Penetrating penile injuries are relatively rare and usually take the form of gunshot and stab wounds. However, one can also encounter penile avulsion injuries from motor-vehicle or bicycle accidents as well as the occasional self-mutilating injuries and animal or human bites. Despite the abovementioned multiple possible mechanisms of penile trauma, significant penile injuries remain rare secondary to the tough tunica albuginea covering of the penis. Penetrating penile injuries may result in a tear of the tunica albuginea encasing the corpora cavernosa, which allows extravasation of blood from the corpora into the penile shaft. Because of the penetrating nature of the injury, blood will exit out of the wound site, typically not extending along fascial lines as with penile fracture. The penis may swell and have some ecchymosis, but you usually do not see the so-called “eggplant penis” appearance in penetrating injuries.

With penetrating injuries to the penis, you should always suspect compromise of the tunica albuginea. The mechanism alone will almost always mandate surgical exploration. However, if the diagnosis is in question, further imaging studies are available, although with highly variable results and inter-interpreter variations. Cavernosograms can be performed with injection of contrast material into the corpus cavernosum, with serial radiographs taken to identify the site of extravasation. The false-negative rate is unfortunately very high with this modality, as the tear can be too small to see, and often the presence of a clot at the tear site will mask the extravasation. False-positive studies result when the physiologic egress of contrast through emissary veins is misinterpreted as extravasation. Similarly, penile ultrasound cannot consistently identify the site of tear unless in the hands of a very skilled examiner. MRI in the T1 phase, although more sensitive than cavernosography and ultrasound, has a limited role secondary to the time required, the difficulty with transportation, and the frequent clinical instability of the patient. These studies have no role in significant penetrating injuries. They have value in cases of penile fracture, when there is an atypical presentation. You should always suspect underlying urethral injury with any penetrating penile trauma. If the patient has not spontaneously voided clear urine or has hematuria, either gross or microscopic, an RUG should be performed prior to surgical exploration to assess for urethral injury.

Tunical violation injuries of the penis should ideally be surgically corrected within 36 h of sustaining the injury. Exploration is mandatory to prevent the sequelae of infected hematomas, impotence, and penile curvature that may result without prompt operative intervention. Again, other more life-threatening injuries should be identified and addressed first.

Once the patient has reached the operative suite, the appropriate area is prepped and draped in standard sterile fashion. Insert a urethral catheter at the beginning to ensure ease of passage into the bladder. You can then use this catheter for the retrograde instillation of saline/dye during the procedure to evaluate for any urethral discontinuity. First make a circumferential (“degloving”) incision, which allows access to the length of the corpora cavernosa and spongiosum. Place a tourniquet at the base of the penis as it can aid with hemostasis and dissection (Fig. 51.2a). Carry out evacuation of the hematoma, and localize the site of tunical violation after you dissect free Buck’s fascia. Once you have identified the defect, debride the wound edges and do copious irrigation, particularly important with gunshot injuries or bites. Carry on primary closure of the defect with 4-0 prolene suture in a figure-of-eight fashion. We prefer to do this with the knots buried to decrease the chance of the patient potentially feeling the suture under the thin penile skin (Fig 51.2b). Avoid any significant length of running suture, as any cinching of the tissue may result in penile curvature. If there has been any rupture of the tunica albuginea close to 1 cm or larger, perform an artificial erection after the repair. This is necessary to determine if any curvature has resulted from the repair. Do this by applying a tourniquet at the base of the penis and injecting one of the cavernosal bodies, via a butterfly needle, with normal saline until appropriate turgor is achieved. If there is any notable curvature, a plication of the tunica on the opposite side of the defect may be necessary. Repair any urethral injuries over a urethral catheter as mentioned in the chapter section to follow. After you have reapproximated the skin, place a compressive dressing and remove it the evening of surgery or the following morning. Leave the catheter in place until the following morning unless a urethroplasty is performed. Administer antibiotics for 7–10 days following the repair to prevent penile abscess development.

Surgical exploration may be unnecessary if the penetrating penile injury fails to result in tunical violation. Relatively small penile tears can be locally irrigated, debrided, and repaired with simple, interrupted closure and an absorbable 2-0 or 3-0 suture. With larger defects, initially perform local irrigation and debridement. Evaluate the wounds later for either primary closure with reapproximation or reconstruction with delayed grafting. These wounds are frequently contaminated, and all patients should be placed on a 10-day antibiotic course with an antibiotic that provides adequate coverage of typical skin flora, such as cephalexin. For penicillin-allergic patients, you can use chloramphenicol.

Penile amputation injuries can be accidental or self-inflicted. The timing of the incident and the presence and handling of the severed penis are crucial to the initial management. The severed penis should be wrapped with saline-soaked gauze, placed into a sterile bag (if possible), and immediately placed in ice water. The ice should never be in direct contact with the penis to prevent necrosis. If possible, the amputated penis should be reimplanted within 24 h of the injury. Transfer to a tertiary medical center is usually required for the expertise of microvascular anastomoses that is often necessary. After appropriate medical and psychosocial issues have been addressed and other more life-threatening injuries have been ruled out, the patient is taken to the operating room immediately for reimplantation. It is extremely important to have an experienced team of urologists, plastic surgeons, and OR staff in order to have a good result. Of primary importance is the cavernosal and spongiosum/urethral reanastomoses. A urethral catheter is inserted prior to the urethral anastomosis. Microsurgical techniques can be used to reapproximate the dorsal arteries and nerve of the penis to improve the recovery of postoperative perfusion and sensation, respectively. Next, the tunica should be reconstructed. Finally, the debrided skin should be sewn together, much like any other superficial anastomosis. It is not unusual to have delayed sloughing of the penile skin. This does not necessarily imply that the reimplant as a whole has not survived. Delayed skin grafting may be all that is necessary. If the severed penis is not available, then overclosure of the corpus cavernosum with advancement of the urethral stump can be performed to allow voiding while standing. An inadequate distal urethral remnant may obviate the need for perineal urethrostomy with delayed genital reconstruction pending complete psychosocial evaluation.

As with other traumatic genitourinary injuries, the mechanism of urethral injury can be divided into blunt versus penetrating. Urethral injuries can be further subdivided into posterior (prostatic/membranous urethra) and anterior (bulbar/pendulous urethra) in location. These subdivisions not only classify the location of the injury but also dictate further management. Penetrating anterior and posterior urethral injuries are usually secondary to gunshot and stab wounds. These injuries are much more prevalent in males than females owing to the shorter urethral length, greater urethral mobility, and lesser pubourethral attachments in females.