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References
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24. Dawood O, Tabibi S, Fiuk J, Patel N, El-Zawahry A.Penile ring entrapment—a true urologic
emergency: grading, approach, and management. Urol Ann. 2020;12(1):15–8. https://doi.
org/10.4103/UA.UA_16_19. Epub 2019 Nov 7. PMID: 32015611; PMCID: PMC6978966.
25. Bhat AL, Kumar A, Mathur SC, Gangwal KC. Penile strangulation. Br J Urol.
1991;68(6):618–21. https://doi.org/10.1111/j.1464- 410x.1991.tb15426.x. PMID: 1773293.
26. Rashid M, Sarwar SU.Avulsion injuries of the male external genitalia: classication and reconstruction with the customised radial forearm free ap. Br J Plast Surg. 2005;58(5):585–92.
https://doi.org/10.1016/j.bjps.2004.12.014. PMID: 15927151.
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Treatment ofPenile Injury. I: Minor
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andIntermediate Surgeries
The treatment of penile trauma is a vast topic that linearly correlates with the anatomopathology and the severity of the injury. It may just be a minor or intermediate
intervention such as supercial wound suturing, zipper or constricting ring removal,
and repair of a penile fracture, but may also consist of complex procedures such as
penile replantation, reconstruction, or transplantation.
39.1 Management ofZipper Entrapment
As already mentioned in the chapter on etiology, zipper accident is the most frequent cause of penile injury, and for obvious reasons, it affects mostly uncircumcised children and adults.
Zippers can be removed through various methods. The most rapid and easiest
one is lubrication and manual disengagement. Sometimes it may be necessary to
saw the median bar with a hacksaw, scissor, or bone cutter, or to disassemble the
fastener by cutting the zipper teeth [1–5]. Also, the insertion of a small-size screwdriver between the outer and inner faceplates of the zipper and twisting it toward the
median bar may widen the faceplates and disengage the prepuce (Fig.39.1a, b) [6].
Of course, the screwdriver should be inserted into the opposite side of the prepuce.
When these non-surgical methods are not successful, minimal surgery will be
required consisting of the excision of the entrapped skin. As a last resort, circumcision can be required.
39
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Ltd. 2023
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https://doi.org/10.1007/978-981-99-6171-9_39
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39 Treatment ofPenile Injury. I: Minor andIntermediate Surgeries
ab
Fig. 39.1 (a) Macrophotography showing the structural anatomy of zip fastener from its inner
aspect. The outer and inner faceplates along with the median bar form the fastener. (b)
Macrophotography showing the position of screwdriver between the two faceplates. It should be
twisted toward the median bar (anticlockwise with reference to the gure). (From Raveenthiran V
[6], with permission from Wolters Kluwer Health)
39.2 Removal ofaPenile Ring
The constricting ring can be metallic (wedding rings, nuts), elastic (rubber bands,
bottlenecks), or made of thread or hair. The elastic rings, threads, and hairs are easily sectioned using ne scissors. The metallic rings can be removed through two
methods [2, 7]:
– The easiest and fastest one is lubricating and sliding the ring off the penis
– Cutting the ring off is indicated after failure of sliding.
When the above two methods have failed, one has to proceed to surgery consisting of lateral corporotomy to reduce the edema and facilitate the rst step, i.e. lubrication and sliding of the ring [8]. Penile amputation and cystotomy or perineal
urethrostomy can be necessary for late presentation of a penile ring with gangrene [9].
39.3 Management ofPenile Fracture
A retrospective analysis comparing interventional and conservative approaches to
penile fracture showed erectile dysfunction in 11.4% and 33.3% of cases, respectively, after a mean follow-up of 19 months. Additionally, 50% of the patients
treated conservatively developed penile deviation [10]. All expert panels (EAU,
AUA, BAUS) strongly recommend surgically treating any penile fracture by repairing the tunica albuginea and eventual urethral injury [11–13].
