The vast majority of penetrating injuries to the genitalia require surgical exploration, irrigation, a careful search for and removal of foreign-body material, anatomic repair, and drainage (Level of Evidence, LOE 4) (2). With traumatic injuries to the genitalia, the importance of a careful and thorough
search for retained foreign body cannot be overstated. Torn and shredded fragments of clothing are commonly found in the wound and if missed can lead to sequelae of poor wound healing and recurrent abscess formation. In our current litigious environment, a missed foreign body following “surgical wound exploration” can be difficult to defend. Because these are often very dirty wounds, at our institute, we prefer the Pulsavac wound irrigation and debridement system to assist with a thorough wash out of the traumatized region.

Penetrating trauma to the genitalia may also involve the urethra. If there is any suspicion of urethral injury, a retrograde urethrogram or cystoscopy should be performed. Saline should be used for irrigation in these cases. Because of the position of the urethra beneath the scrotum and perineum, significant penetrating injuries to the scrotum can also often spare the urethra.

Avulsion injuries of the genital skin most frequently involve the loose hanging scrotal skin. Genital skin avulsion injuries are most commonly seen with either rapid deceleration injuries such as motorcycle accidents, when the rider is thrown over the handlebars and his clothing is caught on various stationary components of the motorcycle handlebars, or related to industrial equipment accidents, when the patient’s clothing becomes entangled in machinery and forcefully ripped away from the body. The loose scrotal tissues ensnare, and as the clothing is ripped off, so is the loose genital skin. These avulsion injuries vary from minimal injuries, which are essentially nothing more than jagged lacerations, to emasculating injuries, which take not only the skin but also the deep structures. Usually, with most scrotal injuries, the testicles are not involved or avulsed. Their mobility and the strength of the tunica albuginea afford the testicles protection. Most avulsion injuries fortunately occur along superficial avascular planes between the scrotal dartos and the external spermatic fascia, taking only the skin and the scrotal dartos fascia/tunica dartos and leaving the underlying Buck fascia of the penis and the external spermatic fascia and tunica vaginalis surrounding the testicle intact. Rarely, the testicle ensnares in the skin and is avulsed. In most cases of avulsion, bleeding is not a problem because the skin and fascia are avulsed in a relatively avascular plane between the fascial structures related to the deep structures and the superficial fascia.

Thermal burns to the genitalia are usually not isolated injuries but reflective of a more extensive area of body burn, as a rule of thumb, exceeding 40% of total body surface area. Genital burns are often seen following entrapment within a burning automobile or the spilling of hot cooking grease during transport. Chemical burns are in general only superficial and involve the skin. Thermal injuries can be deep, but often, even with extensive deep burns proximate to the genitalia, the multiple clothing layers (i.e., underwear and other clothing) afford some degree of protection of the genitalia. Electrical burns disseminate via the deep vascular and neurologic structures, and what may appear to be a minimal burn to the skin and scrotum may have associated significant deep injury, which can be devastating. Usually, however, the deepest burns associated with electrical contact occur at the site of the current inflow and the ground site. These sites are usually not the genitalia. However, it is not uncommon to have thermal burns in concert with electrical burns, as frequently the clothing is ignited by the electrical spark. Thus, with electrical burns, fortunately, if the genitalia are involved, it is usually a more superficial process.

For the most part, genital burns are managed like all other burns with a few exceptions. Debridement of the glans penis
should be approached cautiously, and early aggressive, overzealous debridement of the glans penis should be avoided in favor of a wait-and-see approach to allow for demarcation. The abundant vascularity of the glans penis often allows for surprising delayed healing with excellent cosmetic results superior to those obtained from split-thickness skin grafts (STSGs). Urinary catheter insertion for fluid monitoring is almost always required in burn patients. In the case of severe genital burns, a suprapubic cystostomy can be placed in its typical location even if the suprapubic area is badly burned. If a urethral Foley catheter is used for fluid monitoring, it is important to continually reassess the necessity of the urethral Foley and to keep the penis secured to the abdomen in the anatomic position. Pressure from prolonged urethral catheterization of the edematous, compromised genital tissue, especially if the catheter is positioned in the customary dependent position and secured to the leg can result on pressure necrosis of the ventral urethra and urethral-cutaneous fistula (Figs. 63.3, 63.4 and 63.5).

