Transcript Structured Clinical Scenarios in Penile Trauma

Structured Clinical Scenarios in
Penile/ Scrotal Trauma
Matthew Liew
Milan Thomas
Ann Crump
June 2014
Thanks to Arie Parnham and Ben Grey
Overview
 Traumatic injuries of the genitourinary tract are seen in
2-10% of patients admitted to hospitals
 Of these 30-60% are associated with injuries to the external
genitalia
 Males>Females
 Anatomical differences
 Increased environmental risk
 Most common 15-40 years old (5% <10 yrs old)
 70% have associated injuries
Risk Factors
 Sports
 Off-road cycling
 In-line hockey skating
 Rugby
 Psychiatric patients
Blunt Trauma
 Penile
 60% during intercourse
 Rare in flaccid penis as tunica 2mm (erect: 0.25mm)
 Scrotal
 Rupture- 50%
 Need 50kg of force
 Testicular dislocation- rare
Penetrating Trauma
 Associated with complex injuries of other organs.
 Always consider tetanus
 Missiles
 Trauma/ extent of injuries in guns related to calibre and
velocity of missile
 Low velocity
 High velocity
200-300 m/s permanent cavity
800-1000m/s temporary cavity
+permanent cavity and tissue vapourisation
Penetrating Trauma
 Animal bites
 Rare
 Dog
 Pasturella Multicida 50%
 Also E.coli, Strep viridans, Staph aureus and Bacteroides
 Treatment
 Augmentin followed by doxycycline, cephalosporin/ erythromycin for 10-14 days
 local wound management
 Clean with warm running water/disinfectant, conservative debridement in the
scrotum
 Consider rabies treatment
• human rabies immunoglobulin & human diploid cell vaccine
Penetrating Trauma
 Human Bites
 Rare
 Streptococci, Staphylococcus aureus, Haemophilus spp., Bacteroides spp
 Treatment
 Although transmission rare consider HIV, Hep B/C and appropriate
prophylaxis
 Wound management
 Augmentin/ clindamycin
Diagnosis
 ATLS protocol (not in the scope of this talk)
 Thorough history
 Consider abuse (genital injury is seen frequently after sexual abuse)
 If weapon, is it:
 Close/far range
 Calibre
 Type of weapon
 Physical examination
 Gynaecological examination
Investigations
 Urinalysis
 If haematuria
 Male
Retrograde urethrogram
 Female
Cystoscopy
Investigations
 Penile Fracture
 MRI may be useful
 Blunt testicular trauma
 USS with a high resolution probe (7.5MHz or greater)
 Accuracy 56%-94%
 some studies show poor specificity 78% and sensitivity 28% for
differentiating rupture
 Colour doppler-duplex may provide useful information on
testicular perfusion
 In case of inconclusive USS CT/MRI
Investigations
 Blunt female genital trauma
 USS/CT/MRI as additional injuries and extensive intra-pelvic
haematoma frequently found
 Penetrating genital trauma
 urethrography irrespective of urinalysis
 Female  may need laparotomy
 Associated pelvic or abdominal injury (usually) require CT.
 CT cystography should be performed in pelvic injuries
associated with non-visible haematuria
 Male
Treatment
 Blunt Penile Trauma
 Penile fracture
 Absorbable/non-absorbable sutures ASAP gives good long-term outcome
and potency
 Post op complications 9%
 Wound infection and impotence 1.3%
 Conservative management NOT recommended
 Increases risk of penile abscesses, missed urethral disruption,
persistent haematoma, fibrosis and angulation 35%
and impotence 62%
Orvis and McAninch. Penile rupture. 1989
Treatment
 Blunt Testicular Trauma
 Haematocoeles <3x size of contralateral testis
 conservative management
 >3x size of contralateral testis with or without rupture
 Delayed surgery >3days
 higher rate of orchidectomy even in non-ruptured
 Prolonged hospital stay
 Early surgery gives >90% preservation
 If tunica (‘testicular’) rupture
 exploration and excision of necrotic tubular tissue and closure of tunica
(Vicryl).
 High rate of testicular preservation and normal endocrine function
Treatment
 Blunt Testicular Trauma
 Extensive disruption of tunica albuginea
 Mobilisation of free tunica vaginalis flap for testis closure
 If unable to reconstruct then orchidectomy
 Traumatic dislocation
 Rare (usually MVA)
 Manual replacement and secondary orchidopexy unless unable to
manually reposition then primary orchidopexy
 Complete disruption of cord
 Realignment without vaso-vasotomy
 Staged secondary microsurgical vaso-vasostomy after rehab (only few case
reports)
Treatment
 Penetrating Penile Trauma
 Surgical exploration with conservative debridement of non-
viable tissue
 Primary reconstruction where possible
 Prophylactic abx although evidence poor
 Superficial injuries with intact Buck’s fascia
 Conservative management
 Extended injuries of penis
 Primary alignment
 In non-alignable tissue then split-thickness graft of at least 0.4mm to
reduce contraction
See Viva questions
Case 1
 Penile Fracture presents at 2am
Case 1
 28 male
 Sudden onset of penile pain
swelling and bruising
preceded by popping noise
and immediate loss of
erection
What else do we want to know?
Case 2
 When did it happen?
 6hrs ago
 How did it happen?
 Rigid penis slipped out of vagina hitting
the mons pubis of female partner
 Has he passed urine yet? Is he in retention?
 No and No
What Next?
Case 2
 Patient underwent immediate surgery with no further
investigation as signs of complex penile trauma were obvious
Anything you would do differently?
Urethrogram
A Foley catheter (8 to 16 French) is inserted into the fossa
navicularis, and the balloon is inflated with 1 to 2 mL.Thirty
to 50 percent aqueous contrast solution is gently injected
while films are obtained. The patient is typically positioned
300 obliquely, to allow visualization of the entire urethra.
Findings
After penile degloving and NVB mobilization,
a very large ventral albuginea tear involving
both cavernosal bodies with urethral rupture
is seen
After urethral mobilization, complete urethral
rupture is obvious
Now What?
What happened
Buccal mucosa graft is used both to cover the
cavernosal defect and to augment urethral
anastomotic repair as a dorsal roof
Remaining cavernosal defect is grafted with
saphenous vein
Penile Fracture
 Disruption of the tunica albuginea with rupture of the corpus




