Open trauma of the penis

Open injuries of the penis arise as a result of the impact of injuring objects (gunshot, cut, stab wounds) and bites of animals (horses, dogs, cows, etc.) Damage by piercing-cutting objects penetrating the thickness of cavernous bodies is often accompanied by full or partial amputation organ and are among the serious injuries of the penis.

[1], [2]

Causes of the open trauma to the penis

Most injuries are accompanied by damage to the hanging section of the urethra. With a technically incorrect operation, circumcision is also possible for iatrogenic lesions of the penis. In the literature repeatedly there were descriptions of the amputation of the penis during circumcision of the foreskin during religious rituals.

Superficial wounds of the penis

Superficial wounds of the penis, not reaching the belly, are accompanied by small bleeding. The leading cause of trauma to the penis is excessive friction. Such problems often arise in passionate lovers and sexually active men. For the first, relatively deep skin lesions are characteristic, after which scars remain.

For the second, damage to the frenulum of the foreskin is typical. Often trauma of the penile frenulum (ruptures or tears) occurs during an intense sexual intercourse and / or with a congenital short frenulum, accompanied by pain and significant bleeding, which can be stopped by surgical intervention - suturing the wound or by electrocoagulation. Often, plastic bridles and circumcision are simultaneously performed.

When the penis is injured by piercing-cutting objects of rotational mechanisms, machines or other instruments, extensive skin wounds of this organ, sometimes with significant defects not only of the skin, but also of the cavernous bodies with significant blood circulation disturbance, leading to necrosis.

[3], [4], [5], [6], [7], [8], [9], [10]

Bites of the penis

Bites of the penis can be the result of the expression of hostility of domestic animals or deliberate acts of sexual partners. For such wounds, a small area of tissue damage, minor bleeding and poor regenerative capacity are characteristic.

Almost always, such injuries are infected; when dogs are bitten in 50% of cases, the wounds are infected with Pasteurella multocida in combination with other microorganisms (Escherichia coli, Aerococcus viridans, Bacteroides spp., etc.).

[11], [12], [13], [14]

Thermal trauma of the penis

These include burns with acids, alkalis,  thermal burns  and frostbites of the penis, arising from exposure to high and low temperatures. It is possible and isolated frostbite of the penis, which can occur in an insufficiently warmly dressed man, a long time coming towards the cold wind.

Burns of the penis occur when exposed to hot liquids and objects, chemically active substances, solar and X-rays, radioactive isotopes. With a superficial burn of the 1st degree