55: Penile and Scrotal Trauma

This chapter will take approximately 11 minutes to read.

By Tiago Rosito, MD, PhD 1, 2
  1. Hospital de Clínicas de Porto Alegre, Buenos Aires, Argentina
  2. Brazilian School of Pediatric Urology, Buenos Aires, Argentina

Introduction

Trauma refers to injury caused by external force from a variety of mechanisms, including traffic- or transportation-related injuries, falls, assault (e.g., blunt weapon, stabbing, gunshot), explosions, animal bites, etc.1 Traumatic injuries are the leading cause of death in the United States for people ages 1–44 years, and a significant cause of morbidity and loss of productive life across all ages.2 Worldwide, traumatic injuries are the sixth leading cause of death and the fifth leading cause of moderate and severe disability.3 The kidneys are the most commonly injured genitourinary organ.

The lower urinary and genital tract may sustain injury through a wide variety of mechanisms. Although rarely life-threatening, mismanagement can lead to devastating long-term morbidity and, in some cases, permanent disability. In the acute scenario, it is of main relevance to distinguish between scenarios when immediate reconstruction is appropriate, as in testicular trauma with albuginea rupture, or better managed by a delayed correction.

Traumatic injuries to external genitalia are relatively uncommon, mainly because of the huge mobility of the penis and scrotum. Trauma to the external genitalia occurs in up to two-thirds of patients who present with GU trauma.1,4 Most cases are caused by blunt trauma, but up to 35% of all gunshot wounds to the GU tract involve the external genitalia.5 Most cases of genital trauma occur in men not only because of anatomic differences but also because of greater rates of exposure to violence in this population as well as participation in contact sports.6,7

When we are talking about pediatric genital trauma, we have some specific characteristics. Although most genital injuries in children are accidental, it is critical to assess whether trauma to the penis or the scrotum in boys, or the vagina in girls, is result of sexual abuse and assault. It is extremely important to know around 1 in 7 boys and 1 in 3 girls will be sexually abused in childhood. This is not obvious sometimes, and if there is any suspicion, we should look for confirmation to a safe discharge to home.

Most trauma data from the 20th century were reported from single-institution data sets. With the expansion of electronic medical records and national trauma networks, national data sets have become a more accessible and significant source of information. The National Electronic Injury Surveillance System (NEISS), originally created in 1970 by the US Consumer Product Safety Commission, is one example of these national data sets. It has been used primarily to evaluate the magnitude of injury associated with consumer products, but because it provides a national probability estimate of all injury-related US emergency department presentations, it has proved to be a useful tool for evaluating many facets of trauma epidemiology. Studies made with NEISS data are probably the best source available right now to study pediatric genital trauma.7 From 1991–2010, the NEISS recorded 19,885 Emergency Department (ED) visits for genital injuries related to consumer products or sports in patients ≤18 years old, representing an estimate of 521,893 nationwide visits. Using U.S. Census Bureau data, this represents 0.35 genital injuries/1000 children/year. Pediatric genital injuries represented 0.6% of all pediatric injuries. In comparison, from 1991–2010, the NEISS recorded 3,268,610 ED visits for any injury related to consumer products or sports in patients ≤18 years old, representing an estimate of 109,559,166 nationwide visits. Using U.S. Census Bureau data, this represents 75.6 injuries/1000 children/year. The absolute number of pediatric genital injuries and the percentage of injuries affecting the genitals have risen between 1991 and 2010.7,8,9,10

Penile Injury

As talked above penile injuries are quite uncommon, mainly because of mobility.11 Blunt phallic traumatic injury is usually of concern with an erect penis, when fracture of albuginea may result. As a general advice, prompt surgical management of penile injuries leads to adequate and acceptable cosmetic and functional results.11,12,13 In larger series, most penile injury in children occurs inadvertently from several causes. These include fractures, circumcision (the most common cause), hair tourniquet strangulation, motor vehicle accidents, animal bites, zippers and burns and scalds.5,7,11

