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Introduction

Traumatic injuries to the external genitalia are rarely fatal, but can have profound ­morbidity that permanently impairs quality of life. In order to minimize both the short- and long-term devastating complications associated with these injuries, prompt evaluation, diagnosis, and management are essential. Although trauma to the external genitalia is uncommon, early intervention coupled with systematic treatment strategies serves to minimize the complications of bleeding, infection, and organ injury while optimizing fertility, sexual health, micturition, cosmesis, and psychological well-being.

Men suffer trauma to the external genitalia at a higher incidence than women both as a result of anatomic exposure and an increased propensity for the most common risk factors for genital trauma. Men are more likely to be involved in violence involving both blunt and penetrating injuries, motor vehicle collisions, and to participate in aggressive sports [1, 2]. In addition to the common causes of genital trauma, urologists must be knowledgeable about the diverse mechanisms of injury including lacerations/avulsion injuries, self-mutilation, burns, bites, female genital mutilation, and sexual assault. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale [3] is a graded scoring system used to classify blunt and penetrating injuries to the external genitalia (Tables 7.1 and 7.2). The AAST Organ Injury Scale systematically categorizes genital injuries and has been shown to be a useful predictor for surgical intervention in traumatic injuries to the external genitalia [4]. Thus, careful examination, diagnosis, and treatment of these injuries will optimize the likelihood of a successful outcome.

Table 7.1 American Association for the Surgery of Trauma (AAST) organ injury scales for male genitalia
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Table 7.2 AAST organ injury scale for female external genitalia
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Pathophysiology of Trauma to the Scrotum and Testicles

Blunt Scrotal Trauma

Blunt trauma to the scrotum can result in a ­variety of injuries including an intrascrotal hematoma, testicular dislocation, testicular rupture, and hematocele (Table 7.1). Testicular trauma occurs predominately in men ages 15–40 [5]. Blunt trauma to the scrotum remains the most common mechanism of traumatic testicular injury, resulting in 85 % of injuries [6]. The vast majority of these injuries are a result of assault, motor vehicle collisions, a variety of sporting events, bicycle and horseback riding, as well as other straddle injuries [7]. Bilateral testicular injury only occurs in about 1 % of patients presenting with scrotal trauma [8].

Testicular Dislocation

Testicular dislocation is a rare traumatic event that results in the testicle being displaced from its normal anatomic position in the scrotum [9]. While the spermatic cord remains intact in the vast majority of cases, testicular torsion and avulsion are possible due to the substantial force involved in these injuries [9]. Dislocation is most commonly a result of a straddle injury related to a motorcycle crash, but can also occur in motor vehicle collisions and car vs. pedestrian accidents. Dislocation is most commonly unilateral, but has been reported to be bilateral as high as 25 % in one series [10]. Sites of testicular dislocation include the inguinal canal, pubic, penile, and abdominal cavity, perineal, acetabular, femoral canal, and crural areas [11]. Patients usually present with considerable pain. A massive scrotal hematoma may limit an effective physical exam, which, if possible, will reveal an empty hemiscrotum. Significant blunt force is required to dislocate the testicle. Therefore, it is imperative to rule out secondary injuries to the testicle such as torsion, rupture, and intratesticular hematoma.

Testicular Rupture

The testicle is protected from injury by both the mobility and elasticity of the scrotum and the durability of the tunica albuginea. The tunica albuginea of the testis provides substantial protection, with an ability to endure forces of up to 50 kg before rupturing [12, 13]. Blunt testicular rupture results from compression of the testis against the pubic arch, symphysis, or thigh with subsequent extrusion of seminiferous tubules. Rupture of the tunica albuginea may result in simple longitudinal or transverse tears or may be more complex with either a stellate tear or complete destruction of the testicle. Regardless of the mechanism of injury, testicular rupture warrants immediate evaluation and surgical treatment to maximize testicular salvage [7, 14].

Hematocele

Blunt trauma to the scrotum can result in blood accumulating between the visceral and parietal layers of the tunica vaginalis resulting in a hematocele. Rupture of the parietal tunica vaginalis will result in fluid extending into the perineum and groin, often with dissection into the subcutaneous dartos. Importantly, this blood can result from a rupture of the tunica albuginea causing blood from within the testicle to accumulate outside the testis. Testicular exam is usually difficult with moderate to large hematoceles, as both the fluid around the testicle and patient discomfort limit an accurate examination. When scrotal ecchymosis occurs in this clinical scenario, it is impossible to ascertain the degree of injury on physical examination alone. Color duplex Doppler ultrasonography can assess the integrity of the tunica albuginea, blood flow to the testicles, and size of hematocele [5, 7, 14, 15].

Intrascrotal Hematoma

Blunt trauma to the scrotum frequently results in intrascrotal bleeding. The distinct anatomical location and configuration of the scrotum lend itself to the accumulation of large amounts of blood and edema. Minor bleeding can evolve into a major hematoma if not treated quickly as the elasticity of the scrotum can accommodate large volumes of blood before tamponading. Significant hematomas left untreated can result in considerable pain, infection, as well as testicular atrophy and infarction [7].

