Traumatic amputation of the : Report of a case

ANTHONY J. CERONE, JR., D.O. JEROME R. PIETRAS, n.o. Stratford, New Jersey F. KENNETH SHOCKLEY, DD., FACOS Cherry Hill, New Jersey

urologist recognize the need for these supportive Traumatic amputation of the glans discussions. In most cases, adequate sexual func- penis is an unusual which has tion on both a physiologic and psychologic basis occasionally been reported in the can be restored. A case of traumatic penile ampu- literature. Usually, the amputation is tation is reported in this article. The amputation the result of an accident; however, it occurred while the patient was masturbating with can be the result of unusual sexual the aid of a hand-held vacuum cleaner. While this behavior. In the case reported, the practice has become more common in recent years, patient was masturbating with a most accounts in the literature on this subject are hand-held vacuum cleaner. presented in a "letters-to-the-editor" section. Practicing urologists should be aware of this traumatic type of injury Report of case and its consequences. The following A 19-year-old white male presented to the hospital fol- operative approaches should be lowing a traumatic injury to the penis. One hour prior to considered: reanastomosis, plastic admission, the patient was engaged in . In reconstruction, or local reshaping. In search of further excitement during this activity, he uti- the case presented, reshaping was lized a hand-held vacuum cleaner. The patient claimed he learned about this so-called enhancer from advertis- utilized since only the distal glans ing in a pornographic magazine. He sustained an ampu- was amputated and the actual tation to the glans penis because the vacuum cleaner amputated segment was extremely contained a rotating fan behind the opening of the hol- lacerated and contaminated. The low suctioning tube. Despite a moderate loss of blood, patient was left with an adequate the patients vital signs were stable on his arrival at the amount of penile shaft. Optimal emergency room. Examination of the genital area, surgical results with minimal which had been packed with towels for compression he- psychiatric sequels can be mostasis, revealed a complete amputation of the glans anticipated if the best operative penis and total maceration of the distal-most tissues procedure is selected and the need (Fig. 1). Bleeding was considerable. The distal-most por- for early, postoperative, psychiatric tion of the severed urethra was not easily identified. The length of the penile shaft was approximately 7 cm. A counseling is recognized. number of minor abrasions could be observed on the skin of the shaft. The testicles were normal on palpation and there was no ecchymosis or edema of the scrotal skin. Rectal examination revealed a normal prostate. The vacuum cleaner was also brought into the emergency room for inspection. The avulsed glans penis was re- Traumatic amputation of the glans penis is a dev- trieved from the device. The tissue was nonviable be- astating urologic emergency requiring prompt cause of the degree of contamination and maceration. evaluation and competent management. Each case Laboratory admission tests and x-rays were all within should be handled individually and the urologist normal limits. The patients hemoglobin was initially must decide whether the primary treatment 15.1 gm./100 ml. After equilibration without transfu- sion, his hemoglobin was 14 gm./100 ml. should be either reanastomosis, plastic reconstruc- The patient readily volunteered all of the above infor- tion, or local reshaping. mation on his injury without demonstrating any embar- Following prompt operative management, the rassment or reservations. After the physical examina- individual involved should undergo early counsel- tion was conducted, the dressings were again removed ing with a psychiatrist. It is imperative that the and the distal end of the penis was copiously lavaged

Traumatic amputation of the glans penis 605/159 Fig. 1. Patient in operating room prior to surgery showing almost complete amputation of glans penis and indwelling Foley catheter. Fig. 2. One-week postoperatively with Foley catheter removed.

