Genital Trauma Management

Diagnosis and Evaluation

• Suspect penile fracture in patients presenting with penile ecchymosis and swelling, cracking or snapping sound during intercourse or manipulation, immediate detumescence, penile pain and/or angulation, as recommended by the American Urological Association 1
• History and physical examination are often sufficient for diagnosis when classic symptoms are present, according to the American Urological Association 1
• Consider ultrasound as first-line imaging for equivocal cases, and MRI if ultrasound results are inconclusive, as suggested by the American Urological Association 1
• Evaluate for signs of urethral injury, such as blood at the urethral meatus, gross hematuria, or inability to void, in patients with genital trauma, and use retrograde urethrography or urethroscopy to diagnose suspected urethral injuries 1

Treatment and Management

• Immediate surgical intervention is recommended for penile fracture, testicular rupture, and most penetrating injuries to prevent complications such as erectile dysfunction and permanent tissue damage, as supported by the American Urological Association 1
• Surgical repair of penile fracture offers the best outcomes for preserving erectile function and preventing long-term complications, and should include identifying, debriding, and performing primary repair of the tear in the tunica albuginea, with absorbable suture for tunical repair 1
• Concomitant urethral injury should be evaluated and repaired during the same procedure, with establishment of urinary drainage as soon as possible 2, 1
• Treatment options for urethral injuries include:

1

• Non-surgical management of penile fracture is associated with higher rates of complications and should be avoided, as recommended by the American Urological Association 1

Wound Management and Reconstruction

• Exploration and limited debridement of non-viable tissue should be performed in patients with genital trauma, with avoidance of excessive debridement due to the well-vascularized nature of genital skin 1
• Wound management options include gauze dressings with frequent changes, silver sulfadiazine or topical antibiotic with occlusive dressing, and negative pressure dressings 1
• Prompt penile replantation is essential, with proper transport of the amputated appendage and surgical approach including re-anastomosis of macroscopic structures, spatulated repair of urethra, and skin closure 1

Follow-up and Complications

• Regular follow-up is necessary to monitor for complications such as erectile dysfunction, penile curvature, and urethral stricture in patients with genital trauma, as recommended by the American Urological Association 3, 1, 2
• Urethrography should be performed every two weeks until complete healing for urethral injuries 2
• Early intervention is critical to prevent permanent erectile dysfunction, and treatment within 24-48 hours is essential to prevent permanent erectile dysfunction in cases of priapism, as stated by the Leukemia journal 4
• Delay in treatment can lead to complications, and early surgical intervention for penile fracture results in better outcomes with lower risk of erectile dysfunction and penile curvature, as supported by the American Urological Association 1

Priapism Management

• First-line treatment for priapism is intracavernosal phenylephrine with or without irrigation, with a concentration of 100-500 μg/mL and dosing of 1 mL injections every 3-5 minutes until detumescence, as recommended by the American Urological Association 3, 5
• If first-line treatment is unsuccessful after 1 hour, distal shunting procedures should be considered, as suggested by the American Urological Association 3, 5
• For non-ischemic priapism, offer observation as initial approach, and if persistent and bothersome, embolization is first-line therapy, according to the American Urological Association 6
• Priapism in patients with chronic myeloid leukemia requires emergency treatment with rapid leukoreduction, penile puncture, and blood aspiration from cavernous tissue, as noted by the Leukemia journal 4
• Corporal blood gas analysis is essential to distinguish ischemic from non-ischemic priapism, according to the American Urological Association 3, 5