Vulvar Trauma

Blunt injury to the female external genitalia is more likely to result in injury to nearby associated organs, including the vagina, urethra, bladder, and rectum. Blunt injuries to the female genitalia must be regarded with particular care because of their association with sexual assault and other interpersonal violence. Sexual assault victims suffer genital trauma in 20–53 % cases [16, 17]. Blunt trauma resulting from motor vehicle collisions, including pelvic fracture, or straddle injuries may result in vulvar hematomas and lacerations, as well as perineal and vaginal injuries (Table 7.2) [18–20]. The management of the more complex picture of concomitant genital and bladder injuries is covered in greater depth in Chaps. 5 and 6.

Penetrating Scrotal Trauma

Gunshot Wound

Penetrating trauma to the scrotum and testicles is significantly less common than blunt injuries. The majority of such injuries are the result of gunshot wounds (Fig. 7.1) [1, 21]. Approximately 21–55 % of genitourinary gunshot wounds result in scrotal injury, while 12–39 % result in an injury to the testicles [1, 22]. Despite the relatively infrequent nature of penetrating injuries to the scrotum, gunshot wounds result in bilateral testicular injury at 15 times the rate as in blunt injury, with bilateral testicular injuries accounting for 6–30 % of penetrating scrotal injuries [1, 21, 23, 24].

Fig. 7.1
figure 00071

Gunshot wound to the scrotum with a low-velocity projectile

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The degree of injury to the scrotum and testicles is related to the caliber of gun and the velocity of the missile. Most hand guns range from 0.22 to 0.45 caliber and have low-velocity missiles that travel at 1,000 ft per second. These low-velocity missiles typically have minimal damage outside the path of the projectile. In contrast, high-velocity missiles travel at greater than 1,000 ft per second and result in significant tissue damage by the explosive effect of the missile upon impact. Consequently, these weapons often result in life-threatening injuries as the projectile damages tissue radially along its path [25]. Shotguns are considered low-velocity weapons; however, the high mass of its projectiles often results in significantly more damage than occurs with a single low-velocity gunshot.

Civilian and battlefield penetrating injuries vary dramatically due to the differences in weapons being used. Historically, military genitourinary injuries involved the use of high-velocity guns. Increasingly, a changing pattern of warfare has led to the implementation of high-velocity fragmentation devices that have resulted in significant pelvic and genital organ injuries. In Operation Iraqi Freedom, 68 % of all patients with a genitourinary injury had one or more injuries to the external genitalia despite the use of protective armor [26, 27].

Any patient with a gunshot wound to the external genitalia should be evaluated with a high index of suspicion for other associated injuries. The reported rate of associated injuries with penetrating scrotal trauma varies by institution, but ranges from 50 to 94 % [2, 28]. Although the mortality rate for an isolated gunshot wound to the genitalia is rare, appropriate consultation with trauma surgeons is imperative to properly manage associated injuries.

Self-Mutilation, Stab Wounds, and Lacerations

Genital self-mutilation usually results in catastrophic testicular injury. A majority of these patients view themselves as male, although a number identify themselves in an alternate nonmale, nonfemale space [29]. Guilt associated with sexual conflicts has been shown to be the most common feeling in the act of psychotic autocastration, although a variety of etiologies for self-mutilation exist [30]. Most men are actively psychotic at the time of self-mutilation, and frequently under the influence of drugs or alcohol [22, 31, 32]. Among nonpsychotic mutilators, disorders of sexual identity, fanatical religious beliefs, other character disorders, and transvestitism can all serve as motivation for autocastation [30, 32]. The testicular salvage rate of men who attempt autocastration is poor, with only 23 % of testicles salvaged in one large Level I trauma center [22].

Stab wounds or lacerations to the scrotum that are not self-inflicted can also lead to devastating injuries to the testicles and spermatic cord. Phonsombat et al. found that only 23 % of testicular injuries secondary to stab wound were a result of a stab wound that was not self-inflicted. While these injuries are less common than self-inflicted wounds, they result in equally disappointing testicular salvage rates, with only 24 % of testicles able to be saved [22]. The poor testicular salvage rate in stab wounds to the scrotum suggests that the spermatic cord is irreparably damaged during the traumatic event, rendering the testicle unsalvageable.

Scrotal Bites

Mammalian bites rarely occur, but are most frequently caused by a canine attack. Approximately 1 % of all emergency department visits in the United States are a result of animal bites, with 60–70 % occurring in children [33–36]. Despite the large number of animal bites, few affect the genitalia [37, 38]. Bites to the scrotum can result in genital skin loss, infection, and injury to the testicle and spermatic cord. One of the most devastating complications, infection, can occur in up to 30 % of uncomplicated wounds, although this can usually be averted with prompt surgical care [39, 40]. The most common infectious organism associated with dog and cat bites is Pasteurella. However, animal bites are often polymicrobial in nature involving Staphylococcus aureus, Streptococcus pyogenes, and anaerobes [41, 42]. Among the most devastating infectious complication associated with animal bites is rabies. Approximately 55,000 people died worldwide in 2004 from Rabies infections. Human bites pose additional infectious risks to the patient. In addition to a higher rate of bacterial infection, human bites pose the risk of human immunodeficiency virus, hepatitis B and C, herpes simplex virus, tetanus, tuberculosis, actinomycosis, and toxic shock syndrome [42, 43].

