What is the appropriate management for a penile and groin injury in men?

Management of Penile and Groin Injuries in Men

The management of penile and groin injuries requires prompt evaluation and treatment based on the type and severity of injury, with immediate surgical intervention recommended for penile fracture, testicular rupture, and most penetrating injuries to prevent complications such as erectile dysfunction and permanent tissue damage. 1, 2

Initial Assessment

• Diagnostic evaluation:
  • Evaluate for blood at urethral meatus, gross hematuria, or inability to void (signs of urethral injury) 1
  • Ultrasound is first-line imaging for suspected testicular rupture or penile fracture 2
  • Retrograde urethrography or urethroscopy for suspected urethral injuries 1, 2

Management Algorithm by Injury Type

Penile Fracture

• Immediate surgical exploration and repair is standard of care 1, 2
• Surgical approach includes:
  • Exposure of injured corpus cavernosum
  • Tunical repair
  • Evaluation and repair of any concomitant urethral injury
• Non-surgical management should be avoided as it leads to higher rates of complications 2

Testicular Rupture

• Scrotal exploration and debridement with tunical closure when possible 1
• Orchiectomy when testicle is non-salvageable 1
• Early exploration and repair prevents complications like ischemic atrophy and infection 1

Urethral Injuries

• Establish urinary drainage as soon as possible 1
• Treatment based on injury type:
  • Anterior urethral injuries (blunt): Initial conservative management with urinary drainage (urethral or suprapubic catheter), followed by endoscopic realignment 1
  • Anterior urethral injuries (penetrating): Prompt direct surgical repair for uncomplicated injuries 1
  • Posterior urethral injuries (blunt): Initial conservative treatment with planned delayed surgical treatment; immediate endoscopic realignment preferred over immediate urethroplasty 1
  • Posterior urethral injuries (penetrating): In hemodynamically stable patients without severe associated injuries, immediate retropubic exploration and primary repair 1

Extensive Genital Skin Loss/Injury

• Exploration and limited debridement of non-viable tissue 1
• Multiple procedures may be required before definitive reconstruction 1
• Wound management options:
  • Gauze dressings with frequent changes
  • Silver sulfadiazine or topical antibiotic with occlusive dressing
  • Negative pressure dressings 1

Traumatic Penile Amputation

• Prompt penile replantation is essential 1
• Transport amputated appendage properly:
  • Wrap in saline-soaked gauze
  • Place in plastic bag
  • Place on ice during transport 1
• Surgical approach:
  • Re-anastomosis of macroscopic structures (corpora cavernosa)
  • Spatulated repair of urethra
  • Skin closure
  • Consult microvascular surgeon when possible for repair of dorsal arteries, veins, and nerves 1

Special Considerations

Degloving Injuries

• Require immediate surgical intervention 3
• May involve replantation of penile skin and closure of scrotal wounds 3
• Postoperative care focuses on infection prevention with antibiotics and daily dressing changes 3

Penile Bleeding

• Evaluate for underlying cause (priapism, trauma, etc.)
• For priapism-related bleeding:
  • Distinguish between ischemic and non-ischemic priapism using corporal blood gas analysis 2
  • Treat ischemic priapism with intracavernosal phenylephrine (100-500 μg/mL, 1 mL injections every 3-5 minutes) 2

Follow-up Care

• Regular follow-up to monitor for complications:
  • Erectile dysfunction
  • Penile curvature
  • Urethral stricture 2
• For urethral injuries, urethrography should be performed every two weeks until complete healing 1
• Long-term follow-up is recommended, especially in pediatric cases 3

Common Pitfalls and Caveats

• Delay in treatment: Early surgical intervention for penile fracture results in better outcomes with lower risk of erectile dysfunction and penile curvature 2
• Incomplete evaluation: Always assess for concomitant urethral injury in penile trauma 1
• Conservative management: Non-surgical management of penile fracture leads to higher complication rates 2
• Excessive debridement: Genital skin is well-vascularized; tissues with marginal viability may survive due to collateral blood flow 1

Remember that severe penile injuries should be treated on an individual basis, applying different techniques tailored to each patient depending on the type and extent of injury, and treatment is most effective when performed at specialized centers 4.