NC.com

Penile Trauma

Fractures

• Diagnosis: suspect when bruising/edema, reported "pop" with immediate loss of erection, obtain US if diagnosis equivocal
• Taqaandan: self-inflicted fracture, penis forcibly bent during masturbation as a method to achieve rapid detumescence
• Management: can take to OR on clinical evidence alone, imaging not required, US preferred for equivocal findings
• Incision: make ventral incision (most common fracture location), localized incision over hematoma, or subcoronal incision
• Urethral injury: can perform intraoperative cystoscopy or preoperative urethrography (time-consuming)
• Close tunical defects with 2-0 or 3-0 absorbable sutures, smaller for urethral injury
• Mimics: rupture of dorsal penile artery, dorsal penile vein, or suspensory ligament
• Surgical delay: up to 7 days does not adversely affect repair results
• Preventing postop erections: consider benzodiazepines, amyl nitrate, or ketoconazole

Penetrating trauma

• Management: exploration, irrigation, excision, surgical closure, antibiotics
• Urethral injuries: can be identified with urethrography or pericatheter dye injection, can repair primarily
• Animal bites: irrigation/debridement, antibiotics (augmentin, cefoxitin, clindamycin + quinolone), do not close human bite wounds primarily

Amputation

• Psychosis: present in 65-87% patients, always consult psychiatry
• Ischemia time: successful if within 16hr for cold or 6hr for warm
• Double bag: wrap in saline-soaked gauze, place in bag, place in second bag with ice
• Microscopic repair: not required to anastomose and regain erectile function, but has less risk for strictures, skin loss, and sensory loss (20% vs 90-100%)
• Skin necrosis: high risk due to loss of blood supply
• Technique: SPT placement, close tunica with absorbable 2-0, close urethra with absorbable 4-0, dorsal artery with 11-0 nylon, dorsal vein with 9-0 nylon, dorsal nerve with 10-0 nylon, skin coverage

Zipper injuries

• First tricks: perform penile block, lubricate with mineral oil, attempt to unzip
• Second tricks: cut cloth between each individual tooth to release support and have zipper fall apart
• Third tricks: consider cutting median bar of zipper with a bone cutter or wire cutter, or screwdriver to pry apart top and bottom

Strangulation injuries

• Examine any idiopathic penile swelling for hidden hair or string
• Attempt reduction of distal edema with penile wrap
• String reduction technique: useful if able to thread string under constricting device, can also puncture glans to drain edematous blood/fluid
• Can incise plastics with scalpel or cast saw
• Metal items may require industrial cutting devices, including from fire or EMS services, perform in OR under anesthesia
• Consider suprapubic tube if patient unable to void and removal delayed

Scrotal/Testis Trauma

Rupture

• Scrotal US: assess for hematoma, incongruity of tunica albuginea, loss of contour, heterogenous parenchyma
• Indications for OR exploration: penetrating injury, scrotal US unable to rule out rupture, hematoma actively enlarging or > 5cm
• Technique: debride extruded tissue, close with 4-0 absorbable suture, consider drain placement, perform orchiectomy if non-viable appearance
• Success: 80-90% salvage rate if explored within 3 days of injury, 32-65% salvage rate for penetrating trauma
• Dislocation: due to high-impact trauma to scrotum, consider imaging with US/CT to find testis if empty hemiscrotum present on exam, explore via inguinal incision and perform orchiopexy

Scrotal skin loss

• Debride non-viable tissue and attempt primary closure
• Thigh pockets: consider on loss of > 50-60% scrotal skin
• Skin grafting: split thickness preferred
• Deep electrical burns: manage conservatively, often leads to autopenectomy or death due to severity of total injuries

Scrotal hematoma/hematocele

• Prevalence: 80% hematoceles are caused by testis rupture and should be explored
• Hematocele: small collections can be observed, otherwise explore if large or persistent bleeding to prevent infection, testicular compression, prolonged pain
• Cutaneous hematoma management: ice, elevation, scrotal support
• Intratesticular hematoma management: difficult to distinguish from testis rupture, therefore requires scrotal exploration, can re-image in 4-6 weeks to assess for resolution (vs concern for testis tumor)