Male genital trauma: Diagnosis and management

Male Genital Trauma: Diagnosis and Management Tania P. Bartkiw, BScN, RN, Bernard Goldfarb, BASc, MD, FRCS(C), and John Trachtenberg, MD, FRCS(C), FACS

Trauma to the male external genitalia represents a serious injury that must be managed promptly and completely. To avoid long-term loss of function, disability, and psychologic effects, wounds should be carefully assessed, protected from further injury, and referred for surgical and social follow-up. (INT J TRAUMA NURS 1995;1:99-107)

he mobility and position of the male external genitalia offer some degree of protection from injury. 1 Most cases of injury are associated with a direct force applied to this region. Thoughout history, the genitalia have been a preferred target during military combat (e.g., rifle bullets, fragmentation weapons, land mines, grenades) and for punishment or torture. 2 Nonmilitary male genital trauma has b e e n associated with intentional actions (self-mutilation, religious practices, psychotic episodes) and accidental causes (agricultural, industrial, sporting, automobile mishaps). 24 S e e Table 1 for a list of the most frequent causes of injury noted in one study.

Tania Bartkiw is clinical research coordinator at The Prostate Centre, The Toronto Hospital, University of Toronto, Toronto, Ontario, Canada. Bernard Goldfarb is a clinical research fellow at the same institution. John Trachtenberg is a professor of surgery and director of The Prostate Centre, Division of Urology of The Toronto Hospital and The University of Toronto, Toronto, Ontario, Canada. For reprints write Tania Bartkiw, BScN, RN, The Toronto Hospital, 200 Elizabeth St., EN1-231 ,Toronto, Ontario, Canada M5G 2C4. Copyright 9 1995 by the Emergency NursesAssociation. 1075-4210/95 $5.00 + 0 6511168023

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The health care team caring for genital trauma is confronted with complex issues. The loss or serious injury to any part of the genitalia requires prompt, careful diagnosis, management, reconstruction, and protection from complications s u c h as sepsis or loss of an organ. The patient undergoes a psychologic and emotional crisis. He may envision disfigurement, malformation, or loss of the part. 5

Throughout history, the genitalia have been a preferred target during military combat... ANATOMIC CONSIDERATIONS The external genitalia of the male consists of the penis, which contains multiple structures including the urethra, and the scrotum with two testicles and their accessory organs (Figure 1). The penis has three different portions: the root, which lies in the superficial perineal p o u c h and provides fixation and stability; the body, made up of three erectile bodies (two corpora

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iers $crotalseptum Tunicaalbuginea Corpora~Buck's cavernosa ~ ~ f a s c i a Corpus,~~~~ spong~osum Urethra

fascia Skin

Figure 1. Top, Relationship of bladder, prostate, seminal vesicles, penis, urethra, and scrotal contents. Lowerleft, Transverse section through penis. Paired upper structures are corpora cavernosa. Single lower body surrounding urethra is corpus spongiosum. Lower right, Fascial planes of lower genitourinary tract. (Reprinted with permission. From Tanagho EA. Anatomy of the genitourinary tract. In: Tanagho EA, McAnnish JW, eds. Smith's general urology. 14th ed. Norwalk, Connecticut: Appleton & Lange, 1995.) cavernosa, which lie side by side on the dorsum of the penis and are enclosed in a dense white fibrous coat, the tunica albuginea, and the corpus spongiosum, which lies ventrally in the median plane, contains the urethra, and is enclosed in the tunica albuginea; all three cavernous bodies are loosely surrounded by a double layer of dense fibrous connective tissue known as the Buck's fascia (or deep fascia of the penis); and the glans, which is the distal expansion of the corpus spongiosum, The penis is highly vascular and obtains ar100

terial blood from a branch of the internal pudendal artery, which is derived from the internal iliac artery. Two branches extend the length of the penis, becoming the deep a n d d o r s a l arteries of the penis. There are also two major veins, the superficial dorsal vein and the deep dorsal vein of the penis. The penile motor and sensory nerve function is supplied by the dorsal nerve of the penis, a branch of the pudendal nerve. The penis is also innervated by portions of the autonomic nervous system (involuntary). Parasympathetic fi-