cavernosum.
Usually occurs during vigorous sexual intercourse as penis
slips out of vagina and strikes the perineum or pubic bone
(faux pas du coit)
Taghaandan most common cause in Middle East
Tunica made from bilaminar structure (inner circular, outer
longitudinal). The outer layer determines the strength and
thickness.
Tunica can resist rupture up to 1500mmHg.
Diagnosis
 Can be made more often than not through history and




examination.
Buck’s fascia intact penile haematoma is contained
between skin and tunica.
Buck’s fascia disrupted haematoma in perineum, scrotum
and suprapubically.
The phallus deviates to the opposite side of the tunical tear
because of haematoma and mass effect
Rolling sign blood clot felt against the fracture site
Concomitant injury
 20% of fractures have urethral injury
 Associated with visible haematuria, blood at the meatus,
inability to void.
 Given that urethral injury occurs not infrequently and that
urethrography is a simple and reliable study, clinicians should
have a low threshold for urethral evaluation in all cases
Imaging
 MRI to be used in atypical presentation.
Management
 Prompt exploration
 Distal circumcising incision
 Closure of tunical defect with interrupted 2-0/3-0 absorbable
sutures.
 Partial urethral injury should be oversewn with fine absorbable
suture over a urethral catheter
 Complete urethral injuries should be debrided, mobilised and
repaired tension free over a catheter
 1 month sexual abstinence
Outcomes and Complications
 Immediate reconstruction <8hrs
 Faster recovery
 Reduced morbidity
 Lower complications
 Lower incidence of long-term penile curvature
Summary
 Clinical diagnosis in most part
 MRI imaging of choice if diagnosis in dispute
 Suspect urethral injury
 Early repair essential
Case 2
 24 year old male presents with amputated penis in a bag of




