity (Fig. 71.1).

However, if the laceration in the tunica albuginea also lacerates through Buck fascia, extravasation will be contained by Colles fascia and ecchymosis will extend in a “butterfly” distribution over the perineum, scrotum, and lower abdomen. Examination may reveal angulation of the penis away from the side of rupture because of the mass effect of the hematoma. In addition, focal tenderness and a palpable defect in the tunica albuginea may help localize the fracture site. There is often a clot lying over or near the fracture site that corresponds to the site of cavernosal rupture. Imaging studies for the diagnosis of penile rupture are unnecessary after a thorough history and physical exam, but recent studies have described penile ultrasound as a low-cost supplement examination that can be easily performed and may be of value in identification of the rupture location (3). In addition, magnetic resonance imaging is a very accurate modality but of limited availability and practicality in this setting (4).

FIGURE 71.1 Fractured penis displaying the pathognomonic “eggplant” deformity with swelling and discoloration extending to the base of the shaft and, in this case, into the scrotum.

Penile rupture can occur anywhere along the shaft, including the base of the penis, where the corpora are fixed by the penile suspensory ligament. The fracture is typically transverse in orientation and located at the base of the penis, just proximal to the penoscrotal junction. However, longitudinal, distal fractures have been described in 30% of cases (4). In general, only one corporal body is injured, although both corpora and the corpus spongiosum can be affected depending on the severity of the injury. Most patients are able to urinate normally, but the urologist must maintain a high index of suspicion for urethral injury. Failure to void spontaneously may signify compression of the urethra by hematoma but should lead to evaluation of urethral injury by retrograde urethrography (RUG). Urethral injury occurs in up to one-third of cases and usually consists of partial disruption, although complete transection can result (4,5). RUG is mandatory in all patients with blood at the urethral meatus, hematuria of any extent, or inability to void (1). However, because RUG is easy to perform and provides reliable results, we perform it routinely in all cases of suspected penile rupture. Adjunctive imaging studies in penile fracture (including ultrasound, magnetic resonance imaging, and cavernosography) are usually unnecessary as the clinical picture is frequently adequate to initiate therapy (6).

Indications for Surgery

Although penile fractures can be managed nonoperatively, the literature shows a clear advantage to early operative repair (1,5). This approach results in faster recovery, shorter hospital stay, less morbidity, and less long-term penile curvature. The goals of acute exploration are evacuation of the hematoma and primary repair of the laceration and should be undertaken even in patients with delayed presentation (7). Of note, dorsal vein injury may mimic the presentation of penile rupture and may lead to a negative penile exploration (8).

Alternative Therapy

Conservative treatment consists of cool compression dressings, anti-inflammatory agents, and sedatives to reduce the frequency of erections. This results in eventual resorption of the hematoma and scar formation at the site of the tunical rupture. Conservative management is associated with significant complications in up to 50% of patients, including hematoma formation, corporal fibrosis and curvature, pseudoaneurysm of the corpora, and erectile dysfunction (8,9). Several studies have shown that surgical exploration and repair of the penile fracture leads to superior outcomes and therefore should be undertaken when the injury is suspected (10,11,12).

Surgical Technique

The patient is placed in a supine position and a Foley catheter is placed to facilitate identification of the urethra and urinary drainage. Exposure is usually obtained through a subcoronal circumferential incision, and the penile skin is degloved down to the base. The distal circumferential incision is favored
because it allows both exposure of the ruptured corpus and adequate assessment of the contralateral corpus and corpus spongiosum. Alternatively, an incision may be made on the shaft directly over the fracture site. This approach is only useful if the fracture is palpable or seen on preoperative imaging, as the corporal bodies may not be easily explored through this incision. Further, the corpus spongiosum cannot be directly inspected via this approach.

FIGURE 71.2 Identification and repair of penile fracture. A distal circumferential subcoronal incision is made and skin and soft tissue are mobilized off the underlying corporal bodies down to the base of the penis. Note that a white elastic tourniquet has been temporarily applied around the base of the penis. A: This maneuver exposes the transverse laceration in the tunica albuginea. Arrow points to site of corporal laceration. B: The laceration is repaired using interrupted 4-0 monofilament suture with the knots buried. Arrow points at laceration repair. Exposed corporal erectile tissue should not be probed or explored as this may cause troublesome bleeding.

FIGURE 71.3 Penile fracture extending beneath dorsal neurovascular bundles. Elevation of the ipsilateral dorsal neurovascular bundle facilitates repair of lacerations and protects these structures from inadvertent injury.

Following the circumcising incision, the corpus spongiosum is carefully inspected to evaluate for potential urethral injury. Inspection of the fracture site usually reveals a transverse laceration, between 0.5 and 2.0 cm long, in the tunica albuginea of the proximal penile shaft (13). After evacuation of the hematoma and irrigation, minimal debridement of nonviable wound edges may be necessary before closure with interrupted 4-0 monofilament synthetic absorbable sutures (Fig. 71.2A and B).

The surgeon should not probe the exposed cavernous tissue unnecessarily as this may elicit troublesome bleeding. A tourniquet may be used intraoperatively to control hemorrhage. Lacerations may run directly under the dorsal neurovascular bundle located on the dorsal surface of the corpora at approximately the 10 and 2 o’clock positions (Fig. 71.3).

This necessitates careful dissection of these structures off the corpora to allow a safe, watertight closure. Division of the deep dorsal vein facilitates unilateral dissection of the neurovascular bundle off the underlying corpus cavernosum. The penile skin is then replaced and the subcoronal incision is closed with interrupted 4-0 chromic sutures. If the patient is uncircumcised, the prepuce must be closely monitored for development of subcoronal edema. Postoperatively, a loose compression dressing (Coban) is gently placed, and the urethral catheter may be removed on postoperative day 1 (assuming no urethral repair was required). Systemic antibiotics, antiinflammatory agents, and fibrinolytics are unnecessary. Most patients can be discharged home within 1 to 2 days of surgery. Sexual activity can be resumed at about 4 to 6 weeks. Painful
erections may be present in the early postoperative period. Suppression of erections with benzodiazepines or amyl nitrate may provide symptomatic relief.

When urethral transection occurs in the context of penile rupture, we advocate primary repair with interrupted 5-0 or 6-0 synthetic, absorbable, monofilament sutures over a 16Fr silicone catheter. In cases of complete urethral transection, additional urinary diversion through a percutaneous suprapubic cystostomy tube may be prudent (1). A voiding cystourethrogram (VCUG) should be carried out at approximately 14 days postrepair to document adequate healing before catheter removal.

Outcomes

Complications

Penile fracture has potential complications, particularly when managed nonoperatively or with delayed repair. However, patients who undergo immediate surgical exploration may also develop some form of sexual dysfunction, such as painful erection, disabling curvature, or erectile dysfunction secondary to corporal veno-occlusive disease (8,14). Patients with a missed urethral injury associated with penile fracture are also at risk of periurethral abscess, stricture, and fistula formation.

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