A d v a n c e s i n Di a g n o s i s a n d

Management of Genital Injuries

Andrew J. Chang, MD*, Steven B. Brandes, MD

KEYWORDS
 Genital  Penile  Scrotal  Testicular  Injuries  Trauma  Amputation  Burn

KEY POINTS
 External genital trauma is uncommon and rarely life-threatening but warrants prompt evaluation for
proper management.
 The treating physician should have a high index of suspicion when evaluating genital trauma.
 A missed diagnosis can lead to undue, long-term morbidity.
 The treating physician should be selective in obtaining imaging studies based on mechanism of
injury and presenting symptoms.
 The primary goal of reconstructive surgery is to preserve tissue, cosmesis, and function.

INTRODUCTION aggressive fluid and electrolyte replacement, and

Foley or suprapubic tube placement to monitor
External genital trauma is uncommon but can sufficient urine output. Evaluation includes a com-
cause devastating long-term physical, psycholog- plete physical examination, laboratory evaluation
ical, and functional quality-of-life consequences. with urinalysis, tetanus prophylaxis, intravenous
Therefore, the treating physician must be able to antibiotics, and an estimate of extent and depth
diagnose the injury in a timely fashion and be of the burn (TBSA) involved. Burns should be
knowledgeable of principles of delayed recon- treated according to the mechanism of injury and
struction. In the civilian population, genital trauma depth of injury.1 Genital burns demand very close
is roughly 45% penetrating, 45% blunt, and 10% observation and admission to an intensive care
burns and industrial accidents.1 The most impor- unit or burn unit.
tant objective of management is preserving genital
function and cosmesis, while minimizing long-term
sequelae. BURN CLASSIFICATION/DEPTH OF BURN

GENITAL AND PERINEAL BURNS First-degree burns affect the epidermis only and
are characterized by pink color, with minimal histo-
Burns of the genitalia and perineum require re- logic damage, but significant pain. First-degree
ferral to a burn center, are rarely isolated, and typi- burns usually do not have long-term scarring.
cally involve other areas of the body. The genitalia Second-degree burns are divided into superficial
alone only comprise 1% of total body surface area partial thickness and deep partial thickness. Su-
(TBSA), and studies have demonstrated an perficial partial-thickness burns involve the ep-
average TBSA of 21% to 56% for all patients idermis and the papillary dermis and present as
with perineal burns.2–4 Initial management of peri- pink, moist, tender skin with thin-walled blisters.
neal burns is removal of all clothing, rapid and Deep partial-thickness burns include the reticular
urologic.theclinics.com

Disclosures: None.
Division of Urologic Surgery, Washington University School of Medicine, 4960 Children’s Place, Campus
Box 8242, Saint Louis, MO 63110, USA
* Corresponding author.
E-mail address: [email protected]

Urol Clin N Am - (2013) -–-

http://dx.doi.org/10.1016/j.ucl.2013.04.013
0094-0143/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
2 Chang & Brandes

dermis and present with mottled red and blanched glans or the ventral shaft of the penis should
white skin with thick-walled blisters and tender have suprapubic tubes rather than Foley cathe-
skin. Third-degree burns are full-thickness burns ters. Foley catheters can cause pressure necrosis,
that destroy the epidermis and the entirety of the resulting in severe hypospadias due to anterior
dermis. Third-degree burns are characterized by urethral slough, especially when left in a depen-
a waxy-white or black, dry skin that is insensate.5 dent position.
Thermal burns have the potential for long-term
sequelae by urethral slough, urethral stenosis,
THERMAL BURNS
and eventually scar contracture at 3 to 6 months
Thermal burns of the genitals are caused mainly by postinjury. These wounds are managed with sur-
flame, but also by boiling water or grease (with gical release and skin grafts.
scald). Genital burns are typically first-degree
and second-degree burns that can be treated
without debridement and require only a topical CHEMICAL BURNS
antimicrobial ointment, usually 1% silver sulfadia- Chemical burns should be managed with imme-
zine. Genital third-degree burns should be treated diate removal of any clothing and aggressive
with prompt surgical intervention, as conservative flushing with copious amounts of sterile water.
management only leads to increased incidence of However, do not peel off adherent clothing. Dura-
infection, longer recovery time and hospital stays, tion of exposure and concentration of the chemical
and burn scar contracture. are directly proportional to the extent of the injury.
Third-degree burns to the scrotum should be Searching for neutralizing agent is not necessary,
promptly débrided of all nonviable tissue and as time is of the essence for these patients; most
then immediately skin grafted. With immediate are best served with sterile water irrigation.
treatment, infection is usually not an issue and
there is no reason for delay in scrotal reconstruc-
tion with thigh pouch creation. ELECTRICAL BURNS
The penile skin is very thin and thus vulnerable
to full-thickness, third-degree burns. Should this Electrical burns can be devastating, as the de-
occur, the nonviable skin should be sharply gree and the depth of the burn can be deceiving.
débrided; the wound should be primarily closed, The damage is often beyond what is obviously
and skin should be grafted to the denuded site visible on the surface and an extensive explora-
(Fig. 1). For circumferential penile injury, severe tion of the deep and surrounding structures are
lymphatic obstruction and lymphedema can warranted to evaluate the extent of the injury. A
occur, so all skin distal from the injury site to the thorough workup for electrical burns include ex-
subcorona should be excised. Owing to the amination for any related bladder, rectum, pelvic
tremendous vascularity, burns to the glans usually organ, or skeletal damage by cystoscopy, sig-
do not need debridement unless it is clearly moidoscopy, vaginal speculum examination (if
necrotic.6 Patients with third-degree burns to the applicable), and pelvic radiograph. Urinalysis
must be obtained for hemoglobinuria and myo-
globinuria, as their presence can cause acute
renal damage. When present, management
should include aggressive hydration along with
urine alkalization. Moreover, as cardiac arrhyth-
mias and arrests have been known to be caused
by electrical injuries, cardiac monitoring is also
warranted. These burns can be managed in the
same manner as a thermal burn, with prompt
debridement, primary wound closure, and skin
grafting. However, these burns are unique in
needing additional debridement, often because
of the extended damage. With serial debride-
ments, these wounds can be eventually covered
with skin grafts, without additional complications.
At times, the debridement can be extensive, and
Fig. 1. Third-degree genital burn to the penis, bone or major vasculature is exposed in the
scrotum, and inner thigh with meshed split-thickness wound. Myocutaneous flaps for coverage may
grafts to cover the denuded area. be necessary at that point.
 Genital Trauma 3