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Table 2. Types of genital injury

Table 1. Causes of genital injury Event Gunshot Motor vehicle crash Sexual intercourse Industrial crush Industrial metal fragment Blunt shearing Fall onto blunt or sharp object Fight Use of autoerotic aid Emasculation Human bite Sporting accident Other

Frequency (%)*

Injury Laceration or perforation Contusion or hematoma Skin avulsion Corpora fracture Rupture Strangulation or gangrene Amputation Pressure necrosis

35 1.8 13 5 3 3 3 2 <1 <1 <1 <1 14

58 15 13 6 3 2 2 1

*Among all causes. Reprinted with permission. From Bertini JE, Corriere JN Jr. Male genital trauma: evaluate promptly, treat with restraint. Contemp Urol 1993;4:7-10, 18.

*Among all causes. Reprinted with permission. From Bertini JE, Corriere JN Jr. Male genital trauma: evaluate promptly, treat with restraint. Contemp Uro11993;4:7-10, 18.

bers from the second through fourth sacral nerve roots supply the erectile tissue of the penis. Venous engorgement and obtaining an erection are considered to be parasympathetic responses. The s c r o t u m is a cutaneous p o u c h develo p e d from the skin of the abdomen. It consists of an outer layer of skin and an underlying subcutaneous layer, the tunica dartos (Figure 1). The scrotum receives its blood supply from branches of the femoral artery. Innervation is provided by the lumbar plexus, which supplies the lowermost portion of the abdominal wall. Located within the scrotum are two testicles (responsible for the production of spermatozoa and testosterone), the epididymis (elongated cordlike structure responsible for storage, transit, and maturation of sperm), and the vas deferens (the excretory duct of the testes). The testicles receive arterial blood from two testicular arteries, which arise from the abdominal aorta. The venous system essentially follows the arteries. Nerve supply to the testicles contain both parasympathetic (vagal) and sympathetic fibers (from the thoracic segment of the spinal cord).

M E C H A N I S M S A N D PATTERNS OF INJURY Injuries to the male external genitalia from numerous types of force have b e e n reported OCTOBER-DECEMBER 1995

Frequency (%)*

(Table 1). Table 2 lists the most frequent types of injuries identified in the same report. It is important to determine whether an injury is the result of blunt versus penetrating forces because the pattern of injury can vary significantly. Penetrating injuries have been reported with stab wounds, gunshot w o u n d s , 1,4-7 intentional trauma, 7-1~ or with the use of a v a c u u m cleaner for sexual stimulation. The severity of injury is influenced by the amount of force applied and the anatomy affected. Injuries sustained with penetrating forces include superficial cuts to the prepuce (foreskin) and glans penis, partial or complete amputation of the penis or scrotum, degloving, urethral interruption, and laceration of the erectile bodies. 1,6,m Blunt forces producing male genital trauma have been reported with automobile, industrial, farm, or athletic mishaps. Penile injuries have been reported with sexual stimulation activities (e.g., forcible manipulation with rings, nuts, washers, sprockets, rubber bands, thread, hair) and with violent sexual intercourse (the cause of penile fracture in 33% to 60% of reported casesnq3). Other reports describe injury to an erect penis while the male attempted to put on pants or turned over during sleep. 1,5,n,12,14,15

Penile Injuries A direct blunt force can produce a fracture, usually in the distal third of the penile shaft (Figure 2). ~ The force ruptures the tunica a l b u g i n e a c o v e r i n g o n e or b o t h c o r p o r a

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cations associated with blunt trauma to the external genitalia. 2,11,12 The bulbous urethra is forced against the ischial rami, causing urethral wall contusion and partial or complete disruption. 8,18

Scrotal Injuries

Figure 2. Hematoma overlying fracture of corpus cavernosum. Penis has distorted appearance. (Reprinted with permission. From Bertini JE, Corriere JN Jr. Male genital trauma: evaluate promptly, treat with restraint. Contemp Urol 1993;4:10.)