Circumcision and Strangulation

Depending on the technique and surgical training, newborn circumcision has been shown to have variable rates of complications and injuries, as severe as amputation. Injuries are less common in the hospital and clinic setting and more often seen when a Mogen type device is utilized. Hair or thread strangulation usually results in circumferential damage with urethral injury associated. Accidental injuries with thread, hair, or rubber bands occur in children, but child abuse must be considered in such cases. Any child with unexplained penile swelling, erythema, or difficulty voiding should be examined closely for a hidden strangulating hair or string. Adults may place objects around the shaft as a means of sexual pleasure or to prolong an erection. The constricting device can reduce blood flow, cause edema, and induce ischemia; gangrene and urethral injury may develop in delayed presentations. Emergent treatment requires decompression of the constricted penis to allow blood flow and micturition. String, hair, and rubber bands should be incised promptly. Initial attempts to remove a solid constricting device causing penile strangulation involve lubrication of the shaft and foreign body and attempted direct removal. The damage is usually slow in onset and may not course with pain. Sometimes the hair is too small to be seen.11,12 Surgical repair of penile amputation in these situations usually course with good cosmetic and functional results after surgery.14 Urethral fistulas can occur in the proximal shaft in hair strangulation and distal in circumcision injury. The outcome of surgical repair as in hypospadias is quite good.11,12,13,14

Fracture

Rare in children, more common in adolescents and young adults during sexual intercourse or masturbation. Penile fracture is the disruption of tunica albuginea and rupture of the corpus cavernosum. It also has been described with rolling over or falling onto the erect penis.15

The site of rupture can occur anywhere along the penile shaft but distal to suspensory ligament are more common. The diagnosis is usually made by clinical history and physical examination. Patients usually describe a cracking sound followed by pain, detumescence and penile shaft swelling resulting in a typical eggplant deformity.1,12,13 The typical history makes adjunctive imaging studies unnecessary, when needed the penile ultrasound is rapid, readily available, noninvasive, inexpensive and accurate. The most recent AUA Urotrauma guideline statement recommend that penile fractures should be promptly explored and surgically repaired.1,12,13 Surgical reconstruction results in faster recovery, decreased morbidity, lower complications rates and lower incidence of long-term penile curvature.

Blunt Trauma

Although relatively rare, some authors have reported high numbers of patients presenting to emergency departments with toilet seat crushes, with more than 9000 occurring from 2002 to 2010. Usually this occurs in toilet training boys and most of these injuries are minor and treated conservatively as an outpatient.16

Burns

Genital burns are more common in children than in the adult population. Scalds are the most common etiology and are usually not isolated to the genitalia and can result in significant skin loss. The treatment may require transposition of skin by either graft or flap technique.17

Animal and Human Bites

The morbidity is related to the severity of the initial wound. Most victims are boys and dog bites are the most common injuries. Infectious complications are rare because treatment is sought early. Initial management includes copious irrigation, debridement, and immediate closure along with prophylactic use of broad-spectrum antibiotics. Human bites produce contaminated wounds and should not be closed.18

Penile Amputation

Very rare and usually the result of genital self-mutilation. Occurs in adolescents with psychosis disorder. Reconstruction with microvascular anastomosis is the treatment of choice. The amputated penis should be kept in a double bag with saline without direct contact with ice to prevent hypothermic injury before surgical replantation.

Gunshot and Penetrating Injuries

Rare in children, more common in teenagers. Associated with significant associated injuries as abdominal and limb shots. Treatment principles include immediate exploration, copious irrigation, excision of foreign matter, antibiotic prophylaxis, and surgical closure. Urethral injuries have been reported in as high as 50% of penile gunshot wounds.13,19

Zipper Amputations

Zipper injuries to the penis more often happen to impatient boys or intoxicated men. Multiple maneuvers are available to free the entrapped skin and to remove the mechanism. After a penile block, the zipper slider and adjacent skin can be lubricated with mineral oil, followed by a single attempt to unzip and untangle the skin.13,20

Scrotal and Testicular Injury

Injuries to the scrotum are not uncommon and occur most frequently in adolescents and young adults. Testis trauma in children is rare. Of all surgical cases for acute scrotum, these make up less than 5% of trips to the operating room.21 Penetrating trauma to the scrotum can include superficial injury to the skin and dartos or deeper injury into the tunica vaginalis. Although the testis is relatively protected by the mobility of the scrotum, reflexive cremasteric muscle contraction, and the tough fibrous tunica albuginea, blunt injury (usually the result of assault, sports-related events, and motor vehicle accidents) can result in rupture of the tunica albuginea, contusion, hematoma, dislocation, or torsion of the testis. Testicular injury results from blunt trauma in about 75% of cases. The right testicle lies higher than the left testicle in 60% to 70% of men and is thus more prone to being trapped against the symphysis pubis in blunt trauma.22