ANIMAL AND HUMAN BITES elastic and so defects with up to even 60%
skin loss can be primarily closed.11 To help pre-
Animal bites to the external genitalia are rare. Dog vent scrotal bleeding/hematoma after injury, a
bites are the most common cause of injury and 2-layered closure of the deep fascia and skin is
children are the most common victims. Initial man- performed with an interlocking, running, absorb-
agement should include copious irrigation with sa- able suture. A scrotal drain after repair is controver-
line and providone-iodine solution, debridement, sial because resultant scrotal hematomas are
broad spectrum antibiotic prophylaxis, tetnus- usually in the interstitium of the skin and are not
rabies immunizations (when appropriate), and hematoceles.12 However, if hemostasis is not
immediate/early closure of wound. Infections after possible or the patient has a coagulopathy, either
dog bites are rare, but treatment is sought soon a Penrose drain or a closed suction drain (eg, a
after the event.7 Recommended antibiotic thera- Blake drain) is recommended. An antibacterial
pies include b-lactam antibiotics with b-lactamase gauze dressing, such as xeroform, with fluff gauze
inhibitor (eg, amoxicillin-clavulanate), second- and a compressive scrotal support should be
generation cephalosporins (eg, cefotetan, cefoxi- placed to promote comfort and to facilitate healing.
tin), or clindamycin with fluoroquinolones.8 If blunt traumatic scrotal skin loss is extensive
Most human bite victims seek medical care after (greater than 60%), several options are available
substantial delay and are more likely to present for coverage. Repair should be performed without
with gross infection of their wound than with a delay if the injury to the scrotum is not contami-
dog bite. Human bites are contaminated wounds nated. Local skin flaps are all preferred options
that should never be closed primarily. Empiric anti- for coverage. When additional coverage is needed,
biotic therapy of choice includes amoxicillin- split thickness skin grafting is the repair of choice,
clavulanate or moxifloxacin.9 because it yields excellent cosmetic and functional
outcome (Fig. 3).13 Other ancillary measures in-
SCROTAL DEGLOVING INJURIES clude autologous skin grafts and tissue expanders.
Due to the pendulous nature of the male genitalia To begin the procedure, the testicles and cords are
and the laxity of the covering skin, the scrotum sutured together in the midline with multiple 3-0
has tremendous capacity to resist injury. The polyglactin (Vicryl; Ethicon, Somerville, NJ, USA)
skin, however, remains vulnerable to degloving in- sutures to create a singular structure, to ease skin
juries (Fig. 2). In the past, most degloving injuries grafting. The thick split-thickness skin graft is
were caused by agricultural (“power takeoff”) and then harvested with a dermatome at 15 to 18
manufacturing machinery, but the incidence has
decreased considerably with improved safety
measures. Most present-day genital skin avulsion
is due to motorcycle or bicycle accidents.
Avulsion injuries are usually along the fascial
planes, often torn free without damage to the un-
derlying tunica vaginalis or dartos fascia.10 The
scrotal skin is very compliant, redundant, and

Fig. 2. Extensive scrotal skin loss following a deglov- Fig. 3. Meshed split-thickness skin graft to cover the
ing injury. scrotum.
4 Chang & Brandes

