What is the proper treatment for a penile wound?

Treatment of Penile Wounds

Penile wounds require immediate surgical exploration and repair in nearly all cases, with the specific approach determined by the mechanism of injury—blunt trauma (penile fracture) demands prompt surgical repair through a degloving incision, penetrating injuries require surgical exploration with debridement and primary repair, and extensive skin loss necessitates staged reconstruction after initial debridement. 1

Initial Assessment and Diagnostic Approach

Key Clinical Presentations to Identify

• Penile fracture (blunt trauma): Look for penile ecchymosis, swelling, history of cracking/snapping sound during intercourse or manipulation, and immediate detumescence 1
• Penetrating trauma: Assess for blood at urethral meatus, gross hematuria, or inability to void—these indicate concomitant urethral injury requiring evaluation 1
• Extensive tissue loss: Evaluate for infection, shearing injuries, burns (thermal, chemical, electrical), or necrotizing infections 1

Imaging Considerations

• Ultrasound may be performed only in patients with equivocal signs of penile fracture, though if diagnosis remains uncertain after imaging, proceed directly to surgical exploration 1
• Retrograde urethrogram or urethroscopy must be performed when blood at meatus, gross hematuria, inability to void, or bilateral corporal fracture is present 1

Treatment Algorithm by Injury Type

Penile Fracture (Blunt Trauma)

Perform prompt surgical exploration and repair at time of presentation through either ventral midline or circumcision (degloving) incision 1

• Expose the injured corpus cavernosum completely 1
• Repair tunica albuginea with absorbable suture 1
• Use intraoperative saline injection to identify additional corporeal or urethral pathology and assess repair integrity 2
• Critical timing: Immediate repair improves long-term outcomes compared to delayed reconstruction 1

Penetrating Trauma (Gunshot, Stab Wounds)

Immediate surgical intervention is mandatory in 95% of cases 3, 4

• Perform surgical exploration to determine extent of scrotal, testicular, epididymal, cavernosal, or urethral damage 4
• Debride all nonviable tissue before attempting repair 2
• Re-anastomose macroscopic structures including corpora cavernosa and perform spatulated urethral repair 1
• Control active bleeding and drain existing hematomas 4
• Conservative treatment may only be considered for superficial lesions not involving corpus cavernosum, urethra, or testicles 3

Extensive Genital Skin Loss or Tissue Destruction

Perform exploration and limited debridement of clearly non-viable tissue only 1

• Irrigate copiously and perform limited debridement—genital skin is well-vascularized and marginally viable tissue may survive due to collateral blood flow 1
• Avoid aggressive initial debridement; typically requires multiple staged procedures before definitive reconstruction 1
• Wound management options include: gauze dressings with frequent changes, silver sulfadiazine or topical antibiotic with occlusive dressing, or negative pressure dressings 1
• Definitive reconstruction includes primary closure, advancement flaps, skin grafts, free tissue flaps, or pedicle-based flaps 1

Traumatic Penile Amputation

Perform prompt penile replantation when amputated tissue is available 1

• Transport amputated appendage wrapped in saline-soaked gauze, placed in plastic bag, then on ice (two-bag system) 1
• Re-anastomose corpora cavernosa, perform spatulated urethral repair, and repair skin 1
• Consult microvascular surgery whenever possible for microscopic repair of dorsal arteries, veins, and nerves—this improves outcomes, especially regarding penile skin viability 1

Critical Contraindications and Pitfalls

When NOT to Perform Primary Repair

Primary repair should not be undertaken if: 1

• Patient is hemodynamically unstable
• Surgeon lacks expertise in urethral/penile surgery
• Extensive tissue destruction or loss is present (requires staged approach)

Specific Injury Considerations

• Straddle injuries to anterior urethra: Establish prompt urinary drainage via suprapubic tube or catheter, but do not perform immediate operative repair—the injury border is indistinct and stricture formation is very high 1
• Human bite wounds: Recognize high risk for polymicrobial infection including Fournier's gangrene; requires emergent parenteral antibiotics plus aggressive irrigation and debridement 5
• Localized glandular gangrene: Avoid distal amputation as this may result in sloughing and complications; hyperbaric oxygen and local wound care may be adequate if no progression 2

Post-Operative Management

• All patients require follow-up surveillance for stricture formation using uroflowmetry, retrograde urethrogram, and/or cystoscopy 1
• Preservation of fertility is paramount—in cases of bilateral testicular injury requiring ablation, consider testicular sperm extraction or squeezing ductus during orchiectomy 4
• Expected outcomes with appropriate surgical management: adequate erection for intercourse without erectile or voiding dysfunction in approximately 87% of patients 2