Radiation injuries to the genitalia can occur either from direct exposure to the genitalia or from delayed effects of the radiation on the venous and lymphatic drainage. Complications of direct radiation injury to the genitalia are now uncommon, as radiation for penile lesions is rarely undertaken. The secondary effects of radiation, as seen in the scrotum, are usually manifested by chronic lymphedema, lymphangiectasia, and, in some cases, chronic recurring cellulitis.

To this list of traumas must be added the patient who has required significant debridement because of rapidly progressive, multiorganism fasciitis (Fournier gangrene). Fournier gangrene is often seen with processes of the anus or rectum, such as perianal abscess. Likewise, processes involving the urethra, such as urethral stricture with periurethral abscess, can accompany Fournier gangrene. Fournier gangrene is often associated with other comorbidities, such as diabetes mellitus and alcoholism. Given this multifactorial etiology, the associated comorbidities, and the rapid spread, these patients are best managed with a multispecialty approach involving urologists, general surgeons, and intensive/critical care specialist.

The necrotizing process can progress rapidly in a matter of only a few hours. Additionally, many of these patients present late; hence, aggressive and extensive surgical debridement (LOE 2) is required and can be lifesaving. At our institute, we take a more aggressive initial approach to debriding the necrotic tissue associated with necrotizing fasciitis than we do for burn patients. This aggressive debridement of necrotic tissue usually leaves a significant defect for the surgeon to reconstruct after the acute process is controlled (2). If the fasciitis is associated with pathophysiology of the urethra (i.e., stricture with perforation, extravasation, and abscess) and/or anus, then these situations must be managed and resolved before reconstruction (3). Urinary diversion in the form of a suprapubic cystostomy and fecal diversion via a colostomy are commonly required in management of the acute process. Recently, there have been descriptions of the use of unprocessed honey to augment or provide an alternative treatment to wide surgical excision. Honey apparently contains antimicrobial agents and enzymes to digest necrotic tissue as well as to promote epithelial growth (4).

Also, in recent years, we have seen several patients who have attempted to enhance the size and bulk of their genitalia with the injection of lipid-containing substances such as paraffin or petroleum jelly or inert substances such as silicone. In these cases, one is often confronted with a fulminant cellulitis that must be treated with broad-spectrum antibiotics. Later, one sees a sclerosing granulomatous process that can be troubling to the patients. In some cases, the skin must be excised along with the deeper involved structures, but it is not unusual to be able to excise the deep process and leave the skin that survives either on its random dermal blood supply or, in some cases, on the tunica dartos fasciocutaneous blood supply.

A contusion of the scrotum, that is, a scrotal hematoma, can be confused with a fracture of the testicle. The latter injury implies disruption of the tunica albuginea of the testicle. With a scrotal contusion, the hematoma usually is noted to be posterior and lateral to the testicle (Fig. 63.6), whereas with fracture of the testicle the parenchyma of the testis is not normal and is often associated with a hematocele if the visceral tunica vaginalis remains intact (Fig. 63.7). Physical examination remains the cornerstone in the diagnosis of blunt testicular trauma. However, the use of ultrasonography in the diagnosis of testicular trauma can be helpful in situations when the physical examination is difficult to perform or interpret. Ultrasonography is the most sensitive and specific imaging technique, with heterogeneity of the parenchyma of the testicle suggestive of testicular rupture (LOE 2) (2). In the presence of penetrating trauma to the genitalia, a cystoscopic evaluation or retrograde urethrogram is always indicated because of the close proximity to the urethra. In all cases of genital avulsion, other than a simple scrotal avulsion, a complete evaluation of the urethra must be done, along with a rectal examination and possibly flexible sigmoidoscopy.