In cases of testicular rupture, the blunt force and trapping of the testicle can lead to rupture of the tunica albuginea, which encapsulates the testicle, resulting in extrusion of the seminiferous tubules. Patients with testicular rupture typically present with immediate scrotal pain after trauma, which is often accompanied by nausea or vomiting. However, patients may present after a delay, up to days after the injury, if they have a small rupture, which becomes increasingly more painful as time progresses. Ultrasonography can be used with very high sensitivity to diagnose a rupture, and if confirmed, operative intervention is required.23 However, if the ultrasonographic result is equivocal, patients should be taken to the operating room for exploration and potential repair if the suspicion for significant injury is high because early repair (within 72 hours) results in a rate of testicular salvage of 90% when compared with delayed repair or conservative management (45–55% orchiectomy rate).24,25 Scrotal ultrasonography can also reveal testicular contusion or hematocele, which are nonsurgical injuries or traumatic torsion or dislocation, which do require surgical intervention but are much less common than testicular rupture.26

Nonoperative management of testicular rupture is frequently complicated by infection, atrophy, necrosis, chronic unrelenting pain, and delayed orchiectomy. Testicular salvage rates exceed 90% with exploration and repair within 3 days of injury, whereas orchiectomy rates are threefold to eightfold higher with conservative management and delayed surgery.25

Vaginal Injury

Female genital trauma includes injuries to the labia, vulva or vagina, as well as the anogenital and urogenital structures. Worldwide, the most common cause of genital trauma in reproductive age women is injury sustained during childbirth. Accidental injuries may occur resulting in minor lacerations and bruising in the genital area that heal rapidly. Profuse bleeding can occur owing to the rich vascular supply in the genital area and may require operative intervention. Women and children may also be victims of violence.12,13 The crime of rape refers to nonconsensual sexual intercourse that is committed by physical force, threats of injury, or other duress. In certain populations, female genital mutilation (FGM), also called ‘‘female circumcision,’’ comprises procedures with partial or total removal of the external female genitalia or other injury for cultural, religious, or other nontherapeutic reasons. This intentionally mutilative practice is strongly discouraged by the World Health Organization (WHO) and women’s rights groups. Genital injuries alone rarely result in death, but may result in chronic discomfort, dyspareunia, infertility, or fistula formation if unattended.17,27

Children and adolescents may sustain accidental genital injuries because of falling onto an object, which results in straddle injuries or impalement. Blunt trauma or crush injuries to the pelvis resulting in pelvis fractures. Straddle injuries occur when the soft tissues of the vulva are compressed between an object (e.g., frame of a bicycle) and the bones of the pelvis, the pubic symphysis, and pubic rami. Ecchymoses, abrasions, and lacerations may occur as a result of this trauma; extravasation of blood into the loose areolar tissue in the labia, along the vagina, the mons, or clitoral area may cause hematoma formation. Examples of commonplace accidental straddle injuries include falling onto the frame of a bicycle, playground equipment, or piece of furniture.5,7 Accidental penetrating and insufflation injuries These injuries occur if the victim falls upon a sharp or pointed object and impales herself. Examples of household and common objects associated with impalement include in-lawn sprinkling systems, pipes, fenceposts, and furniture (chair-tops, bedposts, or legs of stools).17,27

Conclusions

Although pediatric genital injuries represent a small proportion of overall injuries presenting to the ED, genital injuries continue to rise despite public health measures targeted to decrease childhood injury. It is of utmost importance to have in mind the high risk of sexual abuse in child with genital trauma and this hypothesis must always be excluded before discharge. Prompt diagnosis and surgical correction leads to high success results, even in high complex lesions like penile amputation. The main diagnostic tool in children genital trauma is history and physical examination. The ultrasound examination is a great tool to help in diagnosis and management, being fast, easy, cheap and available. The long term results and sequel are typically good and acceptable when proper management is done.

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Last updated: 2023-02-22 15:40