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References
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org/10.1007/s12519- 015- 0015- 5. Epub 2015 Mar 9. PMID: 25754752.
19. Boillot B, Teklali Y, Moog R, Droupy S. Les malformations congénitales du pénis [Penile
congenital abnormalities]. Prog Urol. 2013;23(9):664–73. French. Epub 2013 Apr 4. https://
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21805016; PMCID: PMC5720069.
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J. 2015;9(11–12):E805–7. https://doi.org/10.5489/cuaj.2833. Epub 2015 Nov 4. PMID:
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https://doi.org/10.1007/978- 3- 662- 43680- 6_2.
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2019;25:1. https://doi.org/10.1186/s12301- 019- 0001- 6.
24. Talebpour Amiri F, Nasiry Zarrin Ghabaee D, Naeimi RA, Seyedi SJ, Mousavi SA.Aphallia:
report of three cases and literature review. Int J Reprod Biomed. 2016;14(4):279–84. PMID:
27351031; PMCID: PMC4918779.
25. Qiang S, Li FY, Zhou Y, Yuan Y, Li Q. Congenital absence of the penis (aphallia): a
rare case report. Medicine (Baltimore). 2019;98(15):e15129. https://doi.org/10.1097/
MD.0000000000015129. PMID: 30985678; PMCID: PMC6485865.
26. Mirshemirani AR, Sadeghyian N, Mohajerzadeh L, Molayee H, Ghaffari P.Diphallus: report
on six cases and review of the literature. Iran J Pediatr. 2010;20(3):353–7. PMID: 23056729;
PMCID: PMC3446048.
27. Jabali SS, Mohammed AA.Triphallia (triple penis), the rst reported case in human. Int J Surg
Case Rep. 2020;77:198–200. https://doi.org/10.1016/j.ijscr.2020.11.008. Epub 2020 Nov 4.
PMID: 33166819; PMCID: PMC7652711.
303
Epidemiology ofPenile Injury
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36
Penile injuries mostly consist of circumcision mishaps in children, penile fractures
in adults, and zipper entrapment at all ages. Other causes include non-sexual-related
accidents, assaults, and self-inicted injuries.
There are approximately 2000 cases of zipper-related penis injury (ZIRPI)
reported every year in the world [1]. Since penile fracture represents the most frequent cause of penile trauma in patients seeking help in hospitals and referred to
specialized Urology care, it will cover the largest place in the following discussion.
The rst report on penile fracture in modern medical literature was written in 1925
[2]. It mostly occurs during sexual activity and mainly affects young adults with a
mean age of 36–39years [3–5], and its incidence varies with ethnicity and geographical regions. It has been globally estimated to be 1in 175,000 male population
but was found to reach 1.02 to 1.8 per 100,000in the United States or to be as higher
as 1.14 to 10.48 per 100,000 men in Iran [6–9] where every urologist may encounter
a case of penile fracture every 3.5months.
Apart from penile fractures, other penile injuries are extremely rare and no robust
epidemiological study can be reliably made. A recent comprehensive American
national database review including 753 accredited trauma centers recruited 722
patients with penile gunshot wounds, representing 1.7% of all GSW [10].
Cases of genital self-mutilations (GSM) are reported here and there in association with psychiatric instabilities. This pathological entity will be discussed separately in a special section at the end of this book. Assaults account also for an
extremely low percentage of penile injuries. A noteworthy epidemic of penile
amputation was observed in Thailand in the 1970s perpetrated by angry wives
against philandering husbands, with an estimate of 100 such incidents between
1973 and 1980 [11].
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_36
305
306
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36 Epidemiology ofPenile Injury
References
1. Leslie SW, Sajjad H, Taylor RS.Penile Zipper and ring injuries. In: StatPearls [Internet].
Treasure Island: StatPearls Publishing; 2022. PMID: 28722916.
2. Malis J.Zur Kasuistik der Fractura Penis. Arch Clin Chir. 1925;129:651–3.
3. Phillips EA, Esposito AJ, Munarriz R.Acute penile trauma and associated morbidity: 9-year
experience at a tertiary care center. Andrology. 2015;3(3):632–6. https://doi.org/10.1111/
andr.12043. PMID: 26013107.