Blunt scrotal injuries are not common, but have b e e n r e p o r t e d w h e n the p e r i n e u m has b e e n forced against handlebars, motorcycle tank, or pa}allel bar. 8,18 It occurs nearly always in m e n <50 years old. TM Blunt injuries to the scrotum can be classified into one of five categories to aid in proper management: 9 Superficial contusion 9 Superficial contusion with skin laceration 9 Severe contusions with intrascrotal injury (including hematocele, laceration or rupture of the testes) 9 Testicular dislocation 9 Partial or c o m p l e t e avulsion of the scrotum. 8

Avulsion Injuries cavernosa. The tunica albuginea is especially vulnerable to injury in an erect penis because it b e c o m e s inelastic and distended (changes from a thickness of 2 m m to approximately 0.25 tO 0.50 ram). n'16 A penile fracture is suspected w h e n the patient describes hearing a "cracking" or p o p p i n g s o u n d a c c o m p a n i e d by imme-

The male with genital injury may have intense physical pain and psychologic distress. diate pain a n d rapid loss of erection. 2,1~ A h e m a t o m a develops along the shaft of the penis, causing swelling, discoloration, and deviation of the penis a w a y from the defect. ~,lr If confined, the h e m a t o m a spreads along the shaft w h e r e it can cause external urethral compression leading to obstructive urinary retention. ~ In some cases Buck's fascia is torn, allowing blood and urine to extravasate along the fascial planes into the scrotum and perineum. 2,11 Anterior urethral injuries are c o m m o n compli-

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The skin o v e r the male genitalia can be avulsed with a shearing action, forcing the genitalia against a stationary object. This has b e e n the r e p o r t e d m e c h a n i s m in falls and pedestrian-car crashes. It has also b e e n n o t e d w i t h stab w o u n d s , g u n s h o t w o u n d s , a n d burns. 2,19 The injury can be partial (Figures 3 and 4) or c o m p l e t e (Figure 5). The avulsed skin usually s e p a r a t e s along the relatively bloodless planes over Buck's fascia of the penis or the dartos fascia of the scrotum. The shaft of the penis and the testicles remain relatively intact and u n c o n t a m i n a t e d . 2

CARE OF' THE MALE PATIENT WITH EXTERNAL GENITAL TRAUMA The male with genital injury will experience intense physical pain along with psychologic distress. Loss or serious injury to the genitalia has b e e n described as similar to the loss of a breast for a w o m a n . 2 Not only must the patient's care provide m a n a g e m e n t for physical changes, the health care providers must be sensitive to the patient's fears or threat to his sense of "manhood." Psychologic support is a critical comp o n e n t of treatment.

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Figure 3. Gunshot wound causing injury to scrotum; damage to testicular contents can be seen.

Emergency Care Patients with external genital injury may have localized or multisystem trauma. The patient should be assessed for other, more serious, or life-threatening disorders before definitive care is started. H i s t o r y . The patient or reliable other source should be asked for details regarding the injury. The injury may be the result of a potentially embarrassing situation or to an act of interpersonal violence. The patient's right to privacy is important to ensure an accurate history and to protect him from further emotional stress. If the injury was due to an action that requires police investigation, the nurse will n e e d to carefully d o c u m e n t statements and clinical findings to help provide evidence. Additional evidence such as clothing, bullet fragments, or foreign matter will n e e d to be handled per protocol. The patient should be questioned about the cause of injury and the circumstances in w h i c h it occurred; the b o d y area involved (especially the point of impact); time since injury; symptoms since injury, including tenderness, ability to void, characteristics of urine; past and present health; history of previous genital injury, surgery, or other genitourinary conditions. Physical Examination. Isolated trauma t o the external genitalia is not generally life-threat-

