Concurrent penetrating injury to the male external genitalia and the anterior urethra is uncommon. This case illustrates an unusual cause of such an injury, and its subsequent management and outcome. A 69-year-old man had his scrotum and anterior urethra pierced by a long thorn when he fell in his farm. He presented with urine leakage from the scrotal wound each time he micturated. Cystoscopic examination confirmed the cause and extent of the injury, and also facilitated the extraction of the thorn. The injury was allowed time to heal by urinary diversion with a urinary catheter. There were no stricture or fistula formations and the patient remained symptom-free at 3 months follow-up. Careful cystoscopic examination was both diagnostic and therapeutic in this case. A conservative approach is a feasible option in the management of selected cases of penetrating anterior urethral injury. Clin Ter 2013; 164(1):35-37. doi: 10.7417/CT.2013.1509.
We report on 40 patients with penetrating trauma to the external genitalia. Initial evaluation and management, operative findings, and treatment outcomes are reviewed.
We retrospectively reviewed the medical records of all patients presenting to our facility with penetrating trauma to the external genitalia since 1988.
Of the 40 patients reviewed, 22 sustained isolated scrotal trauma, 10 sustained isolated penile trauma, and 8 had both scrotal and penile injuries. Twenty-nine of the 30 men with scrotal injuries underwent surgical exploration, and 21 of these were found to have injuries to the spermatic cord or testes (in 2 patients, bilateral injuries were noted). The testicular salvage rate was 35%. Penile trauma occurred in 18 patients. Eight corporal injuries and four urethral injuries were managed with debridement and primary repair. Erection and normal voiding was present in all men undergoing reconstruction who returned for follow-up. Thirty-eight percent of tested patients were positive for hepatitis B, C, or both. More than 60% of tested patients were legally intoxicated at the time of injury. Injuries separate from genitourinary trauma were identified in 72% of the men.
Early surgical exploration with conservative debridement and primary repair of injured structures is recommended for most men who sustain penetrating injuries to the external genitalia. Selected patients with superficial injuries can be managed nonoperatively, but delayed wound complications are not uncommon. Although universal precautions are recommended for all patients, the high prevalence of hepatitis B and C in this group reemphasizes their importance. Long-term follow-up in this largely young, mobile, indigent population was poor.
The erectile function, cosmetic appearance, indications for surgical exploration and need for specific diagnostic tests were evaluated in patients with penetrating penile trauma.
We reviewed 26 cases of penetrating penile trauma seen during a 4-year period.
All patients with corporeal injuries who were followed (73%) were potent. Two patients with minimal corporeal injury who did not undergo exploration did well. Retrograde urethrography did not identify any previously unsuspected urethral injuries.
Excellent functional results may be obtained after penetrating trauma to the penis. Select patients may not require retrograde urethrography and some with minimal wounds, even if involving the corpora, can be treated nonoperatively.
Anterior urethral injuries, although rare, may be associated with substantial long-term morbidity. Urethral injuries that occur due to penetrating trauma or penile fracture are best treated by meticulous two-layer primary repair. Those that occur due to rapid deceleration injury are usually best treated by suprapubic diversion and delayed reconstruction because of associated injuries and concomitant contusion of the supporting spongiosum.
To assess the occurrence and treatment of posterior urethral (most often caused by traffic accidents and comprising half of all cases of urinary tract traumas) and anterior urethral injury (usually iatrogenic during catheterization or cystoscopy, or caused by blunt trauma, e.g. straddle injury or penetrating trauma).
The records and details of patients with posterior and anterior urethral trauma were analysed from 61 urological departments in Poland between 1995 and 1999.
During the 5-year period there were 268 cases of posterior and 255 of anterior urethral injury; for the former, most occurred during traffic accidents, and of the latter 206 were iatrogenic (during catheterization or cystoscopy), of which 48 were accompanied by perineal injury. The posterior injuries were isolated or involved many organs, mainly pelvic bones. Both types of injuries were diagnosed using ascending urethrography, voiding cysto-urethrography and urethroscopy/endoscopy. Treatment for posterior injuries included cystostomy alone or cystostomy with abdominal drainage or perineal drainage; some patients also had their urethra reconstructed. The treatment for anterior injuries was conservative in 193 patients and surgical in 62.
