Urol Clin N Am 33 (2006) 117–126 Penile and Genital Injuries Hunter Wessells, MD, FACS*, Layron Long, MD Department of Urology, University of Washington School of Medicine and Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104, USA Genital injuries are significant because of their Mechanisms association with injuries to major pelvic and vas- The male genitalia have a tremendous capacity cular organs that result from both blunt and pen- to resist injury. The flaccidity of the pendulous etrating mechanisms, and the chronic disability portion of the penis limits the transfer of kinetic resulting from penile, scrotal, and vaginal trauma. energy during trauma. In contrast, the fixed Because trauma is predominantly a disease of portion of the genitalia (eg, the crura of the penis young persons, genital injuries may profoundly in relation to the pubic rami, and the female affect health-related quality of life and contribute external genitalia in their similar relationships to the burden of disease related to trauma. Inju- with these bony structures) are prone to blunt ries to the female genitalia have additional conse- trauma from pelvic fracture or straddle injury. quences because of the association with sexual Similarly, the erect penis becomes more prone to assault and interpersonal violence [1]. Although injury because increases in pressure within the the existing literature has many gaps, a recent penis during bending rise exponentially when the Consensus Group on Genitourinary Trauma pro- penis is rigid (up to 1500 mm Hg) as opposed to vided an overview and reference point on the sub- flaccid [6]. Injury caused by missed intromission ject [2]. This article reviews the mechanism, initial or manual attempts at detumescence can cause pe- evaluation, and operative management of injuries nile fracture [7]. Less severe bending injuries may to the male and female external genitalia including still lead to long-term disability related to tunica the penis, scrotal skin, and vaginal structures. albuginea disruption (Peyronie’s disease) or arte- rial insufficiency. Firearms and missiles have an Prevalence excess of kinetic energy, which overcomes the pro- tective mechanisms of flaccidity. The incidence of genital injuries has not been Another characteristic of the male genitalia determined, but in civilian centers is likely to be particularly pertinent to injury mechanisms is the low, given that most case series span many years looseness and laxity of genital skin. Although this and include relatively small numbers of patients generally has a protective role, allowing the skin [3]. In the battlefield, the massive destruction to deform and slide away from a potential point caused by fragmentation devices, combined with of contact, in the case of machinery injury, the use of protective torso armor, has led to sur- rotating or suction devices can grab hold of vival of soldiers with increasingly severe pelvic a portion of the genital skin [8]. Laxity of skin be- and genital organ injury [4]. Penile fracture is comes a liability because the entire penile and the most commonly described blunt injury to the scrotal skin can be trapped and avulsed. penis, and over 1300 cases have been reported in The vascular supply of the genitalia also predicts the literature [5]. outcomes of other forms of injury, such as chem- ical, radiant, and infectious injury. Deep structures * Corresponding author. have multiple sources of arterial inflow. The penis E-mail address: [email protected] derives a triple blood flow from the dorsal, cav- (H. Wessells). ernosal, and bulbourethral arteries. Ischemic loss 0094-0143/06/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ucl.2005.11.003 urologic.theclinics.com 118 WESSELLS & LONG of this organ because of injury is only seen with Table 1 complete amputation or prolonged constriction Organ injury scale for penile injury injury. Likewise, the testis derives blood supply AAST AIS-90 from the cremasteric, testicular, and vasal arteries. grade Penile injury score In cases of Fournier’s gangrene neither of these I Cutaneous laceration or 1 organs is lost. Conversely the skin, although richly contusion vascularized through multiple sources, receives its II Laceration of Buck’s fascia 1 arterial perfusion from deeper fascial layers, and (cavernosum) without when these are affected by synergistic bacterial tissue loss infection during Fournier’s gangrene, total skin III Cutaneous avulsion, 3 loss is inevitable. Because burns start superficially laceration through glans and progressively spread their damage down into or meatus, or cavernosal ! deeper tissues in the opposite fashion from Four- or urethral defect 2cm IV Partial penectomy or 3 nier’s gangrene, preservation of some portion of the