Regarding the timing of intervention, a systematic review comparing immediate
and delayed repair of penile fracture did not show a signicant difference for ED
and tunical scars with values of 6.6% vs 4.5%, and 5.4% vs 4.5%, respectively.
Nevertheless, the rate of curvature signicantly favored immediate repair over the
39.4 Penile Wound Repair
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delayed approach with values of 1.8% and 4.5%, respectively, although the curvature was reported as mild and not affecting sexual function [14]. These studies are
supported by a meta-analysis and other systematic reviews that reached the same
conclusions: any penile fracture is better repaired, and the intervention should
be performed early, preferably within 24 h [15, 16]. These conclusions were
unequivocally endorsed by the British Association of Urological Surgeons
(BAUS) [13].
329
39.3.1 Technique forCorporeal Repair
The patient should be given prophylaxis with a broad-spectrum antibiotic and a
catheter be inserted before the procedure after ruling out a urethral injury [13, 16–18].
– Incision: The surgeon has a choice between two common incisions to approach
the corporeal tear: a sub-coronal incision with penile degloving (the most popu-
lar), or a penoscrotal vertical incision. The rst incision allows full inspection of
the corpora and is useful when the exact location of the tear is not dened. It has
also a cosmetic advantage as the nal scar will be confused with the post-
circumcision one. However, its drawback is the risk of neurovascular injury if the
incision is too deep dorsally, urethral injury if too deep ventrally, or skin necrosis
if too supercially and thin skin is peeled off during degloving. The advantage of
the vertical incision is direct exposure to the injury site but supposes that precise
information is available beforehand.
– Repair of the corporeal tear: Once the injury site is exposed, the hematoma is
removed, and the tunical defect is identied and washed with a saline solution.
The tear is most commonly sutured using interrupted resorbable 2/0 suture mate-
rials (polyglactin or polydioxanone PDS) in a watertight technique with bur-
ied knots.
– If the urethra is also injured, it should be repaired with 4/0 resorbable sutures,
and stented with a catheter
– Regloving and skin closure with interrupted 2/0 or 3/0 resorbable suture (rapid
vicryl).
Patients are generally discharged home the next day, advised abstinence for
4–6weeks, and reviewed after 2weeks in the outpatient department. Cyproterone
tablets can be prescribed to reduce libido and prevent erection.
39.4 Penile Wound Repair
A simple skin incision with no tissue loss can be directly closed using interrupted
4/0 resorbable sutures. When there is isolated skin loss, a split-thickness skin grafting is a good means for reliable coverage [19]. Scrotal skin aps (based on the
330
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39 Treatment ofPenile Injury. I: Minor andIntermediate Surgeries
anterior and posterior scrotal arteries), or commercial dermal substitutes such as
Integra (bovine collagen, Integra Life Sciences Corp., Plainsboro, NJ) are good
options in cases not amenable to immediate split-thickness skin grafting [19]. In
order to ensure a high potency rate and minimize the occurrence of urethral stricture, low-velocity gunshot injuries with urethral rupture must be repaired layer by
layer after debridement and urethral spatulation [20, 21].
A recent American national database analysis of 722 cases of gunshot penile
injury revealed that penile salvage is successful in most patients, with only 13 of
them (1.8%) requiring penectomy [22]. Indeed low-velocity bullets generally cause
limited wounds with no complete destruction of the penis [23, 24] (Figs. 39.2
and 39.3).
Fig. 39.2 (a) A forceps demonstrating the bullet path through the penile the glans penis and distal
urethra. (b) The glans penis after reconstruction. (From Ozkan Onuk etal. [23]. Creative Commons
Attribution-Share Alike 4.0 International (CC BY-SA 4.0) license)
ab
References
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331
Fig. 39.3 Low-velocity penile GSW. (a) Perioperative view of extensive urethral and corporal
disruptions (yellow arrow), and scrotal laceration (green arrow). (b) One-week postoperative
photo showing a good cosmetic appearance of the external genitalia. (From Ghabisha S etal. [24],
Creative Commons Attribution License)
References
1. Kim JH, Park JY, Song YS.Traumatic penile injury: from circumcision injury to penile amputation. Biomed Res Int. 2014;2014:375285. https://doi.org/10.1155/2014/375285. Epub 2014
Aug 28. PMID: 25250318; PMCID: PMC4164514.