thousandths of an inch, ideally from the inner thigh,

and meshed 1.5:1. Skin grafts to the penis are typi-
cally performed with nonmeshed grafts for both
cosmesis and erectile function. For the scrotum,
meshed grafts are used as the meshing simulates
rugae, while allowing exudates to escape, thus
improving graft take. The graft is then applied to
cover the testes and cords and sutured in place
at the perineum and ventral penile base. Multiple
interrupted chromic sutures are placed in the graft
to “quilt” it to the underlying tissue. The “neoscro-
tum” is then covered with xeroform, mineral oil–
soaked cotton batting, and fluff gauze bandage.
Bolster sutures of purple-dyed 2-0 Vicryl are then Fig. 5. Creation of testicular thigh pouch following
placed at the graft margins and tied over the dress- scrotal avulsion injury.
ings to facilitate immobilization. An easier-to-apply
and quicker alternative to a bolster dressing is the are very large, the testicles may be protected in
use of a negative pressure wound therapy device superficial thigh pouches as long as necessary
(refer to section Management of Complex Urologic (Figs. 4 and 5).15 Thigh pouches not only protect
Wounds). Postoperatively, the patient is typically the testes but augment future scrotal reconstruc-
kept on bed rest for 48 hours (to prevent graft tion, reduce the size of the perineal skin defect
movement and allow for maximal imbibitions) and via secondary intention closure, and lighten the
the dressings are removed on postoperative day burden of labor-intensive and dressing changes
5. The patient then showers twice a day with that are often very painful to the patient. Thigh
soap and water, using a blow dryer on cool or pouches prevent the testes and cord from forming
gently patting the graft or harvest site with a towel a thick, fibrous, infected rind of granulation tissue.
to dry the graft.12 Should this “rind” of granulation tissue form, it
If the circumstances of the injury prevent imme- must be completely removed down to the sper-
diate repair of the scrotum, the testicle should be matic fascia and tunica for skin graft to take. The
wrapped in saline-soaked gauze for protection un- rind is chronically infected tissue and is a poor
til surgery.14 If definitive reconstruction is going to bed for skin graft to take. If the rind is left in situ,
be delayed or the genital and perineal skin defects the neoscrotum becomes contracted and flat-
tened out into an abnormal, nondependent posi-
tion. Care must be taken to avoid transmission of
the infection to the thigh region, so gross contam-
ination must be eliminated beforehand.
To create thigh pouches, the testis and cord are
initially dissected to the level of the external ring.
To prevent stretching of the spermatic cord with
thigh abduction, subcutaneous tissue pockets in
the fascia of the thighs should be dissected as
far posteriorly and caudally as possible to allow
for slack in the cord. Next, the fascia lata of the
thigh is identified and then the pouch is dissected
superficial to the fascia lata with a sponge stick
and 2 narrow deavers into the anterior thigh. If
the testes are placed too medially, it may cause
pain and discomfort when patients adduct their
legs. The plane usually dissects out easily and
bluntly. Placing the testes and cord directly on
top of the fascia lata facilitates mobilization for de-
layed scrotal reconstruction.

PENILE DEGLOVING INJURIES

Fig. 4. Extensive penile and scrotal skin loss following Penile degloving injuries typically require immedi-
a degloving injury. ate reconstruction and should be treated with a
 Genital Trauma 5

sense of urgency owing to the nature of their func-

tion. Similar to the repair of the scrotum, primary
closure of the skin should be attempted. Primary
closure of the penis is often difficult, because the
shaft skin is not as elastic or as redundant as scrotal
skin. Not infrequently, the penile skin defect is
circumferential, disrupting distal lymphatic
drainage. With circumferential avulsion, the re-
maining skin distally must be excised to the subcor-
ona to prevent chronic, disfiguring lymphedema.
The primary objective of reconstruction is to
preserve erectile function. If a primary closure is
not feasible, a thick nonmeshed split-thickness
skin graft should be placed because it is less likely
to contract (Fig. 6). Meshed split-thickness skin
grafts on the penis can occasionally contract to
the extent that erections become impaired. The
skin graft should be wrapped around the penis
with the seam on the ventral aspect of the shaft,
to simulate a median raphé, while avoiding chor-
dee. (Skin grafts placed on the penis shaft never
regain normal sensation. However, sexual function
is often preserved due the intact sensation in the Fig. 7. “Penis-house” following skin grafting of penis.
glans.16) The graft is temporarily held in place
with staples, and then quilting sutures (interrupted
3-0 chromic suture) are placed. At the proximal graft is to wrap the fluff dressing with elastic
and distal aspect of the penis, 4 sutures of long, bandage (conform) and staple the conform period-
purple-dyed 2-0 Vicryl are placed circumferentially ically while wrapping it around the penis, leaving
to tie over a bolster dressing. the glans exposed. The final tight dressing is sta-
The layers of dressing placed on top of the skin pled at the edges of the skin.
graft around the penis are Xeroform gauze, fol- If the patient is impotent and elderly, a meshed
lowed by a layer of mineral oil–soaked cotton split-thickness skin graft is acceptable. In addition,
wadding, fluff gauze, and then a compressive a scrotal flap (modified Cecil technique) can be
wrap of elastic bandage (conform). The long, used to cover the denuded penis, as long as the
purple-dyed stay sutures are then tied down to patient does not mind a hair-bearing penis and is
hold this bolster fixed in place (Fig. 7). Postopera- impotent.12 To create the scrotal flap, a transverse
tively, the patient is kept at bed rest for 48 hours, incision is made in the inferior aspect of the
and the dressing removed at approximately post- scrotum followed by the formation of a subdartos
operative day 5. These instructions are then fol- tunnel. The penis is then mobilized through the
lowed by twice-daily showers and gentle drying tunnel, leaving only the glans exposed, while
of the graft with the cool setting of a hair dryer. covering the denuded penile shaft. The scrotal
An alternative, simpler way to immobilize the skin flap edge is then sutured to the subcoronal skin

Fig. 6. (A) A thick nonmeshed split-thickness skin graft around the shaft of the penis. (B) Two months postoper-
ative following penile skin grafting.
6 Chang & Brandes