The early detection and appropriate surgical treatment of posterior and anterior urethral injury is crucial for the recovery of urethral function, and avoids many complications.
We describe our experience with treating a series of 40 penile injuries, including 2 gunshot wounds, 1 stab wound, 1 zipper injury and 34 penile fractures, of which 29 were corrected surgically and 5 were managed conservatively, as well as 2 cases of glandular gangrene at 3 large inner city medical centers in a 12-year period. We describe our standard diagnostic and therapeutic modalities, which have evolved with time.
Between 1989 and 2000, 34 patients were evaluated after blunt trauma to the erect penis resulted in penile fracture. Four patients had penetrating trauma to a flaccid penis and 2 had localized penile gangrene. Of the patients with blunt trauma 32 were injured during sexual intercourse and 2 were injured during masturbation. A single gunshot wound occurred during a crime, 2 penetrating traumas were intentionally inflicted and the remaining penetrating injury was due to a zipper. The 2 patients with penile gangrene had diabetes and were on dialysis.
A total of 32 patients were treated with surgery using a degloving incision. The corpora and urethra were evaluated with radiography or injection of saline intraoperatively. Five patients were treated conservatively for presumed penile fracture after they refused diagnostic confirmation and/or surgery, and the 2 with localized glandular gangrene were also treated conservatively. At followup 35 of the 40 patients available reported erection adequate for intercourse without erectile or voiding dysfunction. Two patients had mild curvature.
In our experience a degloving procedure provided the best exposure for blunt and penetrating trauma. All penetrating injuries were débrided before repair. Saline injection showed additional corporeal body and/or urethral pathology, and also assessed the integrity of repair. Distal amputation in patients with localized glandular gangrene may result in sloughing and further complications. However, hyperbaric oxygen and local wound care may be adequate if there is no progression of gangrene.
In this continuation of the section on genitourinary trauma, the authors describe the consensus on urethral injury. This is an in-depth statement, describing all aspects of the condition, from anatomy to general recommendations.
We examine the characteristics, outcomes and incidence of penetrating external genital trauma at our level I trauma center.
Patient records entered into our urological trauma registry were reviewed from 1977 to August 2006.
A total of 110 patients sustained penetrating external genital trauma. Injuries were divided into gunshot wounds (49%), stab wounds/lacerations (44%) and bites (7%). Half of the stab wounds/lacerations were self-emasculation injuries. Operative exploration was performed in 78%, 63% and 75% of gunshot wounds, stab wounds/lacerations and bite injuries, respectively. Of 6 patients with complete penile amputations 5 underwent replantation with an 80% success rate. Testicular injury occurred in 39% and 27% of patients with gunshot wounds and stab wounds/lacerations, respectively. Of the 24 testicles injured via gunshot wounds 18 were reconstructed (75%). Testicular salvage rates were 24% (4 of 17) for self-emasculation stab wounds and 20% (1 of 5) for all other stab wounds/lacerations injuries. Of patients with penetrating external genital trauma 11% also had associated urethral injuries. The incidence of penetrating external genital trauma has remained stable during the last 30 years (r(2) = 0.98). Of patients treated with operative exploration 8% and of those treated nonoperatively 4% reported complications.
Conservative débridement of penetrating injuries to the external genitalia should be stressed to maximize tissue preservation. Testicular salvage rates are significantly higher in gunshot wound injuries (75%) compared to stab wounds/lacerations injuries (23%) (p <0.001). A select group of patients with penile and scrotal injuries (ie those with injuries superficial to Buck's or dartos fascia) may undergo nonsurgical treatment of the penetrating external genital injury with minimal morbidity.