Editing Lower Urinary Tract Trauma (section)

===== 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'''