with interrupted absorbable sutures. Patients have can also lead to the rupture of the dorsal vein of
the option to undergo a second-stage repair to the penis and mimic penile fracture, the use of
free the penis, which few select. diagnostic imaging should be highly selective
(Fig. 9). In contrast, if urethral injury is suspected,
PENILE FRACTURE retrograde urethrography or flexible cystoscopy
must be performed. Urethral injury has been re-
Fracture of the penis is a tear of the tunica ported in 10% to 38% of penile fracture cases.10
albuginea of the corpus cavernosum, frequently Any signs of urethral injury, such as difficulty void-
while the penis is rigid and erect. When erect, the ing, blood at the urethral meatus, or any degree of
tunica albuginea stretches and thins to 0.25- to hematuria, should cause a high index of suspicion
0.5-mm-thick, compared with 2-mm-thick when in the physician and deserve further evaluation.
flaccid.17–20 Thus, the erect penis is more prone Immediate surgical repair is the treatment of
to serious injury (axial rupture) than the pendulous, choice for penile fracture, as low complication
flaccid penis during blunt trauma. In the Western rates and good outcomes have been reported by
Hemisphere, the most common cause of fracture numerous centers.12 Although conservative man-
is vigorous vaginal intercourse, most commonly agement may be an option in patients with minor
when the woman is on top and the penis is acutely tears of the tunica albuginea, most untreated frac-
bent.21,22 In the Middle East, however, the most tures will develop delayed and persistent penile
common cause of fracture is self-penile manipula- pain or curvature with erection. However, Kozacio-
tion in an attempt to achieve rapid detumes- glu and colleagues26 have looked at delayed
cence.23 Classically, signs and symptoms of versus immediate repair and concluded that de-
penile fracture are a snapping or “popping” sound, layed repair had no ill effect as a consequence of
followed by rapid detumescence, severe pain, a delay in surgery in patients without urethral
ecchymosis, and swelling of the damaged side, involvement. Neither serious deformities nor erec-
with deviation away from the damaged side.24,25 tile dysfunction was seen in the long term for these
Typically, the penile fracture is a transverse patients who had delayed repair. Although penile
corporal tear on the ventral portion of the penis, fracture is treated as a surgical emergency, from
close to the urethra (Fig. 8). Many patients present a practical view, waiting until the next morning
in a delayed fashion because of embarrassment. for repair seems reasonable.
The incidence of penile fracture is higher than prior Surgical repair of the fracture requires exposure
reports, as some develop minor corporal tears, but of the defect in the corpora cavernosum and gross
never seek medical care. inspection of the urethra, given the 20% rate of
Penile fracture is a clinical diagnosis. Imaging is associated urethral injury.12 Depending on the
not needed, particularly when the patient presents location of the injury, the options for exposure
with a convincing history and physical examina- include a circumferential, subcoronal, degloving
tion.12 Despite that there are numerous reports of incision of the penile skin or a longitudinal incision
the accuracy of cavernosography and magnetic directly over the injury exposing only the tunical
resonance imaging to diagnose penile fractures, tear. At first, the hematoma should be evacuated,
such methods are too invasive, time consuming, and the fracture site washed out. If the location of
or costly to justify, particularly when the diagnosis
can be made clinically.19 Although sexual trauma

Fig. 9. Superficial dorsal vein rupture imitating penile

Fig. 8. Penile fracture with urethral tear. fracture.
 Genital Trauma 7

the corporal tear is not clear, a Penrose tourniquet evidence of rupture. Scrotal ultrasonography, in
can be placed at the penile base with a butterfly the hands of a skilled sonographer, can serve as
needle placed into the corporal shaft and injected a vital addition to the physical examination, partic-
with saline (as in a Gittes test). Extravasating saline ularly if examination findings are equivocal.28–31
usually helps identify the location of the defect. Pri- The sonographic findings are a heterogeneous
mary closure of the corpora is usually performed echo pattern of the testicular parenchyma with
using a running absorbable suture (2-0 Vicryl). loss of contour of the testis tunica (100% sensi-
Complete urethral disruptions should be reanas- tivity and 93.5% specificity).32 Injuries that are clin-
tamosed without delay, with the ends debrided, ically benign and homogeneously echogenic on
spatulated, and reapproximated tension-free ultrasound do not require surgical exploration.
over a urethral catheter. If there is a partial tear In all cases of testicular rupture, urgent surgical
of the urethra, then a “stenting” urethral catheter exploration is essential for salvage of the testicle.12
can be placed with a suprapubic tube, but primary Although testis rupture is not life threatening, it can
repair of the tear should be performed when have numerous repercussions including infertility,
possible. Pericatheter urethrography is performed hypogonadism, and low self-esteem. The surgeon
after 2 to 3 weeks after the procedure to confirm should attempt to salvage/preserve any remaining
urethral healing before catheter removal. viable tubules, as studies have revealed reduced
endocrine abnormalities and improved semen
TESTICULAR RUPTURE quality compared with orchiectomy.33,34 Blunt
ruptured testes explored within 72 hours have a
A testicular rupture is a tear of the tunica albuginea salvage rate of greater than 90%, whereas those
with extrusion of seminiferous tubules (Fig. 10). explored late have a 45% salvage rate.35
Although both penetrating and blunt mechanisms To achieve maximal exposure to both testes and
can cause testicular rupture, most are blunt. The cords in addition to maintaining cosmesis, the
age group most vulnerable to testicular rupture is scrotum is typically explored through a vertical
10- to –30-year-old men and boys involved in incision of the median raphé. The tunica vaginalis
sports-associated activity or motor vehicle acci- is then opened and the testis is brought out of
dents.27 In all cases of blunt scrotal trauma, the the scrotum and the testicle is inspected for injury.
physician should have a high index of suspicion Any nonviable seminiferous tubules are then
and the rupture ruled out. Clinical examination sharply excised and any hematoma is drained,
can be rather difficult in these patients because leaving only healthy bleeding edges. The tunica al-
many present with severe pain and swelling. buginea is then closed, using a running 3-0 absorb-
Although all penetrating injuries deep to the able suture (Fig. 11). The testis is returned into the
scrotal dartos fascia should be surgically scrotum, with the lateral groove of the testis ori-
explored, not all blunt injuries require exploration. ented properly to prevent torsion, and the scrotum
Many physicians will conservatively manage in- is closed in 2 layers with absorbable sutures. A
juries that do not show clinical or radiological Penrose or closed suction drain can be placed
through a separate stab incision if hemostasis is
a concern. The wound is protected with fluff gauze

Fig. 10. Close-up view of testis rupture with extrusion Fig. 11. Closure of tunica albuginea following testis
of seminiferous tubules. rupture.
8 Chang & Brandes

and held in place with a scrotal support for

compression. Anti-inflammatory medications, ice
packs, and scrotal elevation may limit postopera-
tive edema and hasten convalescence.