2. Leslie SW, Sajjad H, Taylor RS.Penile Zipper and ring injuries. In: StatPearls [Internet].
Treasure Island: StatPearls Publishing; 2022. PMID: 28722916.
3. Nakagawa T, Toguri AG.Penile Zipper injury. Med Princ Pract. 2006;15:303–4. https://doi.
org/10.1159/000092995.
4. Flowerdew R, Fishman IJ, Churchill BM. Management of penile zipper injury. J Urol.
1977;117(5):671. https://doi.org/10.1016/s0022- 5347(17)58581- x. PMID: 859209.
5. Krishna Reddy SV, Shaik AB, Sreenivas K.Penile injuries: a 10-year experience. Can Urol
Assoc J. 2014;8(9–10):E626–31. https://doi.org/10.5489/cuaj.1821. PMID: 25295134;
PMCID: PMC4164551.
332
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6. Raveenthiran V.Releasing of zipper-entrapped foreskin: a novel nonsurgical technique. Pediatr
Emerg Care. 2007;23(7):463–4. https://doi.org/10.1097/01.pec.0000280505.37300.c1. PMID:
17666927.
7. Dawood O, Tabibi S, Fiuk J, Patel N, El-Zawahry A.Penile ring entrapment—a true urologic
emergency: grading, approach, and management. Urol Ann. 2020;12(1):15–8. https://doi.
org/10.4103/UA.UA_16_19. Epub 2019 Nov 7. PMID: 32015611; PMCID: PMC6978966.
8. Alkhureeb M.Case report of early release of penile strangulation by metallic rings. Int J Sci
Res. 2016;5:1442–4.
9. Nuhu A, Edino ST, Agbese GO, Kallamu M.Penile gangrene due to strangulation by a metallic
nut: a case report. West Afr J Med. 2009;28:340–2.
10. Yamaçake KG, Tavares A, Padovani GP, Guglielmetti GB, Cury J, Srougi M. Long-term
treatment outcomes between surgical correction and conservative management for penile
fracture: retrospective analysis. Korean J Urol. 2013;54(7):472–6. https://doi.org/10.4111/
kju.2013.54.7.472. Epub 2013 Jul 15. PMID: 23878691; PMCID: PMC3715712.
11. EAU guidelines. Edn. presented at the EAU annual congress Amsterdam March 2022.
isbn:978-94-92671-16-5. https://uroweb.org/guidelines/urological- trauma/chapter/
urogenital- trauma- guidelines
12. Morey AF, Brandes S, Dugi DD 3rd, etal. Urotrauma: AUA guideline. J Urol. 2014;192:327.
https://www.auanet.org/guidelines- and- quality/guidelines/urotrauma- guideline
13. Rees RW, Brown G, Dorkin T, Lucky M, Pearcy R, Shabbir M, Shukla CJ, Summerton
DJ, Muneer A, BAUS Section of Andrology and Genitourethral Surgery (AGUS). British
Association of Urological Surgeons (BAUS) consensus document for the management of male
genital emergencies - penile fracture. BJU Int. 2018;122(1):26–8. https://doi.org/10.1111/
bju.14167. Epub 2018 Apr 2. PMID: 29438589.
14. Wong NC, Dason S, Bansal RK, Davies TO, Braga LH.Can it wait? A systematic review of
immediate vs. delayed surgical repair of penile fractures. Can Urol Assoc J. 2017;11(1–2):53–60.
https://doi.org/10.5489/cuaj.4032. PMID: 28443146; PMCID: PMC5403677.
