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Pediatric – Penile Trauma

While the penis is one of the least injured organs, it is not risk-free. What can put it at risk? And how is it repaired? The following information should tell you when it is imperative to see your doctor about problems. 

How does the penis normally function? 

The two main functions of the penis are urinary and reproductive. Inside the penis there are three tubes. One is called the urethra. It is hollow and allows urine to flow from the bladder through the hole in the prostate through the penis and to the outside. The two other tubes are called the corpora cavernosa. The three tubes are wrapped together by a very tough fibrous sheath called the tunica albuginea. The corpora cavernosa are spongy tubes that are soft until filled with blood during an erection. At the time of sexual activity the erection of the penis allows it to be inserted into the woman's vagina. In this situation, the urethra acts as a channel for semen to be ejaculated into the vagina. The penis facilitates conception and pregnancy and also serves as a source of sexual pleasure for the man and his partner.

What are the causes and symptoms of penile injury? 

The penis is much less frequently injured than other parts of the body such as the abdomen, legs, arms and head. However, it can be wounded as a result of various injuries, including automobile accidents, gunshot wounds, burns sexual activity and, in the case of mental disturbance, self-mutilation. 

Perhaps the most common injury to the penis occurs during sexual activity. In the flaccid state, injury to the penis is rare because of the mobility and flexibility of the organ. During an erection, arterial blood flow causes the penis to be come rigid thus placing it at higher risk for injury. Although there is no bone in the penis, urologists frequently refer to the injury as a penile "fracture." During vigorous thrusting, the erect penis may accidentally slip out of the vagina. Due to the fast action, the penis strikes the outside of the woman instead of being reinserted into the vagina. The penis may then bend sharply despite the erection. A typical sign of this problem is a sharp pain in the penis joined by a "popping" sound. The pain and sound are produced by a rupture of the tunica albuginea, which is stretched tightly during the time of an erection. The pain may last for a short time or it may continue. The penis develops a collection of blood under the skin called a hematoma, which can distort the appearance of the penis (eggplant deformity). The injury is usually limited to one or both of the corpora cavernosa and, on rare occasions, the urethra.

The penis can also be injured by tearing the suspensory ligament, the structure that supports the organ at its base. Attached to the pelvic bone, this ligament can rip if an erect penis is pushed down suddenly causing pain and bleeding. 

Further injuries can occur if a man places a rubber tube or other instrument around the base of the penis that is too tight or on for too long. Cutting off the blood supply, it can produce a wound known as a strangulation lesion. Also, if an object is inserted into the urethra, both it and/or the penis can be injured. 

How are injuries to the penis treated? 

If a person sustains a penile injury, a urologist will take a thorough medical history and complete a physical examination along with blood and urine tests. The focus of any initial examination is to define the injury and assess the damage to the penis. Given that information, the doctor may call for other tests including a retrograde urethrogram if he/she thinks the urethra is involved. This test is performed by injecting a liquid radio contrast solution through the opening at the top of the penis and then taking X-rays. If the X-ray shows any leakage outside the urethra, it may indicate damage to that part of the urinary tract. 

Additional imaging techniques might include an ultrasound of the penis, MRI or a special test called a cavernosogram. In the latter test, a thin hypodermic needle is inserted into one area of the penis before a radio contrast solution is injected and X-rays taken. 

If the injury is amputation of the penis, the amputated portion should be wrapped in gauze soaked in sterile saline solution and placed in a plastic bag. The plastic bag should then be put into a second bag or cooler with an ice water slush. If reattachment of the penis is possible, the lower temperature produced by the slush will increase the likelihood of successful reattachment. Penile reattachment even after 16 hours has been reported to be successful.

Historically, treatment for a penis fractured during sexual activity was non-surgical management (e.g., cold compresses, pressure dressings, penile splinting and anti-inflammatory medications). Today, the treatment of choice will probably be for the individual to undergo surgery since it has the best long-term results by lowering complication rates often linked to non-surgical approaches. The most common surgical technique is to "deglove" the penis by making a cut around the shaft near the glans penis and peeling back the skin to the base to examine the inner surface. The surgeon will then evacuate any hematoma that helps to make examination of any tears in the tunica albuginea easier. If tears exist, they are repaired before the skin is sewn back into position.  A Foley catheter may be placed through the penile urethra into the bladder to drain urine and allow the penis to heal. With the entire penis bandaged, the patient will probably remain in the hospital for one or two days, and go home with or without the catheter. They may be given antibiotics and pain medication and will probably be asked to make a followup office visit with their doctor.

For massive injuries to the penis, major reconstruction is frequently possible by urologists experienced with this difficult surgery.  How closely the reconstructed penis can return to normal urinary or sexual function varies greatly.

What can be expected after treatment for injuries to the penis?

Most cases of fractured penis caused by sexual activity and most other minor penile injuries will heal without problems. However, complications can and do occur. Possible complications include: infection, erectile dysfunction due to blockage of the nerve or blood supply to the penis, priapism in which the penis becomes erect and stays erect to the point of pain, fistula formation in which urine may leak out of the urethra and through the skin of the penis to the outside, curvature (chordee) of the penis after the injury has healed or major loss of skin, portion of the urethra or corpora cavernosum. Failure for the return of sufficient sexual function is dependent upon the degree of injury to the arteries, nerves and corpora cavernosum and whether the patient was experiencing erectile dysfunction just prior to the injury.

Frequently asked questions: 

How frequent are penile injuries?

Unfortunately, doctors have not been able to gather meaningful statistics as to how many penile injuries actually occur in the United States.

How does a Foley catheter work? 

Ever since E.B. Foley, a Minneapolis urologist, first introduced the catheter bearing his name; doctors have had an effective way to efficiently and continuously drain the urinary tract. Held in place by its own configuration — primarily with a sterile liquid-filled balloon — the Foley can be inserted simply by passing the rubber tubing through the urethra into the bladder. It remains there until the penis is healed.

How do I prevent penile injury?

Penile injuries related to sexual intercourse can be prevented in most cases if your partner is simply aware of the possibility. If your penis is erect and inadvertently slips from the vagina of your partner, stop the thrusting immediately. For other injuries, caution on the job, especially near machinery, defensive driving and gun safety are obvious precautions for the other types of injuries.

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