with saline and scrubbed with Betadine solution. nected to gravity drainage. Bucks fascia was reapproxi- Through trial and error, the distal portion was probed. mated over the distal aspect of the corporal bodies. A se- Eventually, a no. 18 French Foley catheter was guided ries of interrupted sutures of 3-0 plain gut approximated in through the urethra and left in the bladder, and the 5 the ventral skin edge, located adjacent to the site where cc. balloon was inflated in the usual fashion. Approxi- the neo-urethra was formed, to its dorsal counterpart. A mately 100 cc. of clear urine was obtained. A number of skin flap across the distal penile shaft was created by Betadine-saturated sponges were placed around the dis- this action (Fig. 2). There was a minimal amount of ten- tal penis postponing further intervention until the pa- sion on the sutured skin edges. The penis was then tient reached the operative suite. Before leaving the prepped again with Betadine solution. A Vaseline gauze emergency room, the patient was given tetanus toxoid dressing was applied and around it, a sterile, gauze com- (0.5 cc.) intramuscularly and 2 gm. of cephapirin intra- pression dressing was placed. venously. The patient was continued on cephalosporin antibiotic Gross inspection was further carried out in the operat- coverage for the duration of his hospital stay. He was ing room while the patient was under general anesthe- seen in consultation by a psychiatrist who suggested sia. This disclosed involvement of the underlying corpor- outpatient, short-term psychotherapy. Antidepressant al bodies and a jagged edge of the severed distal urethra. medication was not indicated; however, psychotropic The skin on the shaft of the penis was more redundant medications were suggested on an as-needed basis only. on the ventral surface due to the way the avulsion was Interestingly, the patient reported an on the made. The distal skin tissue was debrided, and both cor- second postoperative day. The hazards of an erection pora cavernosum were dissected back to healthy tissue were explained to him and he was placed on estrogen in- where a sharp, distal-cleavage plane was made. The cor- jections until he left the institution. On the seventh pora cavernosum were closed with a series of interrupt- postoperative day, the Foley catheter was removed. The ed sutures of 2-0 chromic. The sutures were placed so the patient subsequently urinated spontaneously without enveloping tunica albuginea was brought together over any complaints. He was discharged on the following day the distal edge of the corpora on either side, thus provid- with instructions for routine wound care. Cephalosporin ing hemostasis. The urethra was then dissected back to antibiotic coverage was given for a total of 10 days. The healthy spongiosum tissue. The redundant skin on the patient was asked to return in 2 weeks for follow-up and ventral aspect of the shaft was mobilized with a small told to restrain from any kind of sexual activity. buttonhole, approximately 8 to 10 mm. in diameter, con- structed in a position to create a urethral meatus. A Discussion small, V-type dart was made in the urethra in order to Fortunately, to the external genitalia widen the new urethral opening. The urethra was su- tured to the skin edge with a series of interrupted su- comprise only a small percentage of the total tures of 3-0 chromic. Once this was completed, the neo- amount of genitourinary trauma. The external urethral opening was sounded. The caliber was genitalias high degree of mobility provides protec- adequate. Through the opening, a no. 18 French silicone tion from traumatic injuries. For the most part, Foley catheter was inserted into the bladder and con- the injuries that do occur are the result of industri-

606/160 April 1983/Journal of AOA/vol. 82/no. 8 al, farming, automobile, or athletic accidents. The employed. Approximately 85 percent of the auto- non-accidental causes of external genital trauma graft took, and their patient experienced adequate include self-mutilation and assault. In a review 2 of sensation, erection, and ejaculation after reanasto- 251 cases of genitourinary trauma, thirty-two mosis. The most frequent complications associated (12.7 percent) involved the penis. Only three of with reanastomosis are distal skin necrosis, ure- these cases (1.2 percent) entailed traumatic ampu- thral strictures at the anastomotic site, and erec- tations of the organ. The types of penile injury are tile impotence. illustrated in Table 1. A rational surgical approach was outlined by The patient will initially be assessed in the Engelman and colleagues, and similarly illus- emergency room. The proximal stump of the penis trated by McDougal and Persky, 5 and McRoberts will typically be wrapped in a compression dress- and co-workers.6 Once retrieved, the distal seg- ing. The degree of blood loss will vary. The loss can ment is pretreated in a solution of iced lactated be so severe as to require substantial blood trans- Ringers, heparin, and antibiotics. First, urethral fusion or it may precipitate hypovolemic shock. anastomosis is carried out by utilizing interrupted After an adequate examination, sterile compres- sutures of either 4-0, 5-0, or 6-0 chromic. The sion dressings are kept in place until definitive op- proximal corpora is then anastomosed to its distal erative intervention is carried out. In our case, a counterpart by approximating the tunica albu- Foley catheter was inserted into the bladder in the ginea on either side with a series of interrupted su- emergency room. However, in reviewing other tures of chromic. The proximal and distal counter- cases in the literature, this procedure is not always parts of Bucks fascia are likewise approximated. If done. Pain is usually not severe in the initial pre- the amputation occurred more than 2 hours before, sentation, yet anxiety may necessitate the use of the distal penile skin is denuded. The degloved sec- intramuscular or intravenous sedatives. Broad tion of the shaft is then buried in the scrotal skin. spectrum antibiotic coverage and tetanus prophy- A second incision is made in the scrotal skin so the laxis should be employed. glans penis can be exposed. It is believed that a The operative approach to the patient can be better blood supply will be augmented to the auto- narrowed to local reshaping, primary reanastomo- graft, particularly to the corpora spongiosum, as a sis, or staged plastic reconstruction. Certain fac- result of this. An improved overall prognosis with tors must be weighed when selecting a particular less incidence of breakdown or fistula formation approach. Some of the more significant factors in- can be expected. However, opponents maintain clude: the actual availability and condition of the that the scrotal submersion of the shaft exerts ex- distal segment of the amputated penis; the pa- cessive tension on the urethral and corporeal su- tients age, overall medical condition, and poten- ture lines and causes diminished blood flow tial for future sexual activity; and the interval be- through the corpora. In order to further enhance tween the time of the injury and operative circulation, Bux and associates 8 postoperatively intervention. It is generally believed that primary aspirated the corpora to evacuate the tissue of old, replantation should be utilized first, if feasible. sludged blood. This is done until circulation in the Should this approach fail, the physician can still autograft is reestablished. Once anastomosis is opt for local reshaping or staged plastic reconstruc- completed, urinary diversion is accomplished tion. through a standard suprapubic, cystostomy drain- If possible, reanastomosis should be attempted age tube. The patients are placed on prophylactic within the first 6 hours after amputation. The re- antibiotic coverage and anticoagulation therapy. ports in the literature on this approach have been Should vessels and nerves be repaired with sepa- very encouraging. Engelman and associates re- rate anastomosis? According to a consensus of viewed eleven cases of penile amputation where opinion in the literature, one should try to accom- the patients later underwent reanastomosis. In all of the cases, the etiologies of the amputation were varied. Nevertheless, amazing results were achieved in each of the eleven patients. All were TABLE 1. TYPE OF PENILE INJURY IN THIRTY-TWO CASES OF GENITO- able to urinate, achieve erection and intromission, URINARY TRAUMA.2 and ejaculate. The degree to which sensation was Type No. restored, in the area of the glans, did vary. Tuerk and Weirs described a case in which a 16-year-old Minor abrasion/laceration 23 Skin avulsion 3 experienced an amputation identical to the one re- Traumatic amputation 3 ported in the case presentation. However, in this Bullet wound 2 instance, primary reanastomosis was successfully "Fractured" penis 1