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ening; however, a victim of blunt trauma m a y have other injuries that can p r o d u c e airway compromise or significant blood loss. A careful primary and s e c o n d a r y survey are d o n e to rule out conditions that m a y be m o r e serious. Examination of the external genitalia involves careful inspection and palpation. Patients usually have intense pain, especially if the scrotum has b e e n injured. Caution should be used to prevent a suboptimal examination because of the patient's d i s c o m f o r t . 2,18,19 Analgesics (if not contraindicated because of other injuries) and palliative measures m a y be u s e d to r e d u c e pain and e n c o u r a g e the patient's cooperation. The skin over the genitalia should be inspected for o p e n w o u n d s , loss of skin, patterns of ecchymosis, and constricting objects. The general appearance of the structures should be observed to detect deformity. Subcutaneous h e m a t o m a s can form because of the elasticity of the tissue, and e d e m a and bleeding can grossly distort the normal form of the organ (Figure 2). 2'17 The c i r c u m f e r e n c e of the penis should be assessed to determine the degree of edema. The scrotum m a y enlarge to several times its n o r m a l size a n d b e c o m e ecchymotic, making it m o r e difficult to evaluate the testicles inside. The area a r o u n d the genitalia should be e x a m i n e d for evidence of

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Figure 4. Avulsion to scrotum causing partial deg!oving of scrotal skin. injury to the p e r i n e u m , l o w e r a b d o m e n , or u p p e r thighs. Any drainage is assessed for a m o u n t and source. The meatus of the penis is inspected for blood, an indicator of urethral injury. The patient's ability to spontaneously void is evaluated. No attempt should be m a d e to pass a urinary catheter until the physician has b e e n able to determine w h e t h e r a urethral injury is present. The genitalia are inspected for signs of injury. If intrascrotal pathology is suspected, the scrotum m a y be further assessed with a bright light placed on one side, facing toward the scrotum. If the light can pass through the swollen tissue, a less s e v e r e c o n d i t i o n , s u c h as a h y d r o c e l e or spermatocele, m a y be present. Nontransillumination suggests a m o r e serious injury, such as a hematocele with or without gonadal fracture. 11 Because of the discomfort to the patient, palpation should be deferred to the physician.

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Figure 5. Avulsion of scrotal and penile skin, complete degloving of male genitalia. (Reprinted with permission. From Bertini JE, Corriere JN Jr. Male genital trauma: evaluate promptly, treat with restraint. Contemp Urol 1993;4:10.) During routine care, however, the nurse m a y note unusual tenderness or swelling. Signs of a penile fracture include a palpable defect over the fracture site in the tunica albuginea and sometimes a blood clot lying directly over the fracture site (discrete, firm, immobile, tender swelling over w h i c h the penile skin can be rolled, referred to as the "rolling sign"2~ A rectal examination is used to determine the presence of h e m a t o m a s and the position of the prostate gland. W h e n necessary, a tend e r s c r o t u m can b e p a l p a t e d by injecting lidocaine hydrochloride in the spermatic cord to block sensation. Initial Care. Initial care is directed toward

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F/gure 6

F/gure 7

Figures 6 and 7. Restoration of form and function after microsurgical reimplantation of penis. preserving genitourinary function and preventing complications. Because the genitalia have a rich blood supply, acute injury usually produces immediate edema and some degree of bleeding. Ice packs, splints, and scrotal supports can be used to relieve pain and promote lymphatic and venous drainage. TM Open wounds are evaluated for evidence of foreign matter and, if indicated, are irrigated with warm sterile normal saline solution. The possibility of preserving evidence if the patient has been involved in a crime should be kept in mind. Avulsed areas are covered with dressings soaked in sterile normal saline solution to protect the skin from contamination and excess drying. An amputated penis should be wrapped in a dressing moistened with sterile