Scrotal Avulsion

Avulsion injuries to the scrotum can result from a variety of mechanisms, but most frequently occur as a result of power take off (PTO) machinery accidents, when clothing becomes entrapped in moving parts (scrotum is trapped by stationary object), or in deceleration injuries (bicycles, motorcycles, motor vehicle collisions) [44]. The unique viscoelastic properties of the scrotum usually preclude injury to the testicles, limited instead to the skin and underlying dartos.

Scrotal Burns

Burns to the genitalia rarely occur in isolation and usually are part of a larger total body surface area burn, occurring in 5–13 % of cases [45]. Genital burns can be a result of thermal, ­chemical, or an electrical etiology. Close attention to children with burns is necessary as child abuse has been found to occur in 46 % of boys and 48 % of girls younger than 2 years old who present with scald burns to the genitalia [46]. While thermal burns are the most common type of external genital burn, it is electrical burns that are the most difficult to treat. Electricity passes through the body from its original point of contact to a point of exit, often damaging deeper tissue layers. The depth of burn is the most important factor in subsequent management and healing. Burns are typically stratified into three categories. First-degree burns affect only the epidermis and are characterized by erythema without blistering. Second-degree burns involve the epidermis and part of the dermis resulting in erythematous, painful lesions. All first- and most second-degree burns will reepithelialize over time. Third-degree burns are the most severe as they are full-thickness burns of the epidermis and entire dermis. These present as painless lesions that are white/brown and firm and require surgical debridement and grafting for successful management.

Initial Evaluation of Scrotal, Testicular, and Vulvar Trauma

Traumatic injury to the scrotum and testicles can be difficult to evaluate due to swelling, bruising, and pain associated with such injuries. A thorough history is important to elucidate potentially more severe injuries than may be initially observed on physical examination. Nausea, vomiting, extreme pain, bruising, or swelling may all suggest more extensive injury. Determining whether the mechanism of injury involved straddle injury, penetrating trauma (type of weapon involved), a bite, or burn is important to identify factors associated with potentially more significant injuries and higher risk of infectious complications.

A complete physical exam of the scrotum or vulva is performed taking note of the integrity of the genital skin and any accompanying hematoma and penetrating, lacerating, or avulsion injuries. Additionally, careful evaluation of all the scrotal contents including the testicles, epididymides, and spermatic cords is mandatory. In addition to a careful physical examination, a urinalysis is mandatory in all patients with trauma to the external genitalia. Due to the difficulty in adequately examining the testicles following blunt traumatic injury, high resolution color Doppler ultrasound with a 7.5–12 MHz probe is essential when the physical examination does not clearly demonstrate normal scrotal or testicular findings [14, 15]. Ultrasound is highly sensitive for the majority of blunt injuries that require surgical management, as it is useful in determining the integrity of the testicle and its arterial blood flow. Sonographic examination will allow identification of tunica albuginea tears with a sensitivity of 100 % and specificity of 65 %, diagnosis of hematocele (sensitivity of 87 %, specificity 89 %), testicular hematoma (sensitivity 71 %, specificity 77 %), and testicular avulsion (sensitivity 100 %, specificity 97 %) [14, 15]. In addition, even minor trauma can result in delayed scrotal pain. Ultrasound is useful in this scenario because testicular torsion must be kept in the differential diagnosis. Retrograde urethrogram should be performed in any patient with blunt injuries suggestive of urethral injury. This includes straddle injuries, blood at the meatus, hematuria on urinalysis, or an inability to void.

Penetrating scrotal injuries often involve multiple organ systems and frequently damage the urethra, corpora cavernosa, and spermatic cords. Consequently, these patients may require additional imaging with a CT scan of the abdomen and pelvis with or without cystography, cystourethrography, and proctoscopy to exclude additional injuries. Patients with a concomitant penile injury, blood at the meatus, hematuria on urinalysis, or an inability to void should undergo a retrograde urethrogram to rule out urethral injury [22].

A complete history and physical examination is essential to proper diagnosis and should always include suspicion of sexual assault. If sexual assault is suspected, informed consent must be obtained for the remainder of the patient ­evaluation, with care being taken to respect the emotional situation of the patient. In addition, the physician should notify the police and appropriate support services that a sexual assault may have occurred, making sure to closely follow all local legal protocols.

It is essential to follow guidelines as outlined by the American College of Obstetrics and Gynecologists for the collection of evidence and laboratory specimens needed for forensic analysis [47]. All female patients with evidence of lower urinary tract trauma should be evaluated for trauma to the external genitalia, including a speculum examination [48]. In cases of suspected sexual assault, this exam should include vaginal swabs or smears for the detection of spermatozoa [49]. Due to both the physical and emotional nature of the traumatic event, examination may need to be performed under anesthesia. Depending on the nature and extent of injuries, other specialists may be required for optimal patient management (pediatrician, gynecologist, trauma surgeon), as complete evaluation of both the vagina and rectum may be necessary to rule out associated injuries.

In blunt trauma of the vulva not related to sexual assault, care must be taken to exclude injuries to the bladder, urethra, vagina, perineum, and rectum. Blunt trauma of the pelvis and straddle injuries can result in perineal and vaginal injuries as well as other gynecologic and gastrointestinal injuries. Blood at the meatus or vaginal introitus implies a vaginal, bladder, or urethra injury. Workup warrants speculum examination and cystourethroscopy and proctoscopy as indicated [50, 51]. Proper imaging with CT or MRI is necessary to exclude pelvic fractures and other intra-abdominal pathology [18, 19, 52].