ice and psychiatric nurse in tow
Known Schizophrenic
Hasn’t been taking antipsychotic medications
Smells of alcohol
Matthew 18:9
 And if your eye causes you to stumble, gouge it out and throw it
away. It is better for you to enter life with one eye than to have
two eyes and be thrown into the fire of hell.
What is the initial management?
What to do with the penis??
Initial assessment and Treatment
Airway
C-spine
Breathing
Circulation
Disability
Exposure
Clear
Clear
RR 25, O2 sats 95%, Bilateral
equal air entry
Cool peripheries, Cap refill 4 sec,
BP 100/50
AVPU, GCS 14/15, PEARL
Penis amputated. Actively
bleeding
What to do with the penis?
 The amputated penis must
be regarded as a free flap.
 Survival with cold
ischaemia 6-24hrs
Patient stabilises and with pressure
bleeding slows but doesn’t stop
What next?
See Viva questions
Penile Anatomy
 Tell me about the blood and nerve supply to the penis (both
skin, urethra and erectile tissue)
Penile Reimplantation
 Patient to be well hydrated and warm to keep peripherally vasodilated
 2 layer spatulated urethral anastomosis over catheter
 Urethral urothelium polyglycolic acid sutures PETCRYL(synthetic
absorbable monofiliament)
 Corpus spongiosum PDS
 Erectile bodies are coaptedPDS
 Structures to be re-anastomosed are
 Dorsal arteries11-0 nylon
 Deep dorsal vein10-0 nylon
 Dorsal nerves
 Epineurium 10-0 nylon
 Catheter removed and soft silicone silastic stent placed
 SPC
Bed rest 1 week
SPC 2-3 weeks
Penile re- implantation
 If no microsurgical capability then macroscopic anastomosis
of the urethra and corporal bodies can be performed with
good erectile results albeit with reduced sensation and
greater skin loss
Penile Amputation
 Most evidence is poor level III or IV
 Western cultures most common cause is psychiatric illness or
assault.
 Many of those psychiatric patients have domineering older
mother with no father figure.
 Klingsor syndrome god or messenger telling the to
amputate penis. Often do it on notion that promised great
things denied the individual because of sexual
thoughts/indiscretion
Summary
 Stabilise patient
 Consider mental health issues particularly consent
 Transfer to centre with microsurgical abilities
Case 3
 38 year old
 Persistent painful erection for 8 hours
What would you ask for in the history?
Risk factors for priapism?
Case 3
 History
 Time of onset- 8 hrs
 No sexual stimulation for 6 hours
 No trauma
 playing football trauma to perineum
 Well in the evening
 ‘Woke up with erection that wouldn’t settle’
 PMHx
 No previous episodes
 FHx
 No sickle cell, haematological malignancies or bleeding dyscrasias
Case 3
 History:




Duration
Association with pain- severity
Previous history
Risk factors







sickle cell or cancer
Medications: viagra, injections, some antipsychotics
Illicit drugs e.g. cocaine, marijuana, ETOH XS
Trauma (pelvic/genital or perineal): e.g. bicycle
Neurological: SCI, anaesthesia, or cauda equina
Infection: mycoplasma (hypercoagualable), malaria
Rare: black widow spider bite, CO poisoning
Case 3
 What are the features on examination?
 How would you investigate priapism?
Case 3
 What are the features on examination?




