What should I do if I'm experiencing penile bleeding?

Management of Penile Bleeding

Penile bleeding requires immediate medical attention to determine the cause and appropriate treatment, as it can indicate serious conditions that may lead to permanent erectile dysfunction if not promptly addressed.

Differential Diagnosis and Initial Assessment

When evaluating penile bleeding, it's crucial to determine the underlying cause:

• Penile fracture: Look for history of trauma during sexual activity, audible "pop" or "snap" sound, immediate detumescence, rapid swelling, ecchymosis, and pain 1
• Priapism: Persistent painful erection lasting >4 hours, not associated with sexual stimulation 2
• Urethral injury: Blood at the urethral meatus, gross hematuria, inability to void 2
• Vascular abnormalities: Anorectal varices can present with bleeding 2
• Penile vein thrombosis: Sudden, almost painless indurations on the penile dorsal surface 3

Management Algorithm Based on Cause

1. Penile Fracture

If signs of penile fracture are present (audible "pop," immediate detumescence, swelling, ecchymosis):

• Prompt surgical exploration and repair is mandatory to minimize complications 1
• Delay in treatment increases risk of erectile dysfunction and penile curvature 1
• Ultrasound is recommended as first-line imaging, but if results are inconclusive, surgical exploration is still recommended 1

2. Priapism

If persistent erection >4 hours:

• Obtain corporal blood gas to distinguish ischemic from non-ischemic priapism 2
• For ischemic priapism:
  • Intracavernosal phenylephrine with or without irrigation 2
  • If unsuccessful, proceed to distal shunting 2
• For non-ischemic priapism:
  • Not an emergency; offer observation as initial approach 2
  • If persistent and bothersome, embolization is first-line therapy 2

3. Urethral Injury

If blood at urethral meatus, hematuria, or inability to void:

• Retrograde urethrography to diagnose 2
• For anterior urethral injuries:
  • Penetrating injuries: immediate surgical closure 2
  • Straddle injuries: suprapubic or urethral drainage 2
• For posterior urethral injuries:
  • Secure catheter drainage of bladder 2
  • Consider primary realignment or suprapubic tube placement 2

4. Massive Urethral Bleeding

For uncontrolled urethral bleeding:

• Consider gradually inflating the balloon of a urethral catheter up to 4 mL to tamponade bleeding 4
• Apply intermittent penile compression or continuous perineal pressure 4

5. Penile Vein Thrombosis

If painless induration on penile dorsal surface:

• Conservative therapy with local heparin ointment (10,000 IU) and oral anti-inflammatory medication for 14 days 3
• Surgical thrombectomy if conservative management fails 3

Special Considerations

Priapism in Children with Leukemia

• Priapism occurs in 2.5-3.3% of boys at diagnosis of chronic myeloid leukemia 2
• Requires emergency treatment with:
  • Rapid leukoreduction via exchange transfusion or leukapheresis
  • Penile puncture and blood aspiration from cavernous tissue
  • Flushing with saline and suprarenin injection if detumescence not achieved 2

When to Seek Emergency Care

Seek immediate medical attention for any penile bleeding, especially if associated with:

• Trauma to the erect penis
• Persistent erection >4 hours
• Inability to urinate
• Significant pain
• Rapid swelling or discoloration

Prevention of Complications

• Early intervention is critical to prevent permanent erectile dysfunction
• For penile fracture, surgical management has significantly better outcomes than conservative management 1
• For priapism, treatment within 24-48 hours is essential to prevent permanent erectile dysfunction 2

Remember that penile bleeding is a urological emergency until proven otherwise 5, and prompt diagnosis and treatment are essential to preserve sexual function and prevent complications.