Traumatic amputation of the glans penis: 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 injury 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 masturbation. 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 erection 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, injuries 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.