cavernosal or urethral vascular integrity of the skin is likely in most defect ¼ 2cm chemical and thermal burns. V Total penectomy 3 A particularly unusual cause of penile injury is Abbreviations: AAST, American Association for the amputation, which is discussed separately because Surgery of Trauma; AIS, Abbreviated Injury Scale. of its unique considerations [9,10]. When assault is From Moore EE, Malangoni MA, Cogbill TH, et al. the cause, appropriate police reporting is required. Organ injury scaling VII: cervical vascular, peripheral Other cases require special input from psychiatric vascular, adrenal, penis, testis, and scrotum. J Trauma and psychologic experts. Penile amputation may 1996;41:523; with permission. be a manifestation of depressive and psychotic be- havior, either caused by schizophrenia or illicit drug abuse. Others amputate the penis to initiate likelihood of associated injuries to the spermatic the process of gender conversion. Finally, con- cord and testis, urinary bladder and urethra, striction rings can cause loss of superficial skin, rectum, and vascular structures of the iliac and deep urethral necrosis, or complete penile loss. femoral region. Blood at the urethral meatus Blunt injuries cause much less damage to the implies injury, whereas its absence can be mis- phallus than firearm and stab injuries. The laxity leading. Urethral injury occurs in 10% to 38% of of the genital skin usually protects the deep penile penile fractures and up to 22% of penile gunshot structures from avulsion, so that after car crashes wounds [12,13]. superficial lacerations of the skin are more com- A delayed presentation is not uncommon after mon. Pelvic fractures with symphyseal or pubic penile fracture and constriction ring use, usually ramus displacement can cause severe injury to the caused by patient embarrassment. The constella- deep structures of the penis, including avulsion of tion of missed intromission, acute bending, and the crus of the corpus cavernosum from its vascular and neural supply [11]. Less severe crush Table 2 injuries may also occur. The long-term conse- AAST organ injury scale for scrotal injury quences of these injuries are more significant AIS-90 than their initial presentation suggests. Although AAST grade Scrotal injury score extensive bleeding may occur, angioembolization of the internal pudendal arterial tree can control I Contusion 1 ! such hemorrhage. More importantly, the delayed II Laceration 25% of 1 scrotal diameter consequences of arterial injury are erectile dys- III Laceration ¼ 25% of 2 function or penile ischemia. Tables 1 and 2 show scrotal diameter the characteristics of injuries to the penis and IV Avulsion !50% 2 scrotum, and corresponding AIS scores. V Avulsion ¼ 50% 2 Abbreviations: AAST, American Association for the Surgery of Trauma; AIS, Abbreviated Injury Scale. Presentation From Moore EE, Malangoni MA, Cogbill TH, et al. Organ injury scaling VII: cervical vascular, peripheral Penetrating injuries to the external genitalia vascular, adrenal, penis, testis, and scrotum. J Trauma require special consideration because of the high 1996;41:523; with permission. PENILE AND GENITAL INJURIES 119 a popping sound followed by immediate detumes- orientation when structures are distorted by he- cence of the penis and acute pain are characteristic matoma. The presence of hematuria should alert of this entity. In the Middle East and other the trauma team to the possibility of a bladder regions, penile fracture may occur as a result of or upper urinary tract injury in cases of penetrat- excessive bending of the shaft in an attempt to ing firearm injuries. Finally, rectal injuries must be achieve rapid detumescence of an embarrass- sought out if complications, such as fistulae and ing penile erection [7]. Penile swelling is usually Fournier’s gangrene, are to be avoided. limited to the attachments of Buck’s fascia and Bleeding from the penis can usually be con- only the shaft of the penis is ecchymotic; a local- trolled in the emergency department with gauze ized hematoma is evident in such cases and has wraps to tamponade any bleeding. Excessively been termed an ‘‘eggplant deformity’’ [2]. When tight compressive dressings that compromise the deep investing fascia of the penis has been rup- blood supply to the distal penis must be avoided. tured by penetrating or blunt trauma, a perineal The mechanism of injury is important. Burns butterfly hematoma or scrotal bleeding can occur. should be covered with appropriate dressings Entrapment of the genitalia by industrial machin- depending on the mechanism. For thermal injury, ery including augers, power takeoff from farm 1% silver sulfadiazine cream is appropriate. tractors, and suction devices can lead to avulsion Chemical