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Genital Trauma

By Noel A. Armenakas, MD

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Most genital trauma occurs in men and includes injury to the testes, scrotum, and penis. Genital mutilation of women by removing the clitoris, which is done in some cultures, is a form of genital trauma and child abuse.

Most testicular injuries result from blunt trauma (eg, assaults, motor vehicle crashes, sports injuries); penetrating testicular injuries are far less common. Testicular injuries are classified as contusions or, if the tunica albuginea is disrupted, as ruptures.

Scrotal injury may be caused by penetrating trauma, burns, avulsions, and bites.

Penile injuries have diverse mechanisms. Zipper injuries are common. Penile fractures, which are ruptures of the corpus cavernosum, occur most often when the penis is forcibly bent during sexual activity; urethral injury may also be present. Amputations (usually self-inflicted or due to clothing trapped by heavy machinery) and strangulations (usually due to constricting penile rings used to enhance erections) are additional mechanisms. Penetrating injuries, including animal and human bites and gunshot wounds, are less common; gunshot wounds often involve the urethra.

Complications of genital injuries include infection, tissue loss, erectile dysfunction, male hypogonadism, and urethral scarring.

Symptoms and Signs

Symptoms after a direct scrotal blow are usually scrotal pain and swelling. Signs may include scrotal discoloration and a tender, firm scrotal mass that fails to transilluminate, suggesting a hematocele. Scrotal penetration suggests the possibility of testicular involvement. Often the examination is limited by patient discomfort. Penile fracture typically occurs during intercourse and results in a cracking sound, immediate pain, marked penile swelling and ecchymosis, and usually a visible deformity. The presence of hematuria suggests the possibility of a concomitant urethral injury; in such cases a retrograde urethrogram should be performed.

Diagnosis

  • Clinical evaluation

  • Ultrasonography (for testicular injury)

  • Retrograde urethrography (for some penile injuries with possible urethral injuries)

Diagnosis of external scrotal and penile injury is made clinically. Clinical diagnosis of testicular contusion and rupture can be difficult because the degree of injury may be out of proportion to the physical findings, so patients with blunt testicular injury typically require scrotal ultrasonography. Most penile injuries are evident on physical examination. An x-ray with urethral contrast ( retrograde urethrography) should be done for any patient with penile fracture or penetrating penile injury in which urethral injury is suspected (eg, with hematuria or inability to void).

Treatment

  • Sometimes surgical repair

Patients with penetrating testicular injuries or clinical or sonographic characteristics that suggest testicular rupture require surgical exploration and repair. Similarly, all penile fractures and penetrating injuries should be surgically explored and the defects repaired. Penile amputations should be repaired by microsurgical reimplantation if the amputated segment is viable. Strangulation injuries can usually be managed simply by removing the constricting agent, which may require the use of metal cutters. Animal and human bites involving the genitalia should be managed with copious irrigation, appropriate debridement and antibiotic prophylaxis; primary wound closure is contraindicated. Zippers should be removed (see Figure: Zipper removal from penile skin.).

Zipper removal from penile skin.

To remove a zipper, local anesthetic is injected into the area. Mineral oil is used to lubricate the zipper, and then one attempt is made to unzip the zipper. If this attempt is unsuccessful, a sturdy wire cutter (diagonal cutter) is used to cut the median bar on the top of the zipper slider, which connects its front and back plates. Then the slider falls off in 2 pieces, and the zipper teeth come apart readily.

Key Points

  • Diagnose external scrotal and penile injuries clinically.

  • Diagnose most blunt testicular injuries with ultrasonography.

  • Do retrograde urethrography to diagnose concomitant urethral injury if patients have either a penile fracture or a penetrating penile injury with hematuria or inability to void.

  • Surgically repair certain injuries (eg, testicular rupture or penetrating trauma; penile fractures, amputations, and penetrating injuries).

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