15. Amer T, Wilson R, Chlosta P, AlBuheissi S, Qazi H, Fraser M, Aboumarzouk OM.Penile fracture: a meta-analysis. Urol Int. 2016;96(3):315–29. https://doi.org/10.1159/000444884. Epub
2016 Mar 9. PMID: 26953932.
16. Kominsky H, Beebe S, Shah N, Jenkins LC.Surgical reconstruction for penile fracture: a systematic review. Int J Impot Res. 2020;32(1):75–80. https://doi.org/10.1038/s41443- 019- 0212- 1.
Epub 2019 Nov 4. PMID: 31685943.
17. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current management of penile fracture: an
up-to-date systematic review. Sex Med Rev. 2018;6(2):253–60. https://doi.org/10.1016/j.
sxmr.2017.07.009. Epub 2017 Sep 2. PMID: 28874325.
18. Kamdar C, Mooppan UM, Kim H, Gulmi FA.Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome. BJU Int. 2008;102(11):1640–4; discussion 1644.
Epub 2008 Aug 14. PMID: 18710448. https://doi.org/10.1111/j.1464- 410X.2008.07902.x.
19. Salgado CJ, Chim H, Tang JC, Monstrey SJ, Mardini S.Penile reconstruction. Semin Plast
Surg. 2011;25(3):221–8. https://doi.org/10.1055/s- 0031- 1281492. PMID: 22851914; PMCID:
PMC3312184.
20. Hall SJ, Wagner JR, Edelstein RA, Carpinito GA. Management of gunshot injuries to the penis and anterior urethra. J Trauma. 1995;38(3):439–43. https://doi.
org/10.1097/00005373- 199503000- 00028. PMID: 7897734.
21. Goldman C, Shaw N, du Plessis D, Myers JB, van der Merwe A, Venkatesan K. Gunshot
wounds to the penis and scrotum: a narrative review of management in civilian and military
settings. Transl Androl Urol. 2021;10(6):2596–608. https://doi.org/10.21037/tau- 20- 1175.
PMID: 34295746; PMCID: PMC8261456.
39 Treatment ofPenile Injury. I: Minor andIntermediate Surgeries
References
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22. Maxwell BG, Chouhan JD, Lundeberg MR, Liu JJ.National patterns of injury and outcomes
of gunshot wounds to the penis: a trauma quality programs retrospective cohort analysis. Acute
Med Surg. 2021;8(1):e636. https://doi.org/10.1002/ams2.636. PMID: 33747534; PMCID:
PMC7962619.
23. Onuk O, Arslan B, Yanaral F, Hazar A, Özkan A, Gezmis C, Nuhoğlu B.Management of
gunshot injury of glans penis that extends to anterior urethra: a rare case report. Haseki Tıp
Bülteni. 2016;54:249–51. https://doi.org/10.4274/haseki.3125.
24. Ghabisha S, Ahmed F, Al-wageeh S, Al-shami E, Alyhari Q, Dajenah M, Mohammed
F.Penetrating trauma to scrotum and penis caused by a gunshot in 17-year old man: a case
report. J Emerg Med Trauma Acute Care. 2022. https://doi.org/10.5339/jemtac.2022.21.
333
Treatment ofPenile Injury. II: Complex
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Procedures
Severe penile injuries (severance, crush, etc. are extremely rare and their management is poorly mastered by most Regional Urological surgeons and are better transferred to specialized centers where multispecialty expertise is available including
plastic surgery.
40.1 Penile Replantation
Penile replantation is the best option when the penis has been sharply sectioned and
the patient presents early with the amputated appendage which should be wrapped
in saline-soaked gauze, then in a plastic bag and covered with ice during transport
[1]. This surgery is more successful nowadays thanks to the introduction of micro-
surgical approach. But before that, pioneers have performed penile replantation
using macrosurgical techniques, the rst case was reported by Ehrich in 1929 [2].
