Editing Lower Urinary Tract Trauma (section)

== External Genitalia Injury ==

=== Background ===
* Traumatic injuries to the genitalia are uncommon, in part because of the mobility of the penis and scrotum
* Ancillary psychological, interpersonal, and/or reproductive counseling and therapy should be considered for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated.

=== Penile trauma ===

==== Penile fracture ====

===== Definition =====

* '''<span style="color:#ff0000">Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum</span>'''

===== Pathogenesis =====
* '''<span style="color:#ff0000">Most commonly occurs during vigorous sexual intercourse</span>''', when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.
** Campbell's 11th edition: In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence.
** Review article
*** 21 studies from Middle East and Central Asia published 2003-2014
*** Results:
**** Etiologies of penile fracture
***** Vigorous sexual intercourse (41%)
***** Manual bending of erect penis (29%)
***** Vigorous masturbation (10%)
***** Rolling over in bed (14%)
***** Blunt trauma (6%)
*** [https://pubmed.ncbi.nlm.nih.gov/26229311/ Majzoub, Ahmad A., and Talib A.] Raidh Onder Canguven. "Alteration in the etiology of penile fracture in the Middle East and Central Asia regions in the last decade; a literature review." ''Urology annals'' 7.3 (2015): 284.
*'''<span style="color:#ff0000">When the erect penis bends abnormally, a laceration can occur and it is usually</span>'''
*# '''<span style="color:#ff0000">On proximal shaft, distal to the suspensory ligament</span>'''
*# '''<span style="color:#ff0000">Transverse</span>'''
*# '''<span style="color:#ff0000">Unilateral</span>'''
*#* '''Tears in both corporeal bodies occur in 10% of injuries'''.
*# '''<span style="color:#ff0000">Ventral or lateral</span>'''
*#* '''<span style="color:#ff0000">Tunica albuginea is the thinnest between the 5 o’clock and 7 o’clock positions</span>'''
*#* Recall that Peyronie's Disease usually occurs dorsally
*#* Laceration location in manual bending will depend on direction of bend
*# 1-2 cm in length

===== Diagnosis and Evaluation =====

* '''<span style="color:#ff0000">Diagnosis of penile fracture can me made reliably by history and physical exam</span>'''

====== History and Physical Exam ======
* '''<span style="color:#ff0000">History</span>'''
** '''<span style="color:#ff0000">Indicators of penile fracture</span>'''
**# '''<span style="color:#ff0000">Penile ecchymosis or swelling</span>'''
**# '''<span style="color:#ff0000">Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.</span>'''
* '''<span style="color:#ff0000">Physical exam</span>'''
** '''<span style="color:#ff0000">Penis</span>'''
***'''<span style="color:#ff0000">Swollen</span>'''
***'''<span style="color:#ff0000">Ecchymotic</span>'''
****'''<span style="color:#ff0000">If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”</span>'''
**** '''<span style="color:#ff0000">If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).</span>'''
***'''<span style="color:#ff0000">Fracture line in the tunica albuginea may be palpable</span>'''
***'''<span style="color:#ff0000">Deviates to the side opposite the tunical tear</span> because of hematoma and mass effect'''

====== Imaging ======
*'''<span style="color:#ff0000">Indication (1)</span>'''
**'''<span style="color:#ff0000">History and physical examination are equivocal for penile fracture</span>'''
***'''<span style="color:#ff0000">Usually unnecessary as diagnosis can often be made based on history and physical exam</span>'''
*'''<span style="color:#ff0000">Options (2):</span>'''
*#'''<span style="color:#ff0000">Ultrasound (preferred)</span>'''
*#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''
*#* Most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision
*# '''<span style="color:#ff0000">Penile-perineal MRI</span>'''
*#* '''<span style="color:#ff0000">Most accurate test</span>'''
*#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.
** '''<span style="color:#ff0000">Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.</span>''' [SASP 2016]
* '''<span style="color:#ff0000">If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed</span>'''

====== Other ======
* '''<span style="color:#ff0000">Urethral evaluation (urethroscopy or retrograde urethrogram)</span>'''
** '''<span style="color:#ff0000">Urethral injury occurs in 10-22% of cases of penile fracture</span>'''
*** '''<span style="color:#ff0000">Bilateral corporeal injuries are more commonly associated with urethral injury</span>'''
**'''<span style="color:#ff0000">Indications</span>''' 
***'''<span style="color:#ff0000">Penile fracture or penetrating trauma with</span>'''
***#'''<span style="color:#ff0000">Blood at the urethral meatus</span>'''
***#'''<span style="color:#ff0000">Gross hematuria</span>'''
***#'''<span style="color:#ff0000">Inability to void</span>'''