PENETRATING WOUNDS
Penetrating trauma to the genitalia is rare.
Most cases are gunshot wounds (GSW) but stab
wounds make up a significant portion. Although
military GSW are from high-velocity weapons with
significant injuries, most civilian GSW reported
are from low-velocity weapons, causing less acute
and delayed tissue damage.36 All patients with
penetrating penile wounds require a retrograde
urethrography or urethroscopy, because up to
50% have an associated urethral injury.37–39
Early surgical exploration, debridement, and pri-
mary repair of penetrating injuries are the pre-
ferred management for both the penis and the
testes.40 Repair of a penetrating penile wound is Fig. 12. Testicle after successful graft with tunica
comparable to that of a penile fracture. Depending vaginalis.
on the location, direct visualization of the corpora
can be obtained via a circumferential, degloving, for the penile amputation patient properly. Less
subcoronal incision or via a penoscrotal, infrapubic, commonly, genital amputations are caused by
or perineal incision for more extensive wounds.12 agricultural and industrial machinery accidents.48
For minor injuries to the corpora, primary closure Of note, the largest series of reanastamosis of
is adequate, as it is done for penile fractures. penile amputations was reported in Thailand.49
Repair of testicular injury from a penetrating During the 1970s, there were an estimated 100
trauma also follows the same principles as that penile amputations by angry wives against their
from a rupture from a blunt injury. Approximately philandering husbands, with 18 cases replanted
50% of GSW to the scrotum strike the testis and, at the same medical center.
of these, one-half of the testes are viable for There are 3 options to treat the amputated penis,
repair.12 Much like testicular rupture, salvage of depending on the degree of damage: closure of the
viable testicular tissue is the primary goal of man- residual stump, surgical reanastamosis of the
agement. After debridement of the nonviable tis- amputated penis, or total phallic substitution with
sue, the tunica albuginea is closed primarily. In reconstruction regardless of the psychological
cases where the defect is wide and there is a defi- state of the patient. Once the psychotic episode
ciency of tunica albuginea to close primarily, a free is properly treated, most patients are very remorse-
graft of tunica vaginalis is used to cover the defect ful of self-amputation. If the amputated penis is
and preserve the testicle.41 A tunica vaginalis graft viable, penile reanastamosis should always be at-
can be easily harvested and sewn to the edges of tempted. The amputated penis should be thor-
the tunica albuginea for coverage (Fig. 12). Syn- oughly washed out and debrided with either
thetic grafts (ie, Gore-Tex) result in poor outcomes normal saline or lactated Ringer solution and then
secondary to infection and eventual orchiectomy. cooled in a “double bag.”50 The “double-bag”
Thus, using the native tunica vaginalis tissue is technique involves wrapping the amputated penis
the optimal tissue for coverage, and a clear alter- in saline-soaked gauze and then placing it in a first
native to orchiectomy.12 sterile sealed bag. Next, the first bag is placed in a
second bag or basin of ice-slush. This maneuver
protects the penile skin from direct contact with
PENILE AMPUTATION
ice while still maintaining a hypothermic state, opti-
Traumatic genital amputations are usually self- mally at 4 C. Penile replantation is attempted up to
mutilations performed by acutely psychotic pa- 24 hours after the injury because success has been
tients or transsexuals unable to have (afford) reported after 16 hours of cold ischemia and
sexual reassignment surgery.42–47 A multidisci- 6 hours of warm ischemia.51,52
plinary team of urologists, plastic surgeons, psy- The patient should be stabilized, with aggres-
chiatrists, and social workers is needed to care sive fluid resuscitation and blood transfusion
 Genital Trauma 9

