Editing AUA: Urotrauma (2020) (section)

===== '''Genital trauma''' =====

* Background
** Clinicians should initiate ancillary psychological, interpersonal, and/or reproductive counseling and therapy for patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated.
* '''Penile trauma'''
** '''Penile fracture'''
*** '''Definition of penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum'''
*** '''Pathogenesis'''
**** '''Most commonly occurs during vigorous sexual intercourse'''
*** '''Diagnosis and Evaluation'''
**** '''History and physical exam'''
***** '''History'''
****** '''Indicators of penile fracture'''
******# '''Penile ecchymosis or swelling''' (most common symptoms)
******# '''Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.'''
******# '''Penile pain'''
******# '''Penile angulation'''
***** '''Physical exam'''
**** '''Imaging'''
***** '''The typical history and clinical presentation of penile fracture usually make adjunctive imaging studies unnecessary. However, when the history and physical examination are equivocal for penile fracture, imaging can establish the diagnosis.'''
***** '''Options (2):'''
*****# '''Ultrasound (preferred)'''
*****#* '''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
*****# '''Penile-perineal MRI'''
***** '''If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed'''
**** '''Other'''
***** '''Endoscopy'''
****** '''Should be performed given that urethral injury occurs in 10-22% of cases of penile fracture'''
*** '''Management'''
**** '''Suspected penile fractures should be promptly explored and surgically repaired'''
**** Technique
***** Incision: ventral midline or circumcision incision.
***** Tunical repair is performed with absorbable suture and should be performed at the time of presentation to improve long-term patient outcomes.
** '''Concomitant urethral injury'''
*** '''In patients with penile fracture or penetrating trauma who present with blood at the urethral meatus, gross hematuria or inability to void, evaluate for concomitant urethral injury'''.
**** All but the most superficial injuries should be evaluated for urethral injury
**** Options for evaluation include urethroscopy and retrograde urethrogram)
** '''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 “double bag” technique.'''
**** '''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.'''
*** Urologists should perform re-anastomosis of macroscopic structures, including the corpora cavernosa, spatulated repair of the urethra, and skin, when the amputated penis is available.
*** A microvascular surgeon should be consulted whenever possible to perform microscopic repair of dorsal arteries, veins, and nerves.

* '''Testicular trauma'''
** '''Blunt scrotal trauma may lead to rupture of the tunica albuginea of the testicle'''.
** '''Diagnosis and evaluation'''
*** '''History and physical exam'''
**** History
**** Physical exam
***** Clinical examination of the scrotum following trauma can be limited due to significant scrotal swelling and patient discomfort
*** '''Imaging'''
**** '''Modality: ultrasound'''
***** 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.
***** '''Ultrasound findings suggestive of testicular fracture include (2):'''
*****# '''Heterogeneous pattern of the testicular parenchyma'''
*****# '''Disruption of the testicular contour/tunica albuginea'''
** '''Management'''
*** '''Indications for scrotal exploration (5):'''
***# '''Imaging findings of testicular rupture'''
***# '''Equivocal imaging but suspected testicular rupture'''
***# '''Large hematoma'''
***# '''Clear physical findings of testicular rupture'''
***# '''Penetrating scrotal injuries'''
***#* Inspect for testicular, vascular and vasal injury; >50% will have testicular rupture
*** '''In patients with confirmed testicular rupture, perform debridement of non-viable tissue with tunical closure (when possible) or orchiectomy (when non-salvagable)'''
**** '''A flap or graft of tunica vaginalis may be used to cover a large defect in the tunica albuginea in an otherwise salvageable testis'''
*** '''Early exploration and repair may prevent complications, such as ischemic atrophy of the testis and infection'''. 

* '''Genital skin loss'''
** '''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.
*** Reconstructive techniques for definitive repair include primary closure and advancement flaps, placement of skin grafts, free tissue flaps, and pedicle based skin flaps
***