===== Management =====
* '''<span style="color:#ff0000">Suspected penile fractures should be promptly explored and surgically repaired</span>'''
* '''<span style="color:#ff0000">Surgical reconstruction results in (7):</span>'''
*# '''<span style="color:#ff0000">Faster recovery</span>'''
*# '''<span style="color:#ff0000">Decreased morbidity</span>'''
*# '''<span style="color:#ff0000">Lower complication rates</span>'''
*# '''<span style="color:#ff0000">Lower risk of erectile dysfunction</span>'''
*# '''<span style="color:#ff0000">Lower incidence of long-term penile curvature</span>'''
*# '''<span style="color:#ff0000">Reduced risk of cavernosal diverticulum (may be pulsatile)</span>'''
*# '''<span style="color:#ff0000">Reduced risk of chronic penile pain</span>'''
* '''<span style="color:#ff0000">Surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair</span>'''

====== Technique ======
* '''<span style="color:#ff0000">Approach (2)'''
*#'''<span style="color:#ff0000">Ventral vertical penoscrotal incision'''
*#*Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
*# '''<span style="color:#ff0000">Distal circumcising incision''' 
*#*May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
*See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]
*Equipment
**Sutures
***2-0 or 3-0 PDS
***3-0 Vicryl
***4-0 Chromic
**Penrose to use as tourniquet
**Injectable saline with methylene blue
**25 Gauge butterfly needle
**Local anesthetic
*Step by step with distal circumcising incision
**Place holding stitch on dorsal aspect of glans, close to coronal sulcus.
**Hold penis on stretch
**Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus
***Skin will need to be very dry for ink to be applied properly
**Use a scalpel to cut down on incision. 
***Cut down to level of Buck's fascia
***Be careful near urethra
** Place holding stich at 12 o'clock on cut penile skin edge.
**Deglove penis
***Use Metzenbaum scissors to dissect skin off of tunica albuginea. Use closed scissors and then spread. Then cut attachments.
****Be careful near urethra
***Use gauze for blunt dissection
***Continue to deglove penis until area of fracture is exposed
** Evacuate hematoma
***Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
**'''Identify defect'''
***Proximal corpora is the most common site of rupture
****'''<span style="color:#ff0000">Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration♦'''
***Laceration usually transverse in direction
***Obtain adequate exposure of defect
**Repair defect
***Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.
** '''If urethral injury'''
***'''Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter'''
***'''Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter'''
** Test repair
***Apply tourniquet proximal to repaired defect
***Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect
***If leak noted, place additional interrupted sutures.
**Repair Buck's fascia overlying defect
**Obtain hemostasis
**Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic
***Start by placing stitches in 4 corners and leave tails long to use as handle
****Place box/U stitch in area of frenulum
***Position penis using stay stitches to align skin edges and perform interrupted stitches
**[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]
***Dorsal penile nerve block
***Ring block
**Apply dressing
*Post-operative management
**Therapy with broad-spectrum antibiotics
**'''1 month of sexual abstinence'''

==== Gunshot wounds ====
* '''Treatment principles include immediate exploration''', copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure.
* '''Urethral injuries resulting from'''
** '''Low-velocity penetrating trauma should be closed primarily by use of standard urethroplasty principles.'''
** '''High-velocity penetrating trauma or close-range shotgun blasts associated with extensive tissue damage from may require staged repair and suprapubic urinary diversion'''

==== Bites ====
* '''<span style="color:#ff0000">Dog bites</span>'''
** '''<span style="color:#ff0000">Initial management includes copious irrigation, debridement, and immediate primary closure (with a drain) along with prophylactic use of a broad-spectrum antibiotic</span>''' '''(amoxicillin/clavulin, cefoxitin, cefotan, or clindamycin with ciprofloxacin).'''
*** Tetanus and rabies immunizations should be used as appropriate.
* '''<span style="color:#ff0000">Human bites</span>'''
** '''<span style="color:#ff0000">Human bites produce contaminated wounds that often should not be closed primarily, unlike animal bites.</span>'''