as indicated.45 Whenever feasible, the patient Cecil technique), which leads to a suboptimal hair-
should be cared for at a center that has the capa- bearing, thick-skinned penile shaft, which may
bility of performing microvascular surgery by a require additional surgery.10 It is crucial to cover
specialist.44,46 Microvascular reattachment has the vascular anastamoses to avoid delayed throm-
shown superior outcomes with decreased skin ne- bosis and necrosis and replantation failure. Finally,
crosis and glans slough, improved sensation, and the penis is wrapped in loose dressings and an
superior function when compared with macrovas- external splint is fashioned vertically to facilitate
cular technique. If a patient cannot be treated at a venous and lymphatic drainage.
center with microvascular capabilities, then a If penile replantation is not an option because of
macrovascular reattachment can be attempted. loss of the detached penis or damaged beyond
This reattachmentn is certainly suboptimal, for repair, then the penile stump can be closed as
the reasons stated above, but is a better option done for a standard elective partial penectomy
then defaulting to a penile stump. (Fig. 13). The neomatus is widely spatulated to
To begin replantation, vascular control is ob- prevent stenosis. A free forearm phalloplasty can
tained at the base of the proximal cut edge of be performed subsequently.
the corpora. Local compression with gauze or Postoperative management must include at
tourniquet may be required depending on the least 48 hours of bed rest and perioperative
extent of the hemorrhage. After controlled hemo- broad-spectrum antibiotics. The Foley catheter
stasis, the tunica albuginea of the corpora caver- can be removed after at least 3 weeks of stenting,
nosa should be reapproximated with interrupted following a pericatheter retrograde urethrogram or
3-0 polyglactin (Vicryl) suture. Placement of a voiding cystourethrogram, which verifies a
several sutures through the intercavernous healed anastomosis. The suprapubic tube is cap-
septum will provide stabilization. The central cav- ped and then removed after a few days of normal
ernosal arteries do not need to be reanastamosed, voiding. In cases of self-mutilation, the patient’s
because it does not improve outcome. The prox- mental health must be addressed and closely
imal and distal urethral edges are then mobilized monitored and the psychiatry department must
for about 1 cm with the ends spatulated. Next, be involved with this patient’s care.
the urethra is reanastomosed over a 16-French sil-
icone Foley catheter with interrupted 5-0 or TESTIS AMPUTATION
6-0 polydioxanone (Maxon, United States Surgical
Corporation, Norwalk, CT, USA or PDS, Ethicon, Although the penis, if properly cooled, can be suc-
Somerville, NJ, USA) suture in a single layer. cessfully replanted, the testes are much more deli-
Placement of a suprapubic tube is recommended cate and cannot tolerate extended periods of
to divert the urine proximally to facilitate healing.12 warm ischemia. Due to their highly metabolic
Once the penis is stabilized, then the deep state, the testes have only a 4- to 6-hour period
dorsal vein is microscopically re-anastamosed following amputation for successful replantation.10
with 11-0 nylon or polypropylene (Prolene, Ethi- If the patient is at risk for hypogonadal state, as
con, Somerville, NJ, USA). This anastamosis is with an atrophic or absent contralateral testis,
critical and must be patent to prevent corporal microvascular technique is recommended for the
edema, swelling, and subsequent ischemia. best possible outcome.
Next, at least one, preferably both, of the dorsal
penile arteries are reapproximated in an end-to-
end fashion, which immediately re-establishes
blood flow to the subcutaneous tissues and pre-
vents postoperative skin necrosis. Last, as many
nerve fibers as can be identified are then reap-
proximated with a simple nylon or polypropylene
suture in the epineurium. Dopplerable blood flow
though the dorsal arteries needs to be confirmed
before completing the case.12
If penile skin is intact, the skin edges are either
reapproximated with interrupted 4-0 chromic su-
tures or a thick, nonmeshed, split-thickness skin
graft is placed when the penile skin is unusable
or denuded. A last resort and less attractive
method of coverage is to bury the penis in a sub- Fig. 13. Urethra mobilized for spatulation following
cutaneous tunnel in the scrotum (using a modified penile amputation.
10 Chang & Brandes

First, the 2 edges of the spermatic cord are complex operative wounds left open to heal by
debrided and the spermatic veins, the spermatic secondary intention, meshed skin grafts and flaps,
artery, and the vas deferens must be identified stage III and IV pressure ulcers, chronic open
within both ends. The spermatic artery is anasta- wounds, diabetic foot ulcers, venous stasis ulcers,
mosed together using an 11-0 nylon or Prolene degloving injuries, and partial-thickness and full-
suture under microscopic view. If performed prop- thickness burns (<12 hours of burn). It should not
erly, the spermatic veins will begin to bleed on the be used for patients with malignancy, necrotic tis-
testicular side and can be easily identified. If tech- sue that has not been debrided, fistulae to body
nically feasible, then at least 2 veins should be cavities/organs, untreated osteomyelitis, wounds
joined together with their severed counterparts. with bleeding bed, or patients on anticoagulation
Last, the vas deferens must be realigned via a vas- therapy.54
ovasostomy in an end-to-end fashion performed In 2005, Armstrong and colleagues55 enrolled
in a 2-layer fashion, connecting first the vasal mu- 162 patients with complex wounds after a partial
cosa using 10-0 nylon or Prolene suture. The vasal foot amputation into a 16-week, multicenter, ran-
muscularis is reapproximated using 9-0 nylon or domized, clinical trial. Seventy-seven patients
Prolene suture, and then the spermatic fascia is were randomly assigned to NPWT with dressing
closed primarily. To protect and support the fragile changes every 48 hours versus 85 control patients
anastamoses, an orchiopexy is performed to who received standard moist wound care accord-
secure the testicle in place. If the native scrotal ing to consensus guidelines. NPWT was delivered
skin is viable, the scrotum should be closed primar- through the vacuum-assisted closure therapy
ily over the reattached testis. Conversely, if more system. Wounds were treated until healing or
than 60% of the scrotal skin is absent, then the re- completion of the 112-day period of active treat-
planted testicles should be placed in thigh pouches ment. This study showed that the NPWT group
until a neoscrotum is reconstructed, in the method healed more than the control group (43 [56%] vs
described earlier for scrotal avulsion. 33 [39%], P 5 .040). The time to complete wound
In all cases of self-inflicted genital amputation, closure was also faster in the NPWT group than in
patients must be closely observed following controls (P 5 .005). In addition, the rate of granula-
replantation surgery. Psychiatry must be closely tion tissue formation was faster in the NPWT group
engaged in these patients’ care, because they than in controls (P 5 .002).
are likely to repeat their actions if not properly The costs of NPWT are significant, and this has
managed. discouraged many clinicians from using the ther-
apy. However, there are reports showing the faster
MANAGEMENT OF COMPLEX UROLOGIC healing time with NPWT compared with conven-
WOUNDS tional therapies correlating to decreased overall
cost of care.56 Philbeck and colleagues showed
Many traumatic wounds are difficult to manage that the average wound closure rate with an
despite optimal care. At times, the wound defect NPWT (vacuum-assisted closure) was 0.23 cm2/d,
may be so large or complex that reconstruction compared with 0.09 cm2/d for a wound treated
is not feasible. Negative pressure wound therapy with saline-soaked gauze. The average 22.2-cm2
(NPWT) is not a new concept in wound therapy; wound in the study took 247 days to heal at a cost
it was first reported by Fleischmann and col- of $23,465 with saline-soaked gauze versus
leagues53 in 1993. An NPWT device (VAC Therapy; 97 days to heal at a cost of $14,546 with an NPWT
Kinetic Concepts, Inc, San Antonio, TX, USA) is system. The study showed that the NPWT is an
used to create a negative pressure over the efficacious and economical therapy option for
wound, which drains the excessive interstitial variety of chronic wounds.
edema, decompresses small vessels, and restores NPWT combines the benefit of both open-
local blood flow. Other benefits of NPWT include wound and closed-wound treatment. NPWT is
reduction of bacterial colonization and stimulation not universally applicable to all type of wounds,
granulation tissue growth to promote wound however. In a carefully selected patient, it can
closure. To set up an NPWT, a piece of foam is serve as a practical addition to the traditional
placed over the wound with a large piece of trans- wound therapy options available to the recon-
parent tape cover and a drain tube is set to trans- structive surgeon.
port fluid to a vacuum pump. Any open wound can
be converted into a controlled closed wound with SUMMARY
an NPWT device.
An NPWT may be used for many types of Traumatic genital injury predominantly affects
wounds, including dehisced surgical wounds, the young and is usually not life threatening.
 Genital Trauma 11