Erect or semierect penis.
Ventral glans or corpus spongiosum rarely rigid
Look for features or underlying cause
Piesus sign: perineal compression in young children causes immediate
detumescence in high flow
 How would you investigate priapism?
 FBC – rare cause leukaemia
 ABG of cavernous to differentiate high and low flow
 If similar to venous blood then usually low flow.
 Imaging? Colour flow penile doppler
Case 3
 How do you manage priapism?
Priapism. Corporeal relaxation causes external
pressure on the emissary veins exiting the tunica
albuginea, trapping blood in the penis and causing
erection.
Case 3
 How do you manage priapism?
 Conservative measures
 Aspiration/injection of corpus cavernosum
 Penile nerve block e.g. 1% lignocaine
 19G needle to large syringe into cavernosum
 Where do you puncture?
 Aspirate 20-30mls
 only need to aspirate from one side
 30% success
 If successful, place bandage around penis to ensure continued emptying and compression
 May need instillation of phenylephrine
 Dilute solution of phenylephine 100μg (alpha adrenergic sympathomimetic)
injected into corpus cavernosum and then aspirate every 10 minutes
What is the diagnosis?
What next?
What issues need to be discussed?
Case 3
Diagnosis?:
Ischaemic Priapism
What needs to be discussed?:
Risk of future erectile dysfunction
What next?:
 Analgesia
 Penile block 0.25% marcaine without adrenaline
 ABG
 PH 6.95, pO2 10, pCO2 80
 Aspiration
 Dark blood slowly evacuated
What next?
What is the maximum dose you can give?
What are the side effects?
What monitoring is advised and in who?
What ways can irrigation be achieved?
What is the success rate?
Case 3
What is the maximum dose you can give?
 1000 μg
What are the side effects?
 Hypertension, tachycardia, palpitations, headache,
arrhythmia, sweating
What monitoring is required and in who?
 BP and ECG in those with high cardiovascular risk
What is the success rate with irrigation and irrigation
with phenylephinerine
 Success rate 30%, 81%
Case 3
What ways can irrigation be achieved?
IN
OUT
Max irrigation but more haematoma risk
IN
OUT
Less haematoma. Prepares for further procedure.
Case 3
 Although some improvement still in pain and erection still
not resolving
What next?
Case 3
 Surgical Shunt
Ebbehoj shunt performed
 Following day the patient had very little pain, and his penis
was full but not rigid.
 A duplex ultrasound was performed
 Peak systolic velocity- 36cm/s
 1 week later he was pain free and swelling resolved. Repeat
duplex
 Peak systolic velocity- 25cm/s
 6 months later no further episodes of priapism, moderate ED
controlled with PDE5 inhib
MCQ- Genital trauma
 External genitalia accounts for 33-66% of urological injuries
 Genital trauma is more common in females
 Commonest age group is between 15-40 years
 Blunt scrotal and testicular trauma is bilateral in 5-10%
 Penetrating injuries account for 20% of genitourinary trauma
MCQ- Genital trauma
 External genitalia accounts for 33-66% of urological injuries
T
 Genital trauma is more common in females
F
 Commonest age group is between 15-40 years
T
 Blunt scrotal and testicular trauma is bilateral in 5-10%
F (1%)
 Penetrating injuries account for 20% of genitourinary trauma
T
Genital Trauma: Background
 33-66% of all urological involve external genitalia
 Commonest in male between 15-40 years
 80% caused by blunt injuries
 Only 1% of scrotal/ testicular injuries are bilateral
Genital Trauma: general principles
 All should have urinalysis:
 any haematuria requires retrogrades in male
 Cystoscopy recommended in female
 Bites:
 Rare in external genitalia
 Pasturella infections account for 50%. Recommend co-amoxiclav 10-14days
 Consider rabies
 Sexual assault





Often seen after sexual abuse
Usually need gynae and forensic support and advice
Send swabs for spermatozoa
Local protocol
Thorough history and examination (+/- EUA)
EAU 2014 guidelines
Case 4
 22 year old male
 Riding a bike fell onto handle bars
 Presents with
 Severe testicular pain
 Scrotal swelling
 Nausea
62
Case 4
 History
 Mode of injury / velocity / PMH
 Other injury
 ATLS - priority to:
 airway with cervical spine control
 breathing
 circulation
 Followed by secondary survey - examination from head to toe.
63
Case 4
 Urinalysis – consider urethral trauma
 Primary goal is to establish if tunica albuginea intact.
 Testis can withstand up to 50Kg pressure before rupture
 May reveal
 Ecchymosis
 Tenderness
 swelling
64
Case 4
 Scrotal USS
 essential if testis cannot reliably be examined
65
Case 4
 Rupture of tunica albuginea
 surgical exploration with excision of necrotic testicular tubules and
closure of the tunica.
 This guarantees a high rate of testicular preservation and normal
endocrine function.
 Antibiotics
 Goal of treatment is to maintain endocrine function
66
See Viva questions
What are the features of acute epididymitis?
Tell me about possible causes. How do you
assess and treat such cases?
Words of wisdom from my ancestors....