Hafidzul jasman

Background 1/3-2/3 of all genitourinary trauma More commonly in male 15-40 years Blunt injuries 80% Male: blunt trauma unilateral 1% bilateral scrotal or testicular injuries Penetrating injuries 20%
40-60% penetrating involves external genitalia
Usually occurs with other associated injuries in 70%
Causes:







 MVA  Domestic violance  Self-mutilation & piercing

- Sports - War & Crime - Burn

Brandes SB, Buckman RF, Chelsky MJ, et al. External genitalia gunshot wounds: a ten-year experience with fifty-six cases. J Trauma 1995 Aug;39(2):266-71.

General Principles


Urinalysis = haematuria  Male – retrograde urethrogram, cystoscopy  Female – cystoscopy, vaginal examination





Gunshot – detail of the weapon, range Bites  Animal e.g dog bite Pasturella Multicida, up to 50% of infections  Choice of antibiotics: penicillin-amoxiclavulanic acid followed by

doxycycline, cephalosporin or erythromycin for 10-14 days  Vaccination with human rabies Ig and human diploid cell vaccine  Human bites: hepatitis B vaccine/ Ig and/or HIV post-exposure prophylaxis


Sexual assault  40% after sexual abuse  only 38% of forensic samples positive for an ejaculate and/or sperm

McGregor MJ, Du Mont J, Myhr TL. Sexual assault forensic medical examination: is evidence related to successful prosecution? Ann Emerg Med 2002 Jun;39(6):639-47 Donovan JF, Kaplan WE. The therapy of genital trauma by dog bite. J Urol 1989 May;141(5):1163-5 Presutti RJ. Bite wounds. Early treatment and prophylaxis against infectious complications. Postgrad Med 1997 Apr;101(4):243-4, 246-52, 254. Guidelines for the Management of Human Bite Injuries. Health Protection Agency North West 2007. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947350692

Blunt penile trauma Trauma to flaccid penis – subcutaneous hematoma with intact tunica albuginea

Penile Fracture


trauma to erect penis during    




sexual intercourse masturbation rolling over in bed self-inflicted bending to produce detumescence in some Middle Eastern Cultures – a practice known as taqaandan “to click”

thickness of tunica albuginea  flaccid 2 mm  erect 0.25-0.5 mm




rupture of the cavernosal tunica albuginea  subcutaneous haematoma  lesions of the corpus spongiosum or urethra in 10-22%

Tsang T, Demby AM. Penile fracture with urethral injury. J Urol 1992 Feb;147(2):466-8 Zargooshi J. Penile fracture in Kermanshah, Iran: report of 172 cases. J Urol 2000 Aug;164(2):364-6

History and examination usually confirm the diagnosis








sudden ‘crack’ or ‘pop’, pain and immediate detumescence local enlarging hematoma of penile shaft develops quickly bleeding may spread along the fascial layers of the shaft and extend to the lower abdominal wall if Buck’s fascia is also ruptured ruptured tunica may be palpable less severe penile injuries can be distinguished from penile fracture which is classically associated with rapid post-traumatic detumescence.




unclear cases  Cavernosography, US or MRI




suspected urethral injury  retrograde urethrogram  flex CE on table




subcutaneous haematoma, without rupture of cavernosal tunica albuginea  conservative with nonsteroidals & ice-packs

Karadeniz T, Topsakal M, Ariman A, et al. Penile fracture: differential diagnosis, management and outcome. Br J Urol 1996 Feb;77(2):279-81

Management




Early surgical exploration Flex CE 2 ways  Circumferential incision prox to coronal sulcus (ie circumcision wound), deglove  Local longitudinal incision at suspected area





Absorbable sutures, Octopus dressing Complications     





wound infection impotence in 1.3% Mild to moderate penile curvature Penile nodules Mild paraesthesia over the scar line

Conservative management not recommended Penile abscess, missed urethral disruption, penile curvature, persistent haematoma requiring delayed surgical intervention, fibrosis and angulations in 35% and impotence in up to 62%

Nicolaisen GS, Melamud A, Williams RD, et al. Rupture of the corpus cavernosum: surgical management. J Urol 1983 Nov;130(5):917-9 Orvis BR, McAninch JW. Penile rupture. Urol Clin North Am 1989 May;16(2):369-75.

Penetrating penile trauma


Small superficial with intact Buck’s fascia  conservative




More significant  surgical exploration  conservative debridement of necrotic tissue  primary alignment of disrupted tissues (good penile

blood supply)  +/- urinary diversion



Loss of moderate amount of skin is ok due to elasticity of the penile skin Large defect in tunica repaired with a patch (autologous saphenous vein or xenograft), either initially or delayed.