Penetrating injuries of the female external genitalia are exceedingly rare. Hemodynamically stable patients should be imaged with a CT scan of the abdomen and pelvis to exclude intra-abdominal injury and require complete examination as previously mentioned. Hemodynamically unstable patients should undergo exploratory laparotomy without further workup.

Pathophysiology of Traumatic Penile Injury

Blunt Trauma

Penile Fracture

Traumatic injuries to the penis are rare, with variable etiology. Penile fracture is an injury of the tunica albuginea that only occurs with full penile tumescence. To illustrate the rarity of this injury, in the United States, approximately 1,000 people were hospitalized over a 2-year period according to the National Inpatient Sample [53]. The largest series of penile fractures are reported from Northern Africa and the Middle East, suggesting that the incidence of injury is higher in these regions of the world [54–56]. Penile fracture usually occurs in men between the age of 30–40, and most commonly occurs during sexual intercourse, masturbation, rolling over in bed, and kneading the penis to achieve detumescence [54–59]. The etiology of penile fracture is variable, often related to the geographic area of study [56–58]. The majority of cases reported in the western hemisphere result from sexual intercourse, while a larger proportion of fractures in the Middle East result from masturbation [54, 58–60].

Blunt injury to the penis in the flaccid state requires extensive kinetic energy and force because the tunica albuginea is approximately 2 mm thick and can undergo maximal degrees of bending without damage. In the fully erect state, increased rigidity and tumescence of the penis cause the tunica albuginea to thin to approximately 0.25 mm [61]. A penile fracture occurs when the sudden rise in intracorporeal pressure associated with bending compromises the integrity of the tunica albuginea and results in a tunical tear [57, 62]. During intercourse this most frequently occurs as the erect penis slips out of the vagina and strikes against the pubic bone or perineum. The resulting pattern of hematoma corresponds to the tissue injured in the fracture. If the patient presents with the classic “eggplant deformity,” the hematoma is confined to Buck’s fascia (Fig. 7.2), whereas if Buck’s fascia is disrupted, the hematoma can spread to the scrotum and perineum.

Fig. 7.2
figure 00072

Blunt trauma to the penis resulting in a penile fracture and an “Eggplant Deformity.” Hematoma contained by Buck’s fascia

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Tears of the tunica albuginea are usually ­unilateral and transverse; however, bilateral ruptures can occur in 5–14 % of cases [55, 59]. Longitudinal tears in the tunica have been reported, but are thought to result as an extension of a transverse rupture [63, 64]. Rupture of the tunica occurs proximally in 25–57 % of cases, whereas it occurs distally in only 6–26 % of cases [54, 55]. Fractures that occur during intercourse typically present ventrally along the shaft of the penis [65]. Penile fracture predominately affects the tunica albuginea, although it has been associated with lacerations of the corpus spongiosum and urethra in 6–22 % of cases [55, 59, 66]. The mechanism of urethral injuries has not been well studied, but generally reflect extensions of a ventral tear across the midline to involve the corpus spongiosum. Urethral injury rarely occurs (1.6 %) when the fracture has a noncoital etiology [54]. In contrast, coital-related penile fractures have urethral injury rates as high as 58–95 % in some series [56, 65–67].

Rupture of the suspensory ligament, dorsal vein, and/or artery can mimic penile fracture and has been reported to occur in up to 12 % of cases suspected of being a penile fracture [59, 68, 69]. This mimicry is a result of a similarly sounding “popping” sound that often occurs with these injuries, although the lack of detumescence should alert the physician to this diagnosis [70].

Penetrating Trauma

Gunshot Wound

Penile gunshot wounds are rare events due to the anatomic location, size, and mobility of the penis. However, these injuries are complex and potentially devastating for the patient. The largest reported series historically are from the military during the Vietnam War era, where 18.5 % of genitourinary injuries affected the penis [71]. Modern warfare has evolved dramatically with the use of improved body armor. Despite the changing patterns of weaponry and armor, a similar rate (6 %) of genitourinary injuries affecting the penis was seen in Operation Iraqi Freedom [27]. Civilian data is limited to large single institution series. Civilians with gunshot wounds to the penis have associated injuries in 80–90 % cases, most commonly in the thigh (69–75 %) and scrotum (52–56 %) [22, 72, 73]. As previously discussed, the degree of tissue destruction is highly dependent on the caliber of weapon and velocity of missile. Careful attention must be given to exclude a concomitant urethral injury, as 6–24 % of civilians with a gunshot wound to the penis sustain a urethral injury [22, 72, 73].

Self-Mutilation, Stab Wounds, and Lacerations

Penile stab wounds occur as a result of assault or are self-inflicted. There is a paucity of literature on stab wounds of the penis, with reports being limited to case reports and small series. The proportion of penile stab wounds and lacerations varies by institution, ranging from 10 to 18 % of traumatic genital injuries in large Level I trauma centers [22, 74]. In addition to a potential laceration or amputation of the penis, any stab wound injury has the potential for urethral injury. The largest series examining both assault and self-inflicted stab wounds to the penis found a 17 % urethral injury rate [22].