4. Barros R, Hampl D, Cavalcanti AG, Favorito LA, Koifman L.Lessons learned after 20 years’
experience with penile fracture. Int Braz J Urol. 2020;46(3):409–16. https://doi.org/10.1590/
S1677- 5538.IBJU.2019.0367. PMID: 32167705; PMCID: PMC7088490.
5. 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.
6. 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.
7. Rodriguez D, Li K, Apoj M, Munarriz R.Epidemiology of penile fractures in United States
emergency departments: access to care disparities may lead to suboptimal outcomes. J Sex
Med. 2019;16(2):248–56. https://doi.org/10.1016/j.jsxm.2018.12.009. PMID: 30770071.
8. Christian-Miller N, Lenis AT, Fero KE, Madrigral J, Eleswarapu SV, Chamie K, Benharash
P.Risk factors for penile fracture compared with a surgical control cohort in the United States:
the role of substance abuse. Asian J Androl. 2021;23(3):236–9. https://doi.org/10.4103/aja.
aja_70_20. PMID: 33243961; PMCID: PMC8152430.
9. Mirzazadeh M, Fallahkarkan M, Hosseini J. Penile fracture epidemiology, diagnosis and
management in Iran: a narrative review. Transl Androl Urol. 2017;6(2):158–66. https://doi.
org/10.21037/tau.2016.12.03. PMID: 28540222; PMCID: PMC5422687.
10. 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.
11. Bhanganada K, Chayavatana T, Pongnumkul C, Tonmukayakul A, Sakolsatayadorn P,
Komaratat K, Wilde H.Surgical management of an epidemic of penile amputations in Siam.
Am J Surg. 1983;146(3):376–82. https://doi.org/10.1016/0002- 9610(83)90420- 8. PMID:
6614331.
Etiology, Mechanism,
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andAnatomopathology ofPenile Injury
Although rare, penile trauma produces a wide range of anatomopathological forms
including open injuries (biting, stabbing, or gunshot) and blunt injuries. Open injuries comprise multiple forms of gravity from a supercial incision with or without
skin loss to a total amputation of the organ. Blunt trauma mainly consists of penile
fracture but includes also injuries by constricting devices, etc.
Multiple mechanisms can be associated with penile injury including stabbing,
animal or human bites, burns, gunshots, constricting rings, and degloving machinery. However, the most frequent mechanism in adults and in children is zipper-
related penis injury (ZIRPI) by prepuce entrapment in uncircumcised
individuals with roughly around 2000 reported cases yearly [1]. Indeed, by pre-
monition, the Swedish-American electrical engineer Gideon Sundback who patented the rst zipper in 1917 as a “Separable Fastener” has reportedly expressed
some reservations with regard to possible genital injury [1]. It is important to
remember that ZIRPIs are extremely rare among circumcised males and are almost
inexistent among Arabian Gulf Countries’ citizens who have another reason to be
spared: there is no zipper in their traditional costume.
A didactic way to study the penile injury etiology consists of the distinction
between pediatric and adult causes as follows:
37
37.1 Pediatric Penile Injuries
ZIRPIs are probably the most common causes of penile injury in children but they
are seldom reported. In the Islamic world, circumcision complications accounted
for 67% of all pediatric penile injuries in a series of 64 boys with penile trauma [2].
However, complications occur in only 0.2% of circumcisions in the neonatal period
[3], and may reach 1.7%, if performed late, and comprise a wide range from bleeding and malignant hyperthermia to disgurement, partial or total amputation of the
penis [4, 5]. In the abovementioned series from an Islamic population, less frequent
© The Author(s), under exclusive license to Springer Nature Singapore Pte
Ltd. 2023
S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_37
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37 Etiology, Mechanism, andAnatomopathology ofPenile Injury
causes of penile injury after circumcision included mother’s hair strangulation
(16%), animal bite injuries (6%), bicycle accidents (6%), zipper injuries (3%), and
electrical injuries (2%) [2]. The rarest causes are self-amputation and burns [6].
Hair strangulation also called “hair tourniquet syndrome of the penis” is caused
by mother hairs and was almost exclusively reported in circumcised children in
whom removal of the prepuce bares the coronal sulcus which is the most frequent
site of the injury [7].