McAninch JW, Kahn RI, Jeffrey RB, et al. Major traumatic and septic genital injuries. J Trauma 1984 Apr;24(4):291-8 Phonsombat S, Master VA, McAninch JW. Penetrating external genitalia trauma: a 30-year single institution experience. J Urology 2008 Jul;180(1):192-5




Penile recon after 4-6 weeks  Split-skin graft not good due to potential

contracture, therefore only minimal use on shaft  Skin graft thickness > 0.4 mm to reduce the risk  Full thickness less contracture, better cosmesis and more resistance to trauma from intercourse  Donor site: abdomen, buttock, thigh or axilla Summerton DJ, Campbell A, Minhas S, et al. Reconstructive surgery in penile trauma and cancer. Nat Clin Pract Urol 2005 Aug;2(8):391-7 McAninch JW, Kahn RI, Jeffrey RB, et al. Major traumatic and septic genital injuries. J Trauma 1984 Apr;24(4):291-8.

Penile Avulsion & Amputation








Surgical re-implantation within 24 h Washed with sterile saline, wrapped in saline-soaked gauze, placed in a sterile bag and immersed in iced water (not direct contact) Pressure or tourniquet around penile stump Non-microsurgical gives a higher postop urethral stricture rate and loss of sensation Microsurgical re-implantation    




corpora cavernosa and urethra are aligned dorsal penile arteries, vein and dorsal nerves repaired cavernosal arteries are too small to anastomose fascia and skin closed, both CBD and SPC placed

If not possible – closed as partial penectomy, later recon for lengthening

Scrotal Trauma


Blunt trauma  testicular dislocation  testicular haematocoele  testicular rupture  scrotal haematoma

Testicular dislocation Bilateral dislocation of the testes has been reported in up to 25% of cases
Either subcutaneous dislocation with epifascial displacement of the testis or an internal dislocation (superficial ext ring, inguinal canal or abdominal cavity)
Manual replacement and secondary orchidopexy
If primary manual reposition cannot be performed, immediate orchidopexy


Nagarajan VP, Pranikoff K, Imahori SC, et al. Traumatic dislocation of testis. Urology 1983 Nov;22(5):521-4

Haematocele Conservative in haematoceles < 3x the size of contralateral testis
Large haematoceles need surgery irrespective of testicle contusion or rupture
Early surgical intervention resulted in > 90% preservation of the testis whereas delayed surgery necessitates orchidectomy in 45-55%


Cass AS, Luxenberg M. Testicular injuries. Urology 1991 Jun;37(6):528-30 Tiguert R, Harb JF, Hurley PM, et al. Management of shotgun injuries to the pelvis and lower genitourinary system. Urology 2000 Feb;55(2):193-7

Testicular rupture





approximately 50% of direct blunt scrotal trauma a force of 50kg is necessary to cause testicular rupture hemiscrotum is tender, swollen, eccymotic, testis itself may be difficult to palpate US to determine intra and/or extratesticular haematoma, testicular contusion, or rupture  Contradictory result in terms of specificity




Exploration with evacuation of clot and haematoma, excision of any necrotic testicular tubules and closure of tunica albuginea with running absorbable sutures

Wasko R, Goldstein AG. Traumatic rupture of the testicle. J Urol 1966 May;95(5):721-3

Penetrating Scrotal Trauma exploration with conservative debridement of non-viable tissue
primary recon of testis and scrotum
complete disruption of spermatic cord, realignment without vaso-vasostomy if surgically feasible, staged secondary microsurgical vaso-vasostomy later
if extensive destruction of tunica albuginea, mobilisation of free tunica vaginalis flap for closure


Altarac S. A case of testicle replantation. J Urol 1993 Nov;150(5 Pt 1):1507-8

Genital Trauma in Females








imaging pelvis with US, CT, or MRI should be performed TRO additional injuries incidence of traumatic vulvar haematomas after vaginal deliveries 1 in 310 blunt injuries associated with pelvic trauma 30%, after consensual intercourse 25%, sexual assault 20%, other blunt trauma 15% vaginal EUA, Flexible or rigid CE to exclude urethral bladder injury conservative with CBD, icepacks, NSAIDs

Goldman HB, Idom CB Jr, Dmochowski RR. Traumatic injuries of the female external genitalia and their association with urological injuries. J Urol 1998 Mar;159(3):956-9 Sotto LS, Collins RJ. Perigenital Hematomas; analysis of forty-seven consecutive cases. Obstet Gynecol 1958 Sep;13:259-63 Okur H, Küçïkaydin M, Kazez A, et al. Genitourinary tract injuries in girls. Br J Urol 1996 Sep;78(3)