Penile amputation is a devastating injury that can be a result of assault or circumcision, but most frequently is self-inflicted. The largest series of penile amputations is from an epidemic in Thailand in the 1980s, with more than 100 cases reported. Most of these amputations were ­performed by disgruntled wives of philandering husbands [75]. Iatrogenic amputation of the penis is rare and usually is a result of a circumcision injury with removal of excess penile skin or a glansectomy [76–79]. Self-inflicted penile amputation is a result of a psychotic event in 87 % patients, with schizophrenia (51 %) and depression (19 %) the most common causes [32]. The underlying delusions in psychotic patients often involve sexual or religious themes. Men who were not psychotic at the time of their penile amputation most often exhibit a personality disorder or transsexual issues that remained unsettled [32].

Another form of self-mutilation that does not involve penile amputation is the placement of foreign bodies in or around the penis. Staples, paper clips, and other sharp objects can all be placed into the glans or corpora cavernosa (Fig. 7.3). As with other forms of self-mutilation, it is thought that underlying psychosis and delusions account for the vast majority of these cases. Additionally, constriction rings can be placed around the penis and can become impossible to remove without surgical intervention. When metal rings or tubing are placed around the penis, and removal with a bolt cutter is unsuccessful, surgical removal with an angle grinder may be necessary. In this situation, metal spatulas, wet towels, and cool running water can be used to minimize injury to the penis as metal sparks and thermal injury are possible [80].

Fig. 7.3
figure 00073

Fluoroscopic images of penis. Self-mutilation of placing staples into the corpora cavernosa

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Penile Bites

Mammalian bites to the penis are exceedingly rare, as reflected in the small series and case reports in the literature. Bites to the penis can result in genital skin loss, infection, injury to the urethra, and partial or complete loss of the organ. Urethral injury rarely occurs, with no reported cases from a large Level I trauma center [22]. The risks of infectious complications from animal and human bites are perhaps the most common and potentially devastating injuries and generally are the result of delays in presentation. The infectious organisms and potential complications related to genital bites were discussed in the section discussing “Pathophysiology of Trauma to the Scrotum and Testicles: Scrotal Bites.”

Penile Avulsion

Avulsion injuries to the penis can result from a variety of mechanisms as previously discussed, but most frequently occur as a result of power machinery accidents, when clothing becomes entrapped in moving parts (penis is trapped by stationary object), or in deceleration injuries (bicycles, motorcycles, motor vehicle accidents). Degloving injury to the penile skin and dartos is the most frequent avulsion injury, with variable amounts of skin being involved (Fig. 7.4) [81]. More severe injuries to the penis in which the corpora are injured or even avulsed off the pubic bone are more likely to occur in machinery accidents [82].

Fig. 7.4
figure 00074

Blunt trauma to the penis in a bicycle accident resulting in an avulsion injury to the penis

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Penile Burns

Burns of the penis are a potentially devastating injury both physically and psychologically. Burns of the penis present in similar manner to the ­scrotum as already mentioned in the section “Pathophysiology of Trauma to the Scrotum and Testicles: Genital Burns.” Careful and prompt evaluation is critical to managing these injuries.

Initial Evaluation of Penile Trauma

Delayed presentation of penile injury is common as many patients feel embarrassed about the nature of their trauma. A thorough history and physical examination is instrumental in making the proper diagnosis for traumatic penile injuries and elucidating potentially more severe injuries that may not be initially appreciated on examination. Determining the mechanism of injury, whether blunt, penetrating (type of weapon involved), bite, or burn, helps identify patients with potentially more significant injuries and risk of infectious complications. In addition to a history and physical exam, a urinalysis is mandatory in all patients with trauma to the penis.

Penile Fracture/Penetrating Injury

Penile fracture classically presents with the patient hearing a snapping or popping sound during missed intromission or acute bending of the penis. This is quickly followed by acute pain and immediate detumescence. Occasionally, a palpable defect in the tunica is felt. As previously mentioned, hematoma is confined to the penis in a classic “eggplant deformity” when Buck’s fascia is intact and will spread to the scrotum and perineum if this investing fascia is disrupted. Penetrating injuries to the penis can be complex due to the flaccid nature of the penis. What Information regarding the type of weapon used (i.e., gun or knife) size of the bullet, and proximity of shooter are all helpful pieces of information for further treatment.

Imaging of the corpora cavernosa with contrast cavernosography has limited sensitivity and specificity and is not recommended in the workup of blunt and penetrating penile injuries [6]. A high index of suspicion is necessary for all penetrating injuries to the penis as there is a high rate of associated urethral, scrotal, testicular, bladder, and rectal injuries. CT of the abdomen and pelvis with or without cystography may be performed in stable patients with penetrating injuries who do not require immediate surgery. Blood at the meatus, gross hematuria, or inability to void imply a urethral injury and warrant further investigation with either a retrograde urethrogram or cystoscopy. Surgical exploration of all suspected penile fractures and penetrating injuries will ensure that all urethral injuries are identified.

Penile Amputation

The initial evaluation of a patient with an amputated penis should focus on stabilization of the patient and assessment of the amputated organ. Successful replantation of an amputated penis requires a properly preserved organ. The amputated penis should be thought of as a free flap, where hypothermia prolongs the ischemic survival times [83]. The amputated penis should be placed in a saline-soaked gauze in a clean plastic bag and sealed. This bag should then be placed into a second plastic bag filled with ice slush [84]. Successful replantation has been performed after 18 h, even with prolonged periods of warm ischemia. An attempt to salvage the organ is reasonable up to 24 h in cases of cold ischemia [83, 85, 86]. Patients who are candidates for penile replantation must be properly consented for surgery. In preparation of surgery, patients should be well hydrated and kept warm in order to peripherally dilate their vasculature.

