MALE GENITAL TRAUMA

Amy McAllister

April 2014

Contents

Anatomical approach Causes Symptoms & Signs Investigations Management Learning points

Introduction

GUT injury in ~10% of all trauma patients

Long term morbidity

-incontinence

-impotence

-psychological Usually not life threatening; need to rule

out other injuries

Aetiology Penetrating

- Knife, bullet Blunt

- MVA

- fall from height

- direct blow/ sports

- straddle injury

- Constriction, Instrumentation Also – avulsion, burns, radiation, iatrogenic

Penile injuries

Penile “fracture” Rupture of the tunica albuginea of one

or both of the corpora cavernosa.

Penile fracture Aetiolgy

- Frequently a sexually related accident but can also be from a direct blow

- May be associated with urethral injury

Investigations

- Usually history is enough

- Diagnostic cavernosography or MRI

Management

- Previous conservative treatment – high complication rates

- Surgery

Penile fracture

“Eggplant” deformityFascial layers of the penis

Penile amputation

Accidental or deliberate “Double Bag” preservation

Management Reimplantation - success has been

reported after 16 hours of cold ischaemia

Penile soft tissue injuries

Penetrating injuries Dog bites Constriction Degloving

Management Sutures Removal of constricting devices Surgery

Testicular injuries•Haematocele

•Haematoma

•Testicular rupture

•Testicular dislocation/ torsion

Testicular injuries

Signs Bruising, swelling, tenderness,

haematuria

Investigation USS Surgical exploration

Testicular rupture

Normal testis Testicular rupture(6)

Urethral injuriesProstatic

Membranous

Bulbous

Pendulous

Anterior urethra

Posterior urethra (most common)

Posterior urethral injury

Commonly associated with pelvic # Violent mechanism

Posterior urethral injury

Signs

Blood at meatusGross haematuriaInability to voidEcchymoses, swelling of penisPelvic/suprapubic tenderness“High riding”/absent prostate on DRE

Anterior urethral injury

Direct trauma history Straddle injury Usually no pelvic # Similar signs to

posterior

Investigations Urinalysis Retrograde

urethrogram

Urinalysis

*False positives* Rhabdomyolysis Food – berries/beets Drugs – Rifampicin, Alphamethyldopa

etc

If more than a trace on dipstick – send for urinalysis

Retrograde urethrogram Patient tilted at 45 degrees Initial KUB film taken Penis sretched obliquely

over thigh to promote visualization of the entire urethra

Inject 25mls of water-soluble contrast using specialised adaptor or Foley catheter

Re-xray

Goldman classification of urethral trauma

Retrograde urethrogram

Normal Goldman type III urethral injury

Urethral injuries Management

Posterior Partial tear - Foley catheter Complete tear – Suprapubic catheter, surgery

Anterior - surgery

NB. If Foley already in place and suspect tear, do not remove

Bladder injuries

Degree of injury

•Contusion (most common) •Extraperitoneal rupture•Intraperitoneal rupture•Combined intraperitoneal/extraperitoneal rupture

Bladder injuries Aetiology

- pelvic # in up to 70% of cases

- blunt abdominal trauma with full bladder

Bladder rupture

Bladder injuriesSigns Gross haematuria Microscopic haematuria with pelvic # Bruising, suprapubic tenderness, peritonism Must rule out urethral injury before placing Foley

Investigations Retrograde CT cystography

Management Contusions/extraperitoneal – conservative Intraperitoneal - surgery

Ureteral injuries

Ureter injury is rare except a complication of surgery/ penetrating trauma

No haematuria in 25% of ureter injuries Have high index of suspicion

Renal injuries

Usually blunt trauma Sudden deceleration MVA / bicycle accidents

Lumbar transverse process #

Renal injuriesSigns

• Eccyhmosis to back / flank / lower thorax / upper abdomen

• Haematuria• Shock

Delayed findings

•Fever•Palpable flank mass (urinoma)

Renal injuries

Investigations

CT with contrast IVP

Classification of renal injuries

Renal injuries

Management

ABCs Grade I and II – conservative Grade III and up – operative including

nephrectomy

Learning points

Rule out life threatening injuries first Identification prevents long term

problems No Foley if urethral trauma suspected –

wait for u/a and pelvic x-ray If Foley is in – do not remove if urethral

trauma suspected afterwards Gross haematuria or microscopic

haematuria plus shock = GUT trauma

References (1) Urol Clin North Am. 2013 Aug;40(3):323-34. doi:

10.1016/j.ucl.2013.04.001. Epub 2013 Jun 12.Current epidemiology of genitourinary trauma. McGeady JB1, Breyer BN

(2) Bhatt S, Kocakoc E, Rubens DJ, Seftel AD, Dogra VS (2005)Sonographic evaluation of penile trauma. J Ultrasound Med 24:993–1000, quiz 1001

(3) Kozacioglu Z., Degirmenci T., Arslan M., et al : Long-term significance of the number of hours until surgical repair of

penile fractures. Urol Int 2011; 87: 75-79 CrossRef (4) J Urol. 2004 Aug;172(2):576-9. Long-term experience with surgical and conservative treatment of

penile fracture. Muentener M1, Suter S, Hauri D, Sulser T. (5) Wei F.C., McKee N.H., Huerta F.J., et al : Microsurgical replantation of a completely amputated penis. Ann Plast

Surg 1983; 20: 317-321 CrossRef

References (6) Bhandary P, Abbitt PL, Watson L (1992) Ultrasound

diagnosis of traumatic testicular rupture. J Clin Ultrasound 20:346–348

(7) Lower male genitourinary trauma: a pictorial review Bruce E. Lehnert & Claudia Sadro & Eric Monroe &Mariam Moshiri

(8)Gomez RG, Ceballos L, CoburnMet al (2004) Consensus statement

on bladder injuries. BJU Int 94:27–32(2)Ramchandani P, Buckler PM (2009) Imaging of genitourinary trauma. AJR Am J Roentgenol 192:1514–1523

(9) Straddle injuries to the bulbar urethra: management and outcome in 53 patients Elgammal MA.Int Braz J Urol. 2009 Jul-Aug;35(4):450-8. .