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normal saline solution and placed in a plastic container (to protect the amputated part from contact with liquids), and then the container should be placed in an iced bath to increase ischemia time and the potential for anastomosis. Primar3~ anastomosis is considered if the distal segment is in good condition and the ischemia time is <18 hours Figures 6 and 7. 21 If anastomosis is not possible, the remaining penis can be reshaped by closing the open corpora and performing a meatoplasy. Providing safe and comfortable urinary drainage will need to be considered early, especially if the patient had been consuming fluids or has an intravenous infusion. The physician will determine whether urethral catheterization is safe or appropriate. Urine should be obtained

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Table 3. Diagnostic studies used to recognize genitourinary trauma

Study Urinalysis Urethrogram Ultrasonography Excretory urography

Computed tomography

Isotope flow scan Soft tissue films

Indication Gross or microscopic hematuria (considered significant if >40 red blood cells per high-power field) Blood at penile meatus, difficulty inserting urethral catheter, "high-riding" prostate gland, scrotal hematoma, or history of penetrating injury involving genitalia, fracture of penis, blunt trauma to lower abdomen Assist in diagnosis of testicular rupture with disruption of tunica albuginea lr Hematuria or significant injuries involving lower abdomen or external genitalia (penetrating wounds, falls, deceleration). If findings are normal, patient may be observed; if abnormal or questionable, computed tomography may be needed. Noninvasive method to evaluate patients with crush injuries, hematoma, lack of urinary tract function (can detect associated injury to genitourinary and other abdominal structures) May be used to diagnose testicular rupture associated with blunt scrotal trauma (limited by its lack of availability in emergency setting) To determine whether foreign metallic particles are present in soft tissue around genitalia or inside urethra or anus

9 Patients will have pain from edema, tissue for laboratory analysis and examined for gross damage, and other injuries. Palliative measures, or microscopic hematuria. If blood is present, such as ice packs and scrotal supports that keep radiographic studies are indicated to determine the scrotum elevated slightly, can be used along the source and extent of injury 18 (Table 3). with judicious use of analgesics. Initially, paThe potential for infection is high w h e n there tient-controlled analgesia with morphine sulis injury to the genital region. Broad-spectrum fate may be n e e d e d for adequate pain relief. antibiotics are administered intravenously in the After an analgesia has been provided, the paacute resuscitation. The patient's tetanus imtient should be instructed to contact the physimunization history should be evaluated, and if cian if he has onset of n e w or different pain, it is not k n o w n to be up-to-date, tetanus imeither in the hospital or after discharge. m u n e globulin and toxoid should be given. Di9 The potential complications associated with agnostic studies used to make a definitive digenital trauma include infection, poor surgical agnosis are discussed in Table 3. results, and altered genitourinary function. InIn a number of cases of genital trauma, emerfection may be in the tissue or urinary tract. gency surgical intervention will be indicated. The w o u n d s a n d inciResuscitation nurses can s i o n s s h o u l d be inanticipate the need for Strict aseptic techniques is s p e c t e d for r e d n e s s , expediting preparations edema, and drainage and contacting surgeons essential for dressing a r o u n d sutures. Drains and notifying perioperchanges and when caring for p l a c e d d u r i n g snrgery ative nurses. drainage systems. should be c h e c k e d for I n - P a t i e n t Managepatency and a m o u n t of m e n t . The patient with drainage. Strict aseptic genital trauma will need technique is essential for dressing changes and adequate pain relief, monitoring for signs and w h e n caring for drainage, systems. Daily care symptoms of complications, education regardof an indwelling catheter s h o u l d be done acing self-care activities, and psychosocial supcording to institutional protocol. The patient's port for himself and significant others.