Management of Scrotal, Testicular, and Vulvar Injuries

Blunt Scrotal Trauma

Blunt trauma to the scrotum should be managed in a standardized fashion in order to minimize missed injuries and complications. All patients with blunt trauma should have a scrotal ultrasound to evaluate for rupture of the tunica albuginea, testicular dislocation, hematocele, testicular hematoma, and testicular avulsion. Surgical exploration is warranted if there is ultrasonographic evidence of testicular rupture, dislocation, avulsion, large intratesticular hematoma, expanding scrotal hematoma, or if the integrity of the tunica albuginea cannot be determined. This standardized approach for early operative intervention of blunt scrotal trauma has led to a testicular salvage rate of 83–91 % [14, 24]. Most intrascrotal hematomas and hematoceles, in the absence of testicular rupture, can be managed conservatively with ice, analgesia, compression, and elevation. Thus, traumatic scrotal hematomas associated with normal testicles on ultrasound should not be explored. Attempts to evacuate the hematoma are usually unsuccessful as the blood has infiltrated through the multiple scrotal layers. As previously described, any patient with scrotal trauma should undergo a retrograde urethrogram if indicated.

Scrotal Exploration

The goals of scrotal exploration include preservation of testicular tissue for hemostasis, hormonal function and fertility, cosmesis, prevention of infection and necrosis, decreased pain, theoretical prevention of antisperm antibodies, shorter hospital stay, and a shorter time to convalescence [5, 12, 14, 21, 24]. Bilateral testicular exploration is best performed with a midline vertical incision, allowing visualization of all the scrotal contents. During exploration, the testes, vas deferens, spermatic cords, and epididymes are inspected.

If injury to the spermatic cord is discovered, the incision should be extended toward the groin. If the testis is not viable, an orchiectomy is performed, ligating the vas deferens and spermatic cord separately. If the testicle is viable, and the vas deferens is injured, both ends are debrided and ligated with nonabsorbable sutures to allow identification at the time of delayed microsurgical repair [87, 88].

Repair of the ruptured testis must address parenchymal extrusion and swelling. In ruptured testicles that are salvageable, extruded seminiferous tubules are debrided to healthy tissue to allow closure of the tunica albuginea. A continuous 3-0 slowly absorbable suture is sufficient. If the tunica albuginea cannot be closed primarily, a tunica vaginalis flap can be used to cover the defect [89].

In cases of testicular dislocation, immediate surgical relocation is recommended to avoid complications of atrophy and subsequent infertility [90]. When the dislocated testis is high in the scrotum, manual reduction can be attempted under sedation [91]. However, if this fails, and in all other cases, surgical exploration and orchidopexy is warranted [92].

After surgical exploration, a penrose drain is brought through a separate incision when hemostasis is an issue. The drain can usually be removed after 24 h. Fluffed gauze and a scrotal supporter should be used to keep the scrotum elevated.

Blunt Vulvar Trauma

Blunt injuries of the vulva most frequently cause labial hematomas. Small hematomas can be managed conservatively, while large hematomas may need to be surgically drained. Lacerations of the vulva may be closed primarily after irrigation and debridement. Interrupted absorbable sutures will allow any accumulated fluid collection to drain from the incision. In the rare situation where hemostasis is poor, the wound may be packed temporarily.

Penetrating Scrotal Trauma

Spermatic Cord and Testicular Trauma

Penetrating injuries of the scrotum require surgical exploration, using techniques previously described. Any penetrating bites, lacerations, or gunshot wounds are debrided, and all devitalized tissues removed. Copious irrigation with saline and bacitracin will help to remove any debris and foreign bodies from the wound in hopes of decreasing infectious complications.

Testicular salvage rates are 23–65 % with penetrating injuries to the spermatic cord, with particularly poor salvage rates for autocastration (23 %) [22, 28, 74]. Microsurgical reconstruction of the severed spermatic cord and vas deferens can be attempted within 6 h of the injury. In testicular avulsion from a stretching type mechanism (i.e., machinery), testicular salvage is extremely unlikely and the spermatic cords should be ligated.

Testicular rupture from gunshot wounds results in a salvage rate of 35–75 % [22, 74, 93]. In contrast to blunt trauma, the defect produced by a gunshot wound is often difficult to close. As previously mentioned, if the tunica albuginea cannot be closed primarily, a tunica vaginalis flap can be used to cover the defect [89]. Testis reconstruction with a synthetic graft should be avoided as those patients have an unacceptably high rate of infection and subsequent orchiectomy [89].

Abrasions, Lacerations, and Avulsions of the External Genitalia

Trauma to the scrotum and penis spans the spectrum from an abrasion, to laceration, and complete avulsion. The majority of scrotal and penile lacerations can be closed primarily, with exceptions in cases of grossly contaminated wounds, associated rectal injuries, or if there was prolonged delay between the injury and presentation for care. Lacerations and avulsions must be vigorously irrigated with removal of all foreign bodies, and the wound edges debrided to remove any potentially devitalized tissue.

