Penile injury

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Penile injury

A penile injury is a medical emergency that afflicts the penis. Common injuries include fracture, avulsion injury, strangulation, entrapment, and amputation. [1]

Contents

Epidemiology

Penetrating and blunt traumas combined make up approximately 90% of all civilian penile injuries (45% each), with burns and other accidents making up the remaining 10%. [1]

Types

Fracture

A still from a 3D medical animation showing tunica albuginea. Tunica Albuginea.jpg
A still from a 3D medical animation showing tunica albuginea.

Penile fractures are the result of rupture of the tunica albuginea. They are fairly rare and can co-occur with partial or complete urethral rupture, though this is rare. [2] [3] [4] Urethral damage occurs in 10–38% of cases. [1] Fractures are treated with emergency surgery, and can be diagnosed with ultrasound, especially in pediatric cases. [2] [3] [4] Penile fractures are caused by trauma to the erect penis, typically by suddenly bending it laterally during penetrative intercourse with the receptive partner on top of the penetrating partner, or during masturbation. Characterized by a loud popping sound at the time of the injury, the result of the tunica albuginea rupturing. Other symptoms include severe pain, loss of erection, and swelling. [5] Symptoms of urethral injury include hematuria, blood at the meatus, and dysuria. [1] If left untreated, complications result in 28–53% of cases; these include permanent curvature of the penis, fistula, urethral diverticulum, priapism, and erectile dysfunction. [5]

Degloving and avulsion

3D medical animation still showing skin grafting in case of penile injury. Degloving and avulsion (Penile injury).jpg
3D medical animation still showing skin grafting in case of penile injury.

Degloving and avulsion injuries involve the removal of the penis skin, which is a serious medical emergency. Treatment of these injuries involves either closure of the torn skin, or a skin graft to replace the skin lost in the injury. Skin grafts are constructed to attempt to preserve erectile function and sensation. [1]

Soft-tissue injuries

Strangulation

(A) A case of penile strangulation by a cable tie at the root of the penis. Both veins and arteries were compressed. (B) Penile ulcer at the root of the penis one week after the removal of the encircled object. The strangulation caused the permanent loss of sensation of the penis. Penile incarceration and ulcer.png
(A) A case of penile strangulation by a cable tie at the root of the penis. Both veins and arteries were compressed. (B) Penile ulcer at the root of the penis one week after the removal of the encircled object. The strangulation caused the permanent loss of sensation of the penis.

Strangulation injuries to the penis, also called incarceration injuries, are caused by hair, rubber bands, or other objects. [6] [7] Hair strangulation may be hard to diagnose due to the anatomy of the penis; the hair causing the strangulation may be hidden under the coronal sulcus if it is swollen. [8] In adults, strangulation injuries that require medical treatment can be caused by a variety of objects typically used for the purpose of sexual gratification, extending the time of an erection, or enuresis, including metal rings, which must be removed by specialized cutting instruments. The object can also be removed by decompressing the penis. [6] [7] Because the vasculature of the penis is compressed, a variety of complications can result from strangulation injuries, depending on whether the veins, arteries, or both are compressed, including mild, reversible vascular obstruction; ischemic necrosis; gangrene and kidney damage; lymphedema; ulceration; urethrocutaneous fistula, loss of sensation; urethral injury; sepsis; and autoamputation. [7]

Penile strangulation injuries that require medical attention are rare: since their first description in 1755, there have been approximately 60–120 reported cases. Though usually acute, cases of chronic strangulation and acute cases lasting up to one month have been reported. [7] [9]

Various objects have been involved in cases of strangulation:

Entrapment

The most common soft-tissue injury is an entrapment injury involving the skin of the penis caught in a zipper; these injuries are particularly common in young children who are uncircumcised and are always superficial. They are treated by removing the zipper with local anesthesia using a bone cutter, lubrication, or hacksaw, dismantling the zipper, or removing the affected tissue, and can be prevented in most situations by circumcision, since the foreskin is the most commonly affected tissue. [5] [6] If not treated promptly, the affected tissue can swell and become infected. [6] In some cases, emergency circumcision is necessary. [8]

Other

Other soft-tissue injuries to the penis can be caused by burns, animal bites, and human bites. [5] Animal bites are common in children, and dogs are the most common animals involved. Though typically not severe, animal bites can cause amputation or infection. [1] [6] Treatment for animal bites and human bites involves antibiotic treatment and closure of the wounds by secondary intention because they are contaminated. [1]

