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penile injuries - Amputation
Blood loss can be severe; resuscitate the
shocked patient and cross-match blood. Place the penis, if found, in a wet swab
inside a plastic bag, which is then placed inside another bag containing ice (
bag in a bag ). It can survive for 24 hours.
Knife and gunshot
wounds
Associated injuries are common (e.g. scrotum, major vessels of the
lower limb). Most injuries, other than minor ones, should undergo primary
repair. Remove debris from wound (e.g. particles of clothing) and debride
necrotic tissue and repair as for penile fractures.
Penile
fracture
Rupture of the tunica albuginea of the erect penis (i.e. rupture of
one or both corpora cavernosa rupture of corpus spongiosum with rupture of the
urethra). The tunica albuginea is 2mm thick in the flaccid penis. It thins to
0.25mm during erection, and is therefore vulnerable to rupture if the penis is
forcibly bent (e.g. during vigorous sexual intercourse). The patient usually
reports a sudden snapping or popping sound and/or
sensation, with sudden penile pain and detumescence of the erection.
The
penis is swollen and brusied, sometimes resembling an aubergine. If Buck's
fascia has ruptured, bruising extends onto the lower abdominal wall and into the
perineum and scrotum. A tender, palpable defect may be felt over the site of the
tear in the tunica albuginea. If the urethra is damaged, there may be blood at
the meatus or haematuria (dipstick/ microscopic or macroscopic) and pain on
voiding or urinary retention. Arrange a retrograde urethrogram in such
cases.
Treatment
There has been a trend away from conservative
management towards surgical repair (lower complication rate e.g. reduced penile
deformity, less chance of penile scar tissue and prolonged penile pain).
-
Conservative: application of cold compresses to the penis; analgesics and
anti-inflammatory drugs; abstinence from sexual activity for 6 - 8 weeks to
allow healing.
- Surgery: expose the fracture site in the tunica albuginea,
evacuate the haematoma, and close the defect in the tunica.
Surgical
reimplantation of amputated penis
Repair the urethra first, over a catheter,
to provide a stable base for subsequent neurovascular repair. Close the tunica
albuginea of the corpora (4/0 absorbable suture). Cavernosal artery repair is
technically very difficult and does not improve penile viability. Anastomose the
dorsal artery of the penis (11/0 nylon), then the dorsal vein (9/0 nylon) to
provide venous drainage, and, finally, the dorsal penile nerve (10/0
nylon).
Surgical repair of penile fracture
Expose the fracture site by
degloving the penis via a circumcising incision around the subcoronal sulcus or
by an incision directly over the defect if palpable. A degloving incision allows
better exposure of the urethra for associated urethral injuries. Alternatively,
use a midline incision extending distally from the midline raphe of the scrotum,
along the shaft of the penis. This latter incision, along with a degloving
incision, allows excellent exposure of both corpora cavernosa so that an
unexpected bilateral injury can be repaired easily, as can a urethral injury
should this have occurred.
Close the defect in the tunica with absorbable
sutures or by non-absorbable sutures (bury the knots so that the patient is
unable to palpate them). Non-absorbable sutures may possibly be associated with
prolonged post-operative pain. Leave a urethral catheter (voiding can be
difficult immediately post-operatively). Repair a urethral rupture, if present,
with a spatulated single or two-layer urethral anastomosis, and splint repair
with a urethral catheter for 3 weeks.
Penile bites
Clean the wound.
Give broad spectrum antibiotics (e.g. cephalosporin and
amoxycillin).
Zipper injuries
If the penis is still caught in the
zipper, use lubricant jelly and gently attempt to open it. The zipper may have
to be cut with orthopaedic cutters or prised apart with a pair of surgical clips
on either side of the zipper.
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