Nevertheless, the treating physician must have a 18. Thompson RF. Rupture of the penis. J Urol 1954;71:
high index of suspicion when evaluating genital 226–9.
injuries. Although missed diagnosis can result in 19. Choi MH, Kim B, Ryu JA, et al. MR imaging of acute
dire consequence with life-long sequelae, rapid penile fracture. Radiographics 2000;20:1397–405.
and proper treatment can help preserve tissue, 20. Miller S, McAninch JW. Penile fracture and soft tis-
cosmesis, and function. sue injury. In: McAninch JW, editor. Traumatic and
reconstructive urology. Philadelphia: WB Saunders;
1996. p. 693–8.
21. Mydlo JH. Surgeon experience with penile fracture.
REFERENCES
J Urol 2001;166:526–9.
1. Brandes SB, McAninch JW. External genital 22. Eke N. Fracture of the penis. Br J Surg 2002;89:
trauma: amputation, degloving, and burns. Atlas 555–65.
Urol Clin 1998;6:127–42. 23. Zargooshi J. Penile fracture in Kermanshah, Iran:
2. McDougal WS, Peterson HD, Pruitt BA, et al. The report of 172 cases. J Urol 2000;164:364–6.
thermally injured perineum. J Urol 1997;121:320–4. 24. El-Taher AM, Aboul-Ella HA, Sayed MA, et al. Man-
3. Peck MD, Boileau MA, Grube BJ, et al. The man- agement of penile fracture. J Trauma 2004;56:
agement of burns to the perineum and genitals. 1138–40.
J Burn Care Rehabil 1990;11:54–6. 25. Beysel M, Tekin A, Gurdal M, et al. Evaluation and
4. Michielsen D, Van Hee R, Neetens C, et al. Burns to treatment of penile fractures: accuracy of clinical
genitalia and the perineum. J Urol 1998;159:418–9. diagnosis and the value of corpus cavernosogra-
5. Evers LH, Bhavsar D, Mailänder P. The biology of phy. Urology 2002;60:492–6.
burn injury. Exp Dermatol 2010;19(9):777–83. 26. Kozacioglu Z, Degirmenci T, Arslan M, et al.
6. Morey AF, Metro MJ, Carney KJ, et al. Consensus Long-term significance of the number of hours
on genitourinary trauma: external genitalia. BJU until surgical repair of penile fractures. Urol Int
Int 2004;94:507–15. 2011;87:75–9.
7. Gomes CM, Ribeiro-Filho L, Giron AM, et al. Genital 27. Baskin LS, McAninch JW. Reconstruction of testic-
trauma due to animal bites. J Urol 2000;165:80–3. ular rupture. In: McAninch JW, editor. Traumatic
8. Talan DA, Citron DM, Abrahamian FM, et al. Bacte- and reconstructive urology. Philadelphia: WB Saun-
riologic analysis of infected dog and cat bites. ders; 1996. p. 693–8.
N Engl J Med 1999;340:85–92. 28. Corrales JG, Corbel L, Cipolla B, et al. Accuracy of
9. Talan DA, Abrahamian FM, Moran GJ, et al. Clinical ultrasound diagnosis after blunt testicular trauma.
presentation and bacteriologic analysis of infected J Urol 1993;150:1834–6.
human bites in patients presenting to emergency 29. Ugarte R, Spaedy M, Cass AS. Accuracy of ultra-
departments. Clin Infect Dis 2003;37(11):1481–9. sound in diagnosis of rupture after blunt testicular
10. Armenakas NA, McAninch JW. Genital reconstruc- trauma. Urology 1990;36:253–4.
tion after major skin loss. In: McAninch JW, editor. 30. Anderson KA, McAninch JW, Jeffrey RB, et al. Ul-
Traumatic and reconstructive urology. Philadelphia: trasonography for the diagnosis and staging of
WB Saunders; 1996. p. 699–713. blunt scrotal trauma. J Urol 1983;130:933–5.
11. McAninch JW. Management of genital skin loss. 31. Fournier GR Jr, Laing FC, Jeffrey RB, et al. High
Urol Clin North Am 1989;16:387–97. resolution scrotal ultrasonography: a highly sensi-
12. Ferguson GG, Brandes S. Reconstruction for gen- tive but nonspecific diagnostic technique. J Urol
ital trauma. In: Montague D, editor. Textbook of 1985;134:490–3.
reconstructive urologic surgery. London: Informa; 32. Buckley JC, McAninch JW. Diagnosis and man-
2008. p. 657–67. agement of testicular ruptures. Urol Clin North Am
13. Balakrishnan C. Scrotal avulsion: a new technique 2006;33:111–6.
of reconstruction by split-skin graft. Br J Plast 33. Lin WW, Kim ED, Quesada ET, et al. Unilateral
Surg 1956;9:38–42. testicular injury from external trauma: evaluation
14. Wessells H, Long L. Penile and genital injuries. Urol of semen quality and endocrine parameters.
Clin North Am 2006;33:117–26. J Urol 1998;159:841–3.
15. Cummings JM, Boullier JA. Scrotal dog bites. 34. Kukadia AN, Ercole CJ, Gleich P, et al. Testicular
J Urol 2000;164(1):57–8. trauma: potential impact on reproductive function.
16. Morey AF, Dugi D. Genital and lower urinary J Urol 1996;156:1643–6.
tract trauma. In: Wein A, editor. Campbell-Walsh 35. Cass AS. Testicular trauma. J Urol 1983;129:
urology. Philadelphia: Elsevier Saunders; 2012. p. 299–300.
2507–13. 36. Brandes SB, Buckman RF, Chelsky MJ, et al.
17. Fetter TR, Gartman E. Traumatic rupture of the External genitalia gunshot wounds: a ten-year expe-
penis. Am J Surg 1936;32:371–2. rience with 56 cases. J Trauma 1995;39:266–72.
12 Chang & Brandes