Penis burns can be very severe and often require specialized care in a burn unit to prevent contractures, severe scarring, or other complications including lymphedema, hypospadias, or necrosis. [8] This treatment can involve debridement, skin grafts, antibiotics, and the use of a suprapubic catheter. Because of its thin skin, the penis is susceptible to full-thickness, third-degree burns. Burns to the penis typically co-occur with other severe burns. Most thermal penis burns are first or second degree burns caused by flame; some are caused by grease or boiling water. Electrical burns are typically deeper than thermal burns and require more extensive tissue removal. [1]

Amputation

Amputation of the penis can be either partial or complete. Often self-inflicted by people with psychiatric disorders, it may be occur with other trauma, such as in an assault or a mechanical accident. These injuries are treated by re-implantation if possible, with or without anastomosis of the vasculature to restore erectile function; skin necrosis and loss of sensation are common complications after treatment. Microsurgery on the vasculature decreases the risk of necrosis significantly. [5] Klingsor syndrome is a psychiatric disorder that causes self-harm, which can involve the penis. Paranoid schizophrenia, eating disorders, and psychotic breaks can also be associated with penile injury. [6] In some cases, transgender people who are not able to access genital surgery may self-amputate their penis. [1] Favorable prognostic factors for replantation of amputated penises include short ischemic time and a clean incision (as opposed to a crush injury or ragged incision). [16]

Replantation of an amputated penis can be done up to 24 hours after the injury, though fewer than 16 hours of cold ischemia or 6 hours of warm ischemia leads to the best outcomes. If replantation is not possible or desired, a penile stump can be closed and phalloplasty could be performed later. [1]

Penetration

Penetrating injuries can be caused by accidents during sexual activities (typically, by foreign objects inserted into the urethra), by weapons (i.e. bullets) during wartime, or by stabbing. These injuries can have varying severity and be superficial, affect the corpora cavernosa, other soft tissue, and/or urethra. [4] [5] [6] In 50% of cases, the urethra is injured. [1] Some foreign objects may be removed like any other penetrating object in soft tissue; using forceps and gentle traction. However, if the foreign object was inserted into the urethra or has damaged the urethra transversely, urethography is used to avoid further injury to the urinary tract while removing the object. [8] Penetrating injuries make up approximately 45% of civilian penile injuries. [1]

Classification

Organ Injury Scale [5]
GradeDescription of injury
ISuperficial injury to the skin (laceration or contusion)
IIInjury to the cavernosa/Buck's fascia, no tissue loss
IIIAvulsion or laceration through the urethral meatus, glans, or cavernosa, or urethral damage less than 2 cm in size
IVPartial penectomy (amputation) or a cavernosal/urethral injury more than 2 cm in size
VComplete penectomy (amputation or replacement)

Causes

The causes of penile injury are mostly the same as other causes of trauma; however, penile injury is more likely to occur during sexual intercourse and masturbation than other traumas. Nocturnal erections and sleeping positions can be another cause of penile injury. Industrial and automobile accidents can also cause penile injury. Self-injury may also affect the penis. [5] [6]

Abnormally curved, bruised penis. Eggplant sign. Penile fracture.jpg
Abnormally curved, bruised penis. Eggplant sign.
Penile Self-Harm.png
Penile injury by self-mutilation involves injury to the glans penis by a needle puncture (left) or to the root of the penis by hanging a heavy-duty combination vise that clamped the penis (right). The type of injury from these self-harming behaviors varies from skin laceration to total amputation of the penis.

Diagnosis

Most penile trauma can be diagnosed by history and physical examination, hearing 'snapping' or 'popping' sound, immediate penile pain, swollen, bruised (often known as eggplant deformity), some may notice blood over the urethral meatus. [17] But in some cases, ultrasonography can indicate the extent of the injury and help a clinician decide if the injured person needs surgical treatment. [18] It is important to rule out urethral injury in those with penile injury, as it is a urological emergency that may result in significant morbidity if left untreated. [19]

Treatment

The type of injury dictates the treatment; however, surgery is a common treatment. Most traumatic penile injury warrant an emergency repairing surgery to prevent complications and maintain functionality of the penis sexually and urologically.

Catheterization is usually a part of treatment for penis injuries; when the urethra is intact, urethral catheterization may be used, but if it has been injured, suprapubic catheterization is used. Some injuries, including animal bites, are also treated with antibiotics, irrigation, and rabies prophylaxis. [6]

Complications

Common complications from penile injury are erectile dysfunction, abnormal penile curvature, penile abscess, formation of fibrotic plaques, painful erection, urethral stricture, uretherocutaneous or corporourethral fistula. [20]

Related Research Articles

<span class="mw-page-title-main">Urethra</span> Tube that connects the urinary bladder to the external urethral orifice

The urethra is the tube that connects the mammalian urinary bladder to the urinary meatus. In placental mammals, the urethra transports urine through the penis or vulva during urination and semen through the penis during ejaculation.