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fluid intake and output should be measured. The urine should be evaluated for changes in color or odor that are suspicious of a urinary tract infection. If a urinary catheter is required for >7 days, a suprapubic catheter should be considered to avoid urethritis, stricture, and epididymitis. 17 Poor surgical results can be due to seepage of urine, failure to control edema, and localized tissue infection. Pressure dressings are used w h e n e v e r skin grafts are p l a c e d b e c a u s e h e m a t o m a s can easily form in the tissue, causing the loss of the graft. 1: D e b r i d e m e n t of exposed tissue can be facilitated with the use of gentle wet-to-dry dressings. Patients w h o require a long-term indwelling urinary catheter should be instructed on catheter care and signs and symptoms of urinary tract infection. It m a y be necessary to refer the patient to a rehabilitation Service for long-term genitourinary management.

SUMMARY Male genital t r a u m a is g e n e r a l l y not life threatening yet has the potential to p r o d u c e long-term genitourinary dysfunction and serious psychosocial consequences. Trauma care providers n e e d to be aware of h o w to diagnose injuries, protect the patient from further injury or complications, and assist the patient to achieve optimal function.

ACKNOWLEDGMENTS

REFERENCES 1. Peters PC, SagalowskyAL. Genitourinary trauma. In: Walsh PC, Retick AB, Stamey TA, et al., eds. Campbell's urology. 6th ed. Philadelphia: WB Saunders, 1992:2571-94. 2. McAnnich JW. GU trauma inside & out: male genitals. Emerg Med 1985;17:19-33. 3. Rayner J. Self harm. NursTimes 1994;90:31. 4.Aboseif S, Gomez R, McAninch JW. Genital self-mutilation. J Uro11993;150:1143-6. 5. McAninch JW, Kahn RI, Jeffrey RB, et al. Major !raumatic and septic genital injuries. J Trauma 1984;24:291-8. 6. Jordan GH, Gilbert DA. Management of amputation injuries of the male genitalia. U rol Clin North Am 1989;16:359-67. 7. Gomez RG, Castanheira ACC, McAninch JW. Gunshot wounds to the male external genitalia. J Uro11993;150:1147-9. 8. Pierce JM. Disruptions of the anterior urethra. Urol Clin North Am 1989; 16:329-34. 9.Tan L, Chiang C, Huang C, Chou Y, Wang C.Traumatic rupture of the corpus cavernosum. Br J Uro11991 ;68:626-8. 10. CassAS, Gleich P, Smith C. Male genital injuries from external trauma. Br J Urol 1985;57:467-70. 11. Orvis BR, McAninch JW. Penile rupture. Urol Clin NorthAm 1989; 16:369-75. 12. Klein FA, Smith V, Miller N. Penile fracture: diagnosis and management. J Trauma 1985;25:1090-2. 13. Nicolaisen GS, Melamud A, Williams RC, McAninch JW. Rupture of the corpus cavernosum: surgical management. J Urol 1983;130:917-9. 14. EI-SherifAE, Dauleh M,AIIowneh N, Vijayan P. Management of fracture of the penis in Qatar. Br J Urol 1991 ;68:622-5. 15. BhatAL, KumarA, Mathur SC, Gangwal KC. Penile strangulation. BrJ Uro11991;68:618-21. 16. Thompson RF. Rupture of the penis. J Uro11954;71:226-8. 17. Bertini JE, Corriere JN. Male genital trauma: evaluate promptly, treat with restraint. Contemp Uro11993;4:7-18. 18. Brothers LR. Blunt scrotal trauma: a review. Hosp Med 1985;21:61-80. 19. McAninch JW. Management of genital skin loss. Urol Clin NorthAm 1989;16:387-97. 20. Naraynsingh V, Raju GC. Fracture of the penis. Br J Surg 1985;72:305-6. 21. Engelman ER, Polito G, Perley J, Bruffy J, Martin DC. Traumatic amputation of the penis. J Uro11974;112:774-8.

We thank Dr. J. Honey, staff urologist at St. Michael's Hospital, Toronto, Ontario, Canada, for the use of clinical pictures of genital trauma.

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