Management of Pediatric Penile Injury

All but the most superficial pediatric penile injuries should be evaluated for urethral injury, surgically explored, and repaired. 1

Initial Assessment and Diagnosis

Examine for signs of urethral injury: blood at the urethral meatus, gross hematuria, inability to void, or urinary retention 1, 2
Document mechanism of injury: falls, straddle injuries, zipper entrapment, circumcision accidents, strangulation, burns, bites, or blunt trauma 3, 4, 5
Assess for penile fracture (corpus cavernosum rupture): look for acute-onset penile pain, ecchymosis, swelling of the penile shaft, and history of forceful trauma—this can occur in prepubertal children from falls or blunt trauma, not just sexual activity 3, 6

For suspected penile fracture with equivocal findings:

Perform urgent ultrasound on the same day or within hours to confirm or exclude tunical disruption 2
Ultrasound is preferred due to wide availability, low cost, and rapid examination times 2
MRI may be used in equivocal cases but should not delay treatment 1

For suspected urethral injury:

Perform urethroscopy or retrograde urethrography before any other genitourinary manipulation 1
Urethroscopy is preferred over retrograde urethrography in the setting of penile injuries 1
Urethral injury occurs in 10-22% of penile fracture cases 1, 2

Perform immediate surgical exploration and repair at the time of presentation—this is a true urologic emergency 3

Prompt surgical repair is associated with significantly lower rates of erectile dysfunction, penile curvature, persistent hematoma, abscess, and fibrosis compared to delayed or conservative management 1, 2, 3
Repair the tunical tear with absorbable suture 2
Use flexible cystoscopy to evaluate for urethral and bladder injury 3

All penetrating penile injuries require surgical exploration as 11-29% have concomitant urethral injuries 1

Tailor surgical techniques to the individual injury pattern 4
Options include primary repair, re-implantation (for amputation), phalloplasty using remaining corpora cavernosa stumps, and fistula repair 4, 5
For complete urethral transection, perform plastic reanastomosis of both corpora cavernosa and urethra 6

If urethral injury is confirmed:

Perform direct surgical repair when feasible during penile exploration 1
In hemodynamically unstable patients, place suprapubic catheter and postpone definitive repair 1
Do not attempt urethral catheter placement until urethrography or urethroscopy is completed 1

Treat pediatric patients using the same principles as adults, with emphasis on being less invasive when possible 1

Children may not exhibit hypotension as adults do, so maintain high index of suspicion even with normal vital signs 1
Penile fractures can occur from non-sexual mechanisms in children (falls, straddle injuries) 3, 6
Common pediatric-specific mechanisms include circumcision accidents, zipper injuries, hair strangulation, and bathing suit mesh entrapment 4, 7, 5

Do not delay surgical repair: Immediate repair within hours provides the best functional outcomes 2, 3
Do not miss urethral injury: Always evaluate for urethral involvement when warning signs are present, as this occurs in up to 22% of cases 1, 2
Do not attempt urethral catheterization before imaging if urethral injury is suspected 1
Do not manage severe penile injuries conservatively: Surgical exploration and repair is mandatory for all but the most superficial injuries 1

Most pediatric penile injuries heal without complication when promptly and appropriately managed 4, 5
Fistula formation may occur after urethral reconstruction, with recurrence rates requiring repeat repair in some cases 4, 5
Long-term follow-up should assess for erectile function, penile curvature, and urethral stricture 1, 2