<span class="mw-page-title-main">Glans penis</span> End of the penis

In male human anatomy, the glans penis or penile glans, commonly referred to as the glans, is the bulbous structure at the distal end of the human penis that is the human male's most sensitive erogenous zone and primary anatomical source of sexual pleasure. The glans penis is present in the male reproductive organs of humans and most other mammals where it may appear smooth, spiny, elongated or divided. It is externally lined with mucosal tissue, which creates a smooth texture and glossy appearance. In humans, the glans is located over the distal ends of the corpora cavernosa and is a continuation of the corpus spongiosum of the penis. At the summit appears the urinary meatus and at the base forms the corona glandis. An elastic band of tissue, known as the frenulum, runs on its ventral surface. In men who are not circumcised, it is completely or partially covered by a fold of skin called the foreskin. In adults, the foreskin can generally be retracted over and past the glans manually or sometimes automatically during an erection.

<span class="mw-page-title-main">Compartment syndrome</span> Condition in which increased pressure results in insufficient blood supply

Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the leg or arm are most commonly involved.

<span class="mw-page-title-main">Urethral stricture</span> Narrowing of the urethra

A urethral stricture is a narrowing of the urethra, the tube connected to the bladder that allows urination. The narrowing reduces the flow of urine and makes it more difficult or even painful to empty the bladder.

Penile cancer, or penile carcinoma, is a cancer that develops in the skin or tissues of the penis. Symptoms may include abnormal growth, an ulcer or sore on the skin of the penis, and bleeding or foul smelling discharge.

<span class="mw-page-title-main">Hypospadias</span> Penis malformation in which the urethral opening is misplaced

Hypospadias is a common malformation in fetal development of the penis in which the urethra does not open from its usual location on the head of the penis. It is the second-most common birth defect of the male reproductive system, affecting about one of every 250 males at birth, although when including milder cases, is found in up to 4% of newborn males. Roughly 90% of cases are the less serious distal hypospadias, in which the urethral opening is on or near the head of the penis (glans). The remainder have proximal hypospadias, in which the meatus is all the way back on the shaft of the penis, near or within the scrotum. Shiny tissue or anything that typically forms the urethra instead extends from the meatus to the tip of the glans; this tissue is called the urethral plate.

<span class="mw-page-title-main">Chordee</span> Downward or upward curving of the penis head from the shaft

Chordee is a condition in which the head of the penis curves downward or upward, at the junction of the head and shaft of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. In many cases but not all, chordee is associated with hypospadias. This is not the same condition as Peyronie's disease, which involves curvature of the shaft of the penis most commonly due to injury during adult life.

<span class="mw-page-title-main">Penile fracture</span> Rupture of the fibrous coverings that envelop the peniss erectile tissue

Penile fracture is rupture of one or both of the tunica albuginea, the fibrous coverings that envelop the penis's corpora cavernosa. It is caused by rapid blunt force to an erect penis, usually during vaginal intercourse, or aggressive masturbation. It sometimes also involves partial or complete rupture of the urethra or injury to the dorsal nerves, veins and arteries.

<span class="mw-page-title-main">Injury in humans</span> Physiological wound caused by an external source

An injury is any physiological damage to living tissue caused by immediate physical stress. Injuries to humans can occur intentionally or unintentionally and may be caused by blunt trauma, penetrating trauma, burning, toxic exposure, asphyxiation, or overexertion. Injuries can occur in any part of the body, and different symptoms are associated with different injuries.

<span class="mw-page-title-main">Replantation</span> Surgical reattachment of a body part

Replantation or reattachment is defined as the surgical reattachment of a body part that has been completely cut from the body. Examples include reattachment of a partially or fully amputated finger, or reattachment of a kidney that had had an avulsion-type injury.

<span class="mw-page-title-main">Human penis</span> Human male external reproductive organ

In human anatomy, the penis is an external male sex organ that serves as a passage for urine during urination and semen during ejaculation. The main parts are the root, body, the epithelium of the penis including the shaft skin, and the foreskin covering the glans. The body of the penis is made up of three columns of tissue: two corpora cavernosa on the dorsal side and corpus spongiosum between them on the ventral side. The urethra passes through the prostate gland, where it is joined by the ejaculatory ducts, and then through the penis. The urethra goes across the corpus spongiosum and ends at the tip of the glans as the opening, the urinary meatus.