37. Miles BJ, Poffenberger RJ, Farah RN, et al. Man- 48. Dogra PN, Gautam G, Ansari MS. Penile amputa-
agement of penile gunshot wounds. Urology tion and emasculation: hazards of modern agricul-
1990;36:318–21. tural machinery. Int Urol Nephrol 2004;36:379–80.
38. Monga M, Moreno T, Hellstrom WJ. Gunshot 49. Bhanganada K, Chayavatana T, Pongnumkul C,
wounds to the male genitalia. J Trauma 1995;38: et al. Surgical management of an epidemic of
855–8. penile amputations in Siam. Am J Surg 1983;146:
39. Cline KJ, Mata JA, Venable DD, et al. Penetrating 376–82.
trauma to the male external genitalia. J Trauma 50. Jordan GH. Initial management and reconstruction of
1998;44:492–4. male genital amputation injuries. In: McAninch JW,
40. Bandi G, Santucci RA. Controversies in the man- editor. Traumatic and reconstructive urology. Phila-
agement of male external genitourinary trauma. delphia: WB Saunders; 1996. p. 673–81.
J Trauma 2004;56:1362–70. 51. Wei FC, McKee NH, Huerta FJ, et al. Microsurgical
41. Ferguson GG, Brandes SB. Gunshot wound injury replantation of a completely amputated penis. Ann
of the testis: the use of tunica vaginalis and polyte- Plast Surg 1983;20:317–21.
trafluoroethylene grafts for reconstruction. J Urol 52. Hayhurst SW, O’Brien BM, Ishida H. Experimental
2007;178:2462–5. digital replantation after prolonged cooling. Hand
42. Baltieri DA, Guerra de Andrade A. Transsexual 1974;6:134–41.
self-mutilation. Am J Forensic Med Pathol 2005; 53. Fleischmann W, Strecker W, Bombelli M, et al. Vac-
26:268–70. uum sealing as treatment of soft tissue damage in
43. Greilsheimer H, Groves JE. Male genital self- open fractures. Unfallchirurg 1993;96(9):488–92.
mutilation. Arch Gen Psychiatry 1979;36:441–6. 54. Health Quality Ontario. Negative pressure wound
44. Aboseif S, Gomez R, McAninch JW. Genital self- therapy: an evidence based analysis. Ont Health
mutilation. J Urol 1993;150:1143–6. Technol Assess Ser 2006;6(14):1–83.
45. Mora W, Drach GW. Self emasculation and self 55. Armstrong DG, Lavery LA, Diabetic Foot Study
castration: immediate surgical management and Consortium. Negative pressure wound therapy af-
ultimate psychological adjustment. J Urol 1980; ter partial diabetic foot amputation: a multicentre,
124:208–9. randomised controlled trial. Lancet 2005;
46. Jezior JR, Brady JD, Schlossberg SM. Manage- 366(9498):1704–10.
ment of penile amputation injuries. World J Surg 56. Philbeck TE Jr, Whittington KT, Millsap MH, et al.
2001;25:1602–9. The clinical and cost effectiveness of externally
47. Darewicz B, Galek L, Darewicz J, et al. Successful applied negative pressure wound therapy in the
microsurgical replantation of an amputated penis. treatment of wounds in home healthcare Medicare
Int Urol Nephrol 2001;33:385–6. patients. Ostomy Wound Manage 1999;45:41–50.