The management of avulsions is different from lacerations. If allowed to heal by secondary intention, the testicles or penis would become fixed in scar tissue. Scrotal avulsion injuries involving less than 60 % of skin loss can be closed primarily or in a delayed fashion depending on whether the wound was grossly contaminated. When greater than 60 % of scrotal skin is avulsed, split-thickness skin grafting or reconstruction with a pedicled thigh flap is necessary for adequate genital coverage [94–97]. Similarly, penile avulsion (degloving) injuries can often be closed primarily when the injury is not circumferential (Fig. 7.5). Split-thickness skin grafting is appropriate for circumferential penile avulsion injuries or when large skin defects cannot be closed without tension.

Fig. 7.5
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Primary closure of the penile avulsion injury

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When the mechanism of avulsion is from the shear forces of a motor vehicle collision, the area may rarely be suitable for cleansing and preparation for immediate split-thickness skin grafting. However, this approach is not preferred when the mechanism of avulsion is due to an animal bite or rotating machinery. Initial wound management with wet to dry dressing is performed to allow the demarcation of viable tissue. Care must be taken to ensure the wound is clean with healthy skin edges, free from infection, and with robust granulation tissue before scrotal reconstruction can be performed. If prolonged wound care is necessary before scrotal reconstruction, or if the patient is unable to tolerate the pain of dressing changes, the testes can be placed in subcutaneous thigh pouches.

Management of Bites to the External Genitalia

Bites to the external genitalia often result in a polymicrobial genital infection. These patients require broad spectrum antibiotics, including the use of a penicillin or cephalosporin, to provide coverage against a host of possible aerobic and anaerobic pathogens including Clostridial, Pasteurella, Streptococci, and Actinomyces species [98]. In addition to local wound debridement and saline irrigation, all patients should receive appropriate prophylaxis against potential infectious diseases. Patients should receive a tetanus vaccination regardless if their bite was of animal or human origin. If rabies is suspected in an animal bite, vaccination with rabies immunoglobulin and human diploid cell vaccine is recommended [99, 100]. Because human bites pose the unique risk of contracting sexually transmitted diseases, all patients should be tested for hepatitis B and C, as well as human immunodeficiency virus. Appropriate disease prophylaxis should be initiated immediately to reduce the spread of these diseases. After debridement and irrigation, wounds without obvious signs of infection or devitalized tissue may be closed, while more complicated wounds should be left open and treated with wet to dry dressing changes until all signs of infection and devitalized tissue have been managed.

Management of Burns to the External Genitalia

The management of patients with genital burns must occur in conjunction with a burn team, because the majority of patients have a larger total body surface area burn. The initial assessment should determine the type and depth of the burn and focus on fluid resuscitation and infection control. Chemical burns should be copiously irrigated with saline to remove any substances remaining on the skin. Acidic burns should then be irrigated with sodium bicarbonate, while alkaline burns should be irrigated with dilute acetic acid. Electrical burns should be managed conservatively for the first 24 h to determine the extent of tissue injury. Additional treatment of electrical burns is similar to thermal burns.

First-degree and superficial second-degree thermal burns should be irrigated with saline and will reepithelialize over time with conservative management. Deep second-degree thermal burns may need excision of bullae larger than 2 cm in order to minimize infection. Antibiotic creams (1 % silver sulfadiazine, 0.5 % silver nitrate, or mafenide acetate) should be applied to deep second-degree and third-degree thermal burns. Third-degree wound management requires eschar excision and antibiotic creams and may take several weeks before the wound is healthy enough to support a skin graft. Once the wound is free of infection and with healthy granulation tissue, split-thickness skin grafting can be performed in a meshed fashion. Whether the penile or scrotum split-thickness skin graft is meshed in a 1:1 or 2:1 fashion is determined by the amount of skin needed to graft all the body’s burn sites and the relative availability of skin for grafting.

Split-Thickness Skin Grafting of the External Genitalia

Traumatic injuries resulting in genital skin deficiency are best managed with split-thickness skin grafts. These grafts have been used for scrotal reconstruction for more than 50 years [101]. Prior to grafting, the host bed must be free of infection, and all healthy granulation tissue excised. If grafting a neo-scrotum, the testicles and spermatic cords should be sutured together to prevent the testicles from being able to “swing” above the penis. Split-thickness skin grafts contain the epidermis and part of the dermis, and thus do not grow hair. Graft are harvested at 0.014–0.018 in. thickness (to minimize contracture) and meshed in either a 1:1 or 2:1 fashion depending on the availability of donor skin and overall graft requirements of the patient [94]. Meshing the graft improves its chance for take, increases the surface area grafted without compromising cosmesis (mimics scrotal rugae), and allows exudates to drain from the host bed. When grafting the penis, it is important to have the penis on maximal stretch when circumferentially placing the graft in order to avoid contraction, shortening, or deviation of the penis with erection. Grafts must be placed on the genitalia to ensure direct, flat contact between the graft and bed. Skin grafts must be completely immobilized as survival is dependent on imbibition and inosculation. After the grafts are adequately secured, a dressing bolster is created consisting of nonadherent Conformant (Smith and Nephew Inc.) and gauze. This is soaked in mafenide acetate and tightly applied to the graft. The bolster is kept moist with mafenide acetate every 6 h and left in place for 5 days. To ensure graft immobilization, patients are kept on bedrest or limited activity until the bolster is removed.