==== Amputation ====
* A rare injury that is usually self-inflicted and associated with extreme mental illness.
* '''Every attempt should be made to locate, clean, and preserve the severed portion in a <span style="color:#ff0000">“double bag” technique.</span>'''
** '''The distal penis should be rinsed in saline solution, wrapped in saline-soaked gauze, and sealed in a sterile plastic bag, and the bag should be placed into an outer bag with ice or slush.'''
* '''<span style="color:#ff0000">Patients should be transferred to a facility with microsurgical capabilities</span>'''
** '''Reconstruction of the urethra and reanastomosis of the corporeal bodies with microsurgical repair of dorsal penile vessels and nerves''' achieves remarkably good results. Reanastomosis of the corporeal arteries is not recommended.
*** '''Macrovascular reconstruction alone can preserve erectile function, glans vascularity, and urethral continuity.'''
*** '''Microvascular re anastomosis is required for preservation of skin''' (dorsal artery and vein re-anastomosis) and sensation (dorsal nerve re-anastomosis).
*** '''Macrovascular or microscopic reconstruction of the penile shaft provides equivalent outcomes for erectile function.'''
** If such a facility is unavailable, macroscopic anastomosis of the urethra and corporeal bodies can be performed with good erectile results, albeit with potential compromise of sensation and skin loss.
* '''Successful reimplantation is possible'''
** '''< 16 hours of cold ischemia time OR'''
** '''< 6 hours of warm ischemia'''

==== Zipper injuries ====

* Risk factors
** Usually occur in impatient boys or intoxicated men.
* Management
** After a penile block, the zipper slider and adjacent skin can be lubricated with mineral oil, followed by a single attempt to unzip and untangle the skin. If this fails, a bone cutter or similar tool can be used

=== Testicular trauma ===
* '''<span style="color:#ff0000">Testicular rupture must be considered in all cases of blunt scrotal trauma</span>'''
** '''Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle'''.

==== <span style="color:#ff0000">Diagnosis and Evaluation</span> ====

===== <span style="color:#ff0000">History and Physical Exam</span> =====
* '''History'''
** Most patients complain of exquisite scrotal pain and nausea.
*** '''≈5% of spermatic cord torsions are believed to be precipitated by trauma'''; torsion should be considered in all cases of significant scrotal pain without signs or symptoms of major scrotal trauma
* Physical exam
** Clinical examination of the scrotum following trauma can be limited due to significant scrotal swelling and patient discomfort
** Swelling and ecchymosis are variable, and the degree of hematoma may not correlate with the severity of testicular injury; absence does not entirely rule out testicular rupture, and contusion without fracture can manifest as significant bleeding.
** Scrotal hemorrhage and hematocele along with tenderness to palpation often limit a complete physical examination.
** '''A nonpalpable testis in a trauma patient should raise the possibility of dislocation outside the scrotum'''. Manual or surgical reduction of the displaced testis is indicated.

===== <span style="color:#ff0000">Imaging</span> =====
* '''<span style="color:#ff0000">Modality: ultrasound</span>'''
** Can reliably diagnose testicular rupture with a high level of accuracy in the setting of blunt scrotal trauma.
*** The utility of scrotal ultrasound for the evaluation of testicular rupture in the setting of penetrating scrotal trauma is limited.
** '''<span style="color:#ff0000">Ultrasound findings suggestive of testicular fracture include (2):</span>'''
**# '''<span style="color:#ff0000">Heterogeneous pattern of the testicular parenchyma</span>'''
**# '''<span style="color:#ff0000">Disruption of the testicular contour/tunica albuginea</span>'''
** '''<span style="color:#ff0000">A normal or equivocal ultrasound study should not delay surgical exploration when physical examination findings suggest testicular damage; definitive diagnosis is often made in the operating room.</span>'''

