What is the approach to managing bleeding from the penis?

Approach to Bleeding from the Penis

Immediately assess hemodynamic stability and identify the anatomical source of bleeding—this determines whether the patient requires emergent surgical intervention or can undergo further diagnostic workup. 1

Initial Assessment and Stabilization

Determine if the patient is in hemorrhagic shock by checking vital signs: systolic BP <100 mmHg, tachycardia >100 bpm, altered mental status, or narrow pulse pressure indicate shock requiring immediate intervention. 1

• Establish IV access immediately and begin fluid resuscitation with crystalloids (0.9% NaCl or balanced crystalloid) if signs of hemorrhagic shock are present. 1
• Target systolic blood pressure of 80-100 mmHg during initial resuscitation until bleeding is controlled (unless brain injury is suspected, then maintain MAP ≥80 mmHg). 1
• Monitor serum lactate and base deficit to estimate and track the extent of bleeding and tissue hypoperfusion. 1
• Do not rely on single hematocrit measurements as an isolated marker for bleeding severity—these can be misleading in acute hemorrhage. 1

Identify the Bleeding Source

The anatomical location of bleeding dictates management:

External Penile Bleeding (Skin/Superficial Vessels)

• Apply direct compression immediately as first-line intervention for all external bleeding wounds. 2
• Consider superficial dorsal vein rupture if bleeding occurred during sexual activity or manipulation of erect penis—this typically presents with acute penile edema and ecchymosis. 3
• Angiokeratoma of the scrotum can cause spontaneous bleeding from small papules on scrotal skin. 4

Urethral Bleeding (Blood at Meatus)

This is a urological emergency requiring immediate surgical consultation. 5, 6

• Suspect penile fracture if there is history of trauma during erection (sexual intercourse/masturbation), especially with a "cracking" sound, immediate detumescence, acute pain, swelling, and "eggplant deformity." 5
• Perform retrograde urethrogram to assess for urethral disruption if urethral bleeding is present with trauma history. 5
• Minimize time between injury and surgical intervention—delayed treatment worsens outcomes and increases risk of erectile dysfunction. 7, 2, 5
• Immediate surgical exploration and repair is indicated for penile fracture with urethral injury, including repair of tunica albuginea defects and urethral reconstruction. 5

Corporal/Deep Penile Bleeding

• Ultrasonography (Doppler) can rapidly assess for tunica albuginea rupture, hematoma, or vascular injury without delaying treatment. 5
• Consider traumatic pseudoaneurysm of pudendal artery if there is persistent bleeding after straddle injury with hemodynamic instability—this requires angiographic embolization. 8

Hemodynamically Unstable Patients

Patients with hemorrhagic shock and identified bleeding source should undergo immediate bleeding control procedure unless initial resuscitation is successful. 1

• Direct surgical bleeding control with packing and local hemostatic procedures should be employed as primary intervention. 1, 2
• Do not delay surgical intervention for extensive imaging in actively hemorrhaging unstable patients. 9, 2
• Damage control surgery principles apply if patient demonstrates signs of hemorrhagic shock, coagulopathy, hypothermia, or acidosis. 1, 2

Hemodynamically Stable Patients

• Perform focused ultrasonography to identify hematoma, vascular injury, or structural defects if trauma is suspected. 5
• CT scan with IV contrast may be considered if bleeding source remains unclear and patient is stable enough for imaging. 9
• Urgent urology consultation is warranted for any suspected penile fracture, urethral injury, or deep vascular injury even if hemodynamically stable. 5, 6

Special Considerations

Priapism-Related Bleeding

• Non-ischemic priapism is NOT an emergency and presents with painless, persistent erection with normal oxygenated blood flow—this can be managed with observation. 1
• Ischemic priapism IS an emergency requiring immediate intervention if erection persists >4 hours—but this typically does not present with bleeding. 1

Resuscitation Targets

• Transfuse packed red blood cells if Hb drops below 7 g/dL, targeting Hb 7-9 g/dL to avoid exacerbating bleeding through over-resuscitation. 1
• Avoid excessive fluid resuscitation while bleeding is uncontrolled—this worsens coagulopathy and increases bleeding risk. 1, 2
• Correct coagulopathy with appropriate blood products (FFP, platelets, fibrinogen) if ongoing hemorrhage is present. 1

Critical Pitfalls to Avoid

• Never rely on wound dressings or compression alone to control active arterial or deep penile bleeding—this delays definitive treatment. 2
• Do not dismiss urethral bleeding as minor—this indicates potential urethral disruption requiring urgent surgical evaluation. 5, 6
• Avoid delaying surgical consultation in any patient with penile trauma and bleeding—"any penile trauma should be considered an emergency until proven otherwise." 6
• Do not discharge patients with unexplained penile bleeding without ensuring concrete urology follow-up within 24-48 hours. 9