Management of Penile Injuries

Blunt Trauma

Blunt penile trauma to the flaccid penis usually results in a subcutaneous hematoma without injury to the tunica albuginea. These injuries can be managed conservatively with ice packs and analgesia. Significant preputial swelling may make voiding difficult. If this situation arises, urethral catheterization may be required until the swelling subsides.

Penile Fracture

Penile fracture is an emergency and should be treated surgically even in cases of delayed presentation. El-Assmy et al. showed that patients with delayed presentation up to 7 days, when treated surgically, had no difference in outcomes compared to patients treated within 24 h [102]. Conservative management of these injuries is not recommended as penile fibrosis and angulation develop in as many as 35 % of patients [62]. Retrograde urethrography or cystoscopy, when indicated, will exclude a urethral injury. A circumferential subcoronal incision and degloving of the penis provides exposure of both corpora and the urethra. For more proximal injuries a penoscrotal incision can be made and the penis degloved by everting the penis through the incision. A subcoronal incision is generally preferred as this allows complete inspection of both corpora, ensuring all defects are repaired.

Tears in the corpus spongiosum are possible with a negative retrograde urethrogram and cystoscopy, and thus a careful inspection of the corpus spongiosum is mandatory. Occasionally, a transversely oriented tear in the tunica can extend behind the corpus spongiosum, or rarely dorsally under the neurovascular bundle. In these situations, the corpus spongiosum or neurovascular bundle must be mobilized and retracted to allow adequate visualization of the injury. The tunica albuginea is repaired with interrupted 3-0 slowly absorbable sutures, and the skin closed with interrupted 4-0 chromic sutures.

Penetrating Penile Trauma

Gunshot and Stab Wounds

All patients with penetrating injuries to the penis require surgical exploration except in tangential, superficial injuries that clearly do not involve structures beyond dartos [22]. As previously discussed, a high index of suspicion for an associated injury is pertinent in all patients. A retrograde urethrogram and cystoscopy should be performed as indicated. A circumferential subcoronal incision is preferred for optimal exposure of all the penile structures and corpus spongiosum. If an injury is suspected proximal to the suspensory ligament or crus of the penis, a penoscrotal or perineal incision may be warranted. All wounds in the skin and corpora should be debrided, and copiously irrigated with saline. An exception may be made with low caliber weapons as they can produce a wound with a clean edge that does not require additional debridement and may simply be irrigated before wound closure. The majority of tunica albuginea defects can be primarily repaired. In cases of extensive tissue loss, autologous rectus fascia can be used to cover large corporeal defects [103]. Split-thickness skin grafts can be used to close areas of extended penile shaft skin loss after infection control has been attained [88]. In extensive penile injuries involving the urethra, a suprapubic cystotomy tube may be required.

After surgical repair of both blunt and penetrating penile injuries, a light compressive dressing is applied to minimize swelling. If urethral injury is present, a urethral catheter is mandatory. Sexual activity is contraindicated for 1 month following surgical repair.

Penile Amputation

Microsurgical replantation is the preferred surgical method for the treatment of penile amputation. Transport of patients to centers experienced in these techniques is preferred. As previously discussed, the amputated penis should be placed in a saline-soaked gauze in a clean plastic bag and sealed. This bag should then be placed into a second plastic bag filled with ice slush [84]. First, a two-layer spatulated urethral reconstruction of the urethral mucosa and corpus spongiosum is completed with interrupted slowly absorbable sutures. A urethral catheter is then placed to stabilize the penis. The tunica albuginea of the corpora cavernosa and septum are subsequently anastomosed with small slowly absorbable sutures. The restored corpora cavernosa provides blood flow to the distal corpora, glans, and urethra, while the corpus spongiosum allows some venous drainage of the penis. Lastly, a microsurgical anastomosis of the dorsal arteries, dorsal vein, and dorsal nerves with fine nonabsorbable sutures is performed. Postoperatively, patients are kept in a warm room on bed rest. They maintain urinary diversion, anticoagulation (select cases), aggressive hydration, and monitoring of arterial flow in the distal penis.

If the patient presents without the amputated penis, if the amputated organ is not salvageable, or if the graft bed is not compatible with replantation, reconstructing the penile stump or total phallic replacement are the remaining options. In the acute traumatic situation, hemostasis and infection control are the primary responsibilities of the surgeon. The amount of skin that is removed and penile length remaining will determine in the short term how the urinary stream is managed. In penises with 2–3 cm of length remaining, a widely spatulated neo-meatus is essential to avoid meatal stenosis. This amount of length affords most men the ability to stand to urinate [104]. While this length is usually adequate to urinate, it is often insufficient for sexual intercourse. In cases when there is less than 2 cm of penile length or when the sexual capacity of the organ is insufficient, penile lengthening procedures or total phallic replacement is necessary.

Summary

A systematic approach to the management of trauma to the external genitalia is essential. The treatment goal for trauma to the genitalia is organ preservation. Knowledge of the anatomy, mechanism of injury, clinical signs and symptoms, imaging findings, and treatment options is critical to ensure successful outcomes. This includes maintenance of fertility, endocrine function, sexual health, micturition, cosmesis, and psychologic well-being. Conservative management may be appropriate in particular situations; however, prompt surgical treatment is often mandatory to minimize complications and optimize patient outcomes. Trauma to the external genitalia often involves multiple organ systems. Maintaining a high index of suspicion for associated injuries while working closely with experts from other medical and surgical teams ensures the greatest patient benefit.