==== <span style="color:#ff0000">Management</span> ====
* Minor scrotal injuries without testicular damage may be managed with ice, elevation, analgesics, and irrigation and closure.
* '''<span style="color:#ff0000">Indications for scrotal exploration (6):</span>'''
*# '''<span style="color:#ff0000">Imaging findings of testicular rupture</span>'''
*# '''<span style="color:#ff0000">Equivocal imaging but suspected testicular rupture</span>'''
*# '''<span style="color:#ff0000">Large hematoma</span>'''
*#* '''Should be explored and drained even in the absence of testicular rupture''' to prevent progressive pressure necrosis and atrophy, delayed exploration, and orchiectomy.
*# '''<span style="color:#ff0000">Clear physical findings of testicular rupture</span>'''
*# '''<span style="color:#ff0000">Penetrating scrotal injuries</span>'''
*#* Inspect for testicular, vascular and vasal injury; >50% will have testicular rupture
*#** The injured vas should be ligated with nonabsorbable suture, and delayed reconstruction should be performed if necessary
*#* '''<span style="color:#ff0000">≈30% of gunshot wounds injure both testes, and exploration of the contralateral testis should be considered, depending on the findings of physical examination and the path of the projectile</span>'''
*# '''<span style="color:#ff0000">Significant hematoceles</span>''' (not in 2020 AUA guidelines)
*#* Up to 80% are caused by testicular rupture
* '''<span style="color:#ff0000">Early exploration and repair of testicular injury is associated with (6):</span>'''
*# '''<span style="color:#ff0000">Increased testicular salvage rates</span>'''
*#* '''<span style="color:#ff0000">Salvage rates with exploration and repair within 72 hours of injury: >90%</span>'''
*#** '''Orchiectomy rates 3-8x higher with conservative management and delayed surgery'''
*#** '''Recall'''
*#*** '''Penile fracture: repair within 7 days does not adversely affect outcomes'''
*#*** '''Ischemic priapism: shunting procedure is considered within 72 hours of onset'''
*# '''<span style="color:#ff0000">Reduced ischemic atrophy</span>'''
*# '''<span style="color:#ff0000">Reduced risk of infection</span>'''
*# '''<span style="color:#ff0000">Preservation of fertility and hormonal function</span>'''
*# '''<span style="color:#ff0000">Reduced convalescence and disability</span>'''
*# '''<span style="color:#ff0000">Faster return to normal activities</span>'''
* '''Technique'''
** '''Incision:''' transverse scrotal incision is preferable in most cases.
** The tunica albuginea should be closed with small absorbable sutures after removal of necrotic and extruded seminiferous tubules.
** '''Every attempt to salvage the testis should be performed;''' loss of capsule tissue may require removal of additional parenchyma to allow closure of the remaining tunica albuginea.
*** '''A flap or graft of tunica vaginalis may be used to cover a large defect in the tunica albuginea in an otherwise salvageable testis'''
*** '''<span style="color:#ff0000">Orchiectomy is performed when the testicle non-salvagable</span>'''
* Males with a solitary testis
** Testicular injuries are exceedingly rare in boys involved in individual or team contact sports and recreational activities.
** Parents of boys with a solitary testis should be appropriately counseled, and a protective cup device should be recommended.

=== Genital skin loss ===
* '''Most common cause of extensive genital skin loss: necrotizing gangrene secondary to polymicrobial infection in the genital area, or Fournier gangrene'''
* '''In patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical), perform exploration and limited debridement of non-viable tissue'''
** Genital skin is well vascularized and tissues with marginal viability may survive due to collateral blood flow.
** Typically, these injuries require multiple procedures in the operating room prior to definitive reconstructive procedures.
** Wound management can include a variety of methods including gauze dressings with frequent changes, silver sulfadiazine or topical antibiotic and occlusive dressing, or negative pressure dressings.
** '''If a urethral catheter is used in a genitalia burn, it should be removed after 72 hours to prevent urethral slough and fistula formation'''
** Reconstructive techniques for definitive repair include primary closure and advancement flaps, placement of skin grafts, free tissue flaps, and pedicle based skin flaps

=== Penile reconstruction ===
* '''<span style="color:#ff0000">Thick (0.012- to 0.015-inch), non-meshed, split-thickness skin grafts are preferred for penile reconstruction</span>'''.
** Meshed grafts can be used but have a tendency to contract and are cosmetically inferior to unmeshed grafts.
* If grafts are to be used, care must be taken to remove any subcoronal skin remaining after debridement. Lymphatic obstruction of this distal foreskin, if it is not excised, results in circumferential lymphedema
* A foreskin flap is the best option for coverage of acute penile skin loss for small distal lesions
* '''Skin grafts placed on the penile shaft never regain normal sensation, although sexual function is often preserved because of intact sensation in the glans'''

=== Scrotal reconstruction ===
* '''<span style="color:#ff0000">Scrotal skin loss defects of up to 50% can often be closed directly.</span>'''
* '''Meshed, split-thickness skin grafts are preferred for scrotal reconstruction'''
* '''For extensive injuries, the testes may be placed in thigh pouches treated with wet dressings, or placed under vacuum pressure dressings until reconstruction'''.
** In cases of infection, thigh pouches are not recommended initially, until the infection is stabilized, because transmission of the infectious process into uninvolved tissues may occur.