Traumatic amputation of the glans penis 607/161 plish continuity of at least one deep or superficial meatal stenosis develop, Harrison and associates9 vein. This would aid in minimizing ischemic time advocate correction with a Z-plasty type of repair. and help in better preserving the epidermis of the penile shaft. Staged, plastic reconstruction is an alternative 1. Culp, D.: Genital injuries. Etiology and initial management. Sympo- sium on genitourinary trauma, pp. 143-56 that can be offered to the patient, particularly 2. Waterhouse, K., and Gross, M.: Trauma to the genitourinary tract. A when the amputation is more proximal in nature. 5-year experience with 251 cases. J Urol 101:241-6, Mar 69 The procedure involves fashioning a tubed, pedicle 3. Engelman, E.R., et al.: Traumatic amputation of the penis. J Urol 112:774.8, Dec 74 graft from the anterior abdominal wall. Other pro- 4. Tuerk, M., and Weir, W.H., Jr.: Successful replantation of a trau- cedures incorporate the gracilis muscle into the ped- matically amputated glans penis. Case report. Plant Reconstr Surg icle graft. The primary aim of staged, plastic re- 48:499-500, Nov 71 5. McDougal, W.S., and Persky, L.: Traumatic injuries of the genitouri- construction is to produce a functional urethra to nary system. Williams Wilkins Co., Baltimore, 1981, vol. 1 aid in micturition and to serve as a seminal con- 6. McRoberts, J.W., Chapman, W.H., and Ansell, J.S.: Primary anasto- mosis of the traumatically amputated penis. Case report and summary duit. Penile implants have been used in the graft of literature. J Urol 100:751-4, Dec 68 to enable satisfactory performance in sexual inter- 7. Mendez, R., Kiely, W.F., and Morrow, J.W.: Self-emasculation. J course. Urol 107:981-5, Jun 72 8. Bux, R., et al.: Primary penile reanastomosis. Urology 11:500-3, May When reimplantation is not feasible and suffi- 78 cient penile length remains, local reshaping of the 9. Bright, T., and Peters, P.: Injuries of the external genitalia. In Urol- proximal tissues is considered to be the procedure ogy, edited by J.H. Harrison, et al. W.8. Saunders, Philadelphia, 1978, ed. 4, vol. 1, pp. 931-5 - of choice. In the case reported, reimplantation was Kaufman, J.J.: Current urologic therapy. W.B. Saunders Co., Philadel- not feasible because of the degree of destruction phia, 1980 and contamination of the tissue. Anastomosis should also not be attempted if the amputated seg- ment has been severed for longer than 18 hours. A Accepted for publication in October 1982. Updating, as neces- urethral neo-meatus of adequate caliber must be sary, has been done by the authors. created in order to prevent any subsequent devel- opment of stenosis. In the case documented, this Dr. Cerone is a resident in urologic surgery at John F. Kennedy Memorial Hospital, Stratford, New Jersey. Dr. Pietras is a was done by spatulating the mucocutaneous anas- clinical instructor in urology at the University of Medicine and tomosis. The operative approach to local reshaping Dentistry of New Jersey, New Jersey School of Osteopathic described in the case presentation is best outlined Medicine. He is also in private practice. Dr. Shockley is chair- man of the Division of Urology, John F. Kennedy Memorial by Harrison and co-workers. 9 Hemostasis was fair- Hospital, Stratford, New Jersey. ly adequate in the 19-year-old, and a tourniquet Dr. Cerone, John F. Kennedy Memorial Hospital, 18 East Lau- was not placed around the base of his penis. Should rel Road, Stratford, New Jersey 08084.

608/162 April 1983/Journal of A0A/vol. 82/no. 8