Urethroplasty is the surgical repair of an injury or defect within the walls of the urethra. Trauma, iatrogenic injury and infections are the most common causes of urethral injury/defect requiring repair. Urethroplasty is regarded as the gold standard treatment for urethral strictures and offers better outcomes in terms of recurrence rates than dilatations and urethrotomies. It is probably the only useful modality of treatment for long and complex strictures though recurrence rates are higher for this difficult treatment group.

<span class="mw-page-title-main">Retrograde urethrogram</span> Medical imaging of the urethra

A retrograde urethrography is a routine radiologic procedure used to image the integrity of the urethra. Hence a retrograde urethrogram is essential for diagnosis of urethral injury, or urethral stricture.

<span class="mw-page-title-main">Urethrostomy</span>

Urethrostomy is a surgical procedure that creates a permanent opening in the urethra, commonly to remove obstructions to urine flow. The procedure is most often performed in male cats, where the opening is made in the perineum.

<span class="mw-page-title-main">Diphallia</span> Genital medical condition

Diphallia, penile duplication (PD), diphallic terata, or diphallasparatus is an extremely rare developmental abnormality in which a male is born with two penises. The first reported case was by Johannes Jacob Wecker in 1609. Its occurrence is 1 in 5.5 million boys in the United States.

<span class="mw-page-title-main">Buried penis</span> Male congenital condition

Buried penis, also called hidden penis or retractile penis, is a congenital or acquired condition in which the penis is partially or completely hidden below the surface of the skin. A buried penis can lead to urinary difficulties, poor hygiene, infection, and inhibition of normal sexual function.

Bulbar urethral necrosis is a problem that can occur after a pelvic fracture associated urethral distraction defect (PFUDD).

Genital trauma is trauma to the genitalia.

Rupture of the urethra is an uncommon result of penile injury, incorrect catheter insertion, straddle injury, or pelvic girdle fracture. The urethra, the muscular tube that allows for urination, may be damaged by trauma. When urethral rupture occurs, urine may extravasate (escape) into the surrounding tissues. The membranous urethra is most likely to be injured in pelvic fractures, allowing urine and blood to enter the deep perineal space and subperitoneal spaces via the genital hiatus. The spongy urethra is most likely to be injured with a catheter or in a straddle injury, allowing urine and blood to escape into the scrotum, the penis, and the superficial peritoneal space. Urethral rupture may be diagnosed with a cystourethrogram. Due to the tight adherence of the fascia lata, urine from a urethral rupture cannot spread into the thighs.

References

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  9. ↑ Li, Chao; Xu, Yue-Min; Chen, Rong; Deng, Chen-Liang (2013-07-01). "An effective treatment for penile strangulation". Molecular Medicine Reports. 8 (1): 201–204. doi: 10.3892/mmr.2013.1456 . ISSN   1791-3004. PMID   23652299.
  10. ↑ Osborne, Hannah (2016-11-16). "Doctors report rare case of penile strangulation after man puts wedding ring on penis". International Business Times UK. Archived from the original on 2017-02-02. Retrieved 2017-01-28.
  11. ↑ "Man with penis stuck in ring suffered three days of pain". Nation. TheStar.com.my. Archived from the original on 2017-02-02. Retrieved 2017-01-28.
  12. ↑ Haines, Lester (10 February 2016). "Firemen free chap's todger from four-ring chokehold". The Register . Archived from the original on 2017-02-02. Retrieved 2017-01-28.
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  16. ↑ Riyach, Omar; El Majdoub, Aziz; Tazi, Mohammed Fadl; El Ammari, Jalal Eddine; El Fassi, Mohammed Jamal; Khallouk, Abdelhak; Farih, Moulay Hassan (2014-01-01). "Successful replantation of an amputated penis: a case report and review of the literature". Journal of Medical Case Reports. 8: 125. doi: 10.1186/1752-1947-8-125 . ISSN   1752-1947. PMC   4000145 . PMID   24716477.
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  18. ↑ Nicola, Refky; Carson, Nancy; Dogra, Vikram S. (2014-06-01). "Imaging of traumatic injuries to the scrotum and penis". AJR. American Journal of Roentgenology. 202 (6): W512–520. doi:10.2214/AJR.13.11676. ISSN   1546-3141. PMID   24848844.
  19. ↑ Nelson, Quentin; Leslie, Stephen W.; Baker, Jeff (2020), "Urethral Injury", StatPearls, StatPearls Publishing, PMID   32119462, archived from the original on 2024-05-03, retrieved 2020-05-05
  20. ↑ "Penile Fracture and Trauma: Practice Essentials, Background, Relevant Anatomy" . 2019-11-09. Archived from the original on 2024-02-11. Retrieved 2024-05-03.
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