This was followed by dozens of cases with fairly satisfactory results.
The technique consisted essentially of urethral anastomosis, repair of the corpora
cavernosa and spongiosa, and skin suturing, but without neuro-vascular anastomosis. Many complications have been reported from the macrosurgical approach
including a high rate of urethral stenosis, stula formation, skin necrosis, nonrecovery of sensation, and erectile dysfunction [3–5]. If the patient loses only the
glans penis, a glansplasty may be all that is required. Herein no identiable vessels
are present and composite grafting, i.e. macrosurgical approach is the only possible
local solution [6].
The rst microsurgical penile replantation was performed in 1977 by two
teams working independently on psychotic patients who self-amputated their genitalia: a Japanese team, Tamai et al., and an American one, Cohen etal. [7, 8].
Nowadays, the microsurgical approach should be considered the standard for this
surgery [5].
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https://doi.org/10.1007/978-981-99-6171-9_40
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A retrospective analysis performed in 2017, and recruiting 106 patients who
underwent penile replantation from self-mutilation or trauma showed maintained
full sensation in 68% of patients, adequate urinary function in 97%, and normal
erection in 77%. The most common complications were skin necrosis and venous
congestion in 55% and 20%, respectively. Others were urethral stricture and stula
in 11% and 6.6%, respectively. The overall patient satisfaction rate was 91.6% [9].
The majority of the patients (67%) underwent a microsurgical approach conrming
the new trend. Unfortunately, this study did not differentiate the outcomes between
the two techniques. This study also showed that anastomosis of the supercial dorsal artery and a larger number of coapted nerves were associated with favorable
sexual, urinary, and sensation outcomes. Paradoxically, however, larger numbers of
anastomosed vessels were associated with unfavorable outcomes, probably because
of longer ischemic time [9].
40 Treatment ofPenile Injury. II: Complex Procedures
40.1.1 Surgical Steps ofPenile Replantation [3, 10]
The amputated penis is washed with saline and preserved in a plastic bag covered
with ice. After a suprapubic catheter is inserted, and an I-V broad-spectrum antibiotic is given, the technique of penile replantation starts with debridement of the
stump, and a silicone urethral catheter is inserted through the amputated penis and
then through the stump and will act as a stabilizing stent. The operating microscope
allows clear identication and safe dissection of vessels and nerves.
The replantation is performed in a progressive way where the Urologist and
Plastic Surgeon work together in a stepwise manner. The operation starts ventrally
and progresses through deep and dorsal structures. Hence, the urethral anastomosis
is rst performed by the Urologist after spatulation and using 4/0 resorbable sutures
(vicryl, polydioxanone), ideally in two layers. This is followed by the challenging
anastomosis of the thin and short deep (profunda) arteries performed by the Plastic
Surgeon. Then the tunica albuginea of both corpora cavernosa is repaired with 5/0
resorbable (Vicryl, polydioxanone) sutures, followed by a watertight repair of the
cavernosa, preferably using a continuous suture. The last structures to be anastomosed are the supercial and deep dorsal veins, the dorsal artery, and the dorsal
nerves using 9/0 or 10/0 Ethilon or nylon. By the end, the fascia, the areolar tissue,
and the skin are approximated with 4/0 Ethilon (Figs.40.1 and 40.2).
Post-operatively, the patient is closely monitored for early ischemia by direct
inspection every 30min and Doppler ultrasound at short intervals or immediately
whenever suspect signs are observed (coldness, change of color). He continues I-V
broad-spectrum antibiotics and is started on prophylactic low-molecular weight
heparins.
Sometimes the venous outow might not be sufcient as it takes around 96h
(4days) for graft neovascularization to be permanently established. The developing
venous congestion might cause an excessive hematoma and edema resulting in skin
necrosis and loss. Herein therapy with medicinal leeches (Hirudo medicinalis) was
proven to be an interesting temporary measure for venous drainage [3, 11].
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