37.2 Adult Penile Injuries
Like in children, zipper entrapment is also probably the most common cause of
penile injuries in uncircumcised adults. However, penile fracture related to
sexual intercourse is the most frequent cause that leads the patient to the operating theater. Other causes involve penile strangulation, generally self-inicted
through the insertion of various objects such as heavy metal rings or plastic bottlenecks, etc. Another group is made of foreign bodies inserted through the urethra,
which are also generally self-inicted: wire, safety pin, etc. Penetrating injuries are
also encountered: stabbing (knife, razor, etc.), gunshots, and blasts.
A 30-year single-institution retrospective study has recorded 110 patients with
penetrating external genital trauma (penis and testicles), caused by gunshots, stabbing/lacerations, and bites, in 49%, 44%, and 7%, respectively, and half of the stabbing/lacerations were self-inicted [8].
A correlation exists between conict zones and increased occurrence of genitourinary injuries. More specically however, a trend toward fewer abdominal urological injuries was observed in well-equipped armies with the introduction of
Kevlar body armor, while casualties involving unprotected anatomical areas such as
the pelvis or external genitalia tended to increase in recent wars (Afghanistan and
Iraq). This prompted the addition of a detachable genital ap on the Kevlar armor in
2004 [9] (Table37.1).
There was an increased number of genito-urinary injuries in the US Army operations in Iraq and the majority involved the external genitalia (73.2%), including the
scrotum, the testes, the penis, and/or urethra, and penile injuries alone occurred in
Table 37.1 Inuence of
body armor on urologic
injury distribution in
contemporary conicts
Theater
Gulf War
Bosnia 45 55
Croatia 48 52
Croatia 53 47
From Hudak SJ etal. [9], with permission from Elsevier
a
Body armor was standard issue for all U.S. soldiers
Abdominal (%)
a
17 83
Pelvic/Genital (%)
37.2 Adult Penile Injuries
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309
423 US service members [10]. War-related penile injuries have also been described
among Libyan and Iraqi populations as the consequence of gunshots and explosions
and they involved both soldiers and civilians [11, 12].
Perhaps the largest study of penile gunshot injury is a recent comprehensive
American national database review of 752 accredited trauma centers that identied
722 patients [13]. It revealed that the vast majority (90.7%) resulted from an assault,
intentional self-harm, attempted suicide, or attempted homicide, while accidental
injuries were very rare.
A systematic review of 86 cases of amputation has revealed that the most
common cause was self-mutilation (43.9%), followed by partner violence
(25.6%). Other less frequent causes were work injury (9.8%), circumcision complications (9.8%), assault (7.3%), and animal bites [14]. Indeed, hundreds of selfinicted injuries have been reported in the medical literature and will be developed
in a separate section at the end of this book due to their complex underlying etiology.
Genital electrocution has been exceptionally reported in the literature, and a new
concept was introduced, the Uromanual injury or uromanual high voltage
trauma. Its main cause is urination on a high-voltage electrical source resulting in
damage to the urogenital area and upper extremities to various degrees, potentially
leading to complete penile destruction and amputation (Fig.37.1) [15]. The electricity is transmitted retrogradely by the urine from the power cable to the penis and the
supporting hand(s) during micturition.
Fig. 37.1 Complete penile
amputation due to
uromanual high voltage
trauma. (From Adamyan
RT etal. [15], with
permission from Wolters
Kluwer)
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37 Etiology, Mechanism, andAnatomopathology ofPenile Injury
Another peculiarity is the penile dislocation with inversion that resulted from a
blunt pelvic trauma, with only a handful of cases reported in the literature [16–19].
The inversion may be total or partial, and the patient may present early in the acute
episode, or late complaining of inability to perform sexual intercourse (Figs.37.2,
37.3, and 37.4a, b).
Other rare events of external genital injury have occurred through inadvertent
suction by a vacuum cleaner, and more exceptionally by a faulty circulation system
in a swimming pool, especially with the Jacuzzi system (Fig.37.5).
Fig. 37.2 Sagittal MRI of
a 26-year-old man who
sustained pelvic fracture in
an RTA: (a) bladder; (b)
‘herniation’ of prevesical
fat; (c) retracted corpora
cavernosa; (d) right
testicle; (e) bowel; and (f)
coccyx bone. Note the
absence of the pars
pendulans penis. (From
Simonis LA etal. [18],
with permission from
Springer Nature)
Fig. 37.3 Pelvis
Computed Tomography of
a 55-year-old man with a
four-year history of RTA
showing a fractured left
pubic bone shifted inside
(arrow) that was pulling
the penis by its suspensory
ligament. (From Masuda H
etal. [19]. Copyright ©
2004 Masuda etal.;
licensee BioMed Central
Ltd.)
ab
37.2 Adult Penile Injuries
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Fig. 37.4 (a) Preoperative view showing partially inverted penis (same patient in Fig.37.3). (b)
Postoperative appearance of the penis after a penile lengthening procedure including suspensory
desmotomy, inverse V-Y-plasty of the dorsal skin of the penile root, and fat removal. (From Masuda
H etal. [19]. Copyright © 2004 Masuda etal.; licensee BioMed Central Ltd.)
Fig. 37.5 A 13-year-old
boy with extensive bruising
of the scrotum, penis,
lower abdominal wall and
upper thighs after
sustaining a suction injury
by the outlet hole of a
Jacuzzi system in the
family swimming pool.
(Courtesy Kurian George,
Retiree from the Urology
Department, The Royal
Hospital, Muscat, Oman)
311
37.2.1 Specific Mechanism andAnatomopathology
ofPenile Fracture
Penile fracture is dened as a traumatic rupture of the tunica albuginea of the corpus
cavernosum. The tunica albuginea is 2mm thick. During a normal erection, the
corpora cavernosa elongate and their circumference widens at the same time.
Therefore, the thickness of the tunica albuginea considerably decreases to about
0.25mm resulting in increased susceptibility to injury once the tunica tensile
strength (1500mm Hg) is exceeded. However, the corpus spongiosum only elon-
gates, hence its tunica maintains its normal thickness and is less prone to rupture.
This explains why only a minority of cases of penile fracture are associated with
spongiosal rupture and urethral injury [20].
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37 Etiology, Mechanism, andAnatomopathology ofPenile Injury
The sexual position carrying the highest risk of penile fracture was shown to be
the doggy style, accounting for 40.3% in a Brazilian series of 285 patients. The
“man on top” position accounted for only 12.1%, and contrary to the general belief
the so-called “Position d’Andromaque” * (“woman on top”) contributed to only
4.3% of all the cases [21].
*This expression is found in French literature and means “Andromache position”
based on the description of the Latin Poet Martial in his Epigrams, Book XI, where
he depicts the position of Hector’s spouse “riding” her husband [22].
A meta-analysis including 58 relevant studies for a total of over 3 thousand
patients showed that intercourse accounts for about half of the causes (48%) of
penile fracture and masturbation and forced exion for 39% [23]. Other systematic
reviews showed a higher rate of sexual intercourse (80%) [24].
Unilateral cavernosal injuries are more frequent than bilateral ones with the
occurrence of 69%, and 31%, respectively [20], and the right corpus cavernosum
fractures are more frequent than left accounting for 65–71% and causing the
penis to bend to the left side [25, 26]. Most tears are transverse in orientation,
and their sizes may be as short as 0.5cm or as long as 6cm. 50% are located in the
midshaft, others are found proximally or distally, and most of them are lateral
(62%), but they can also be found ventrally or dorsally [26]. Ureteral injuries are
encountered in 10–38% of penile fractures [19, 20, 26], but complete urethral
rupture is associated with bilateral cavernosal injuries in 100% of cases [27–
29] (Figs.37.6, 37.7, and 37.8).
For these reasons, the EAU and AUA strongly recommend excluding urethral
injury in the evaluation of any penile fracture [30, 31].
Interestingly, in the Middle East the so-called “Taqaandan,” a forcible manual
self-squeezing and bending of the distal penis to achieve sudden detumescence, is
the most common reported cause of penile fracture, accounting for 62–76.4%, while
sexual intercourse was confessed only by a minority of patients (7.9–9.5%) [24, 32].
Fig. 37.6 Urethral injury
at the site of a corporal
tear. (From Phillips EA
etal. [27], with permission
from John Wiley and Sons)
37.2 Adult Penile Injuries
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Fig. 37.7 Complete
rupture of the urethra
associated with bilateral
injury in the corpus
cavernosum. (From Barros
R etal. [21]. Creative
Commons Attribution
License)
Fig. 37.8 Penile fracture
with urethral injury and
bilateral rupture of the
corpora cavernosa. (From
Barros R etal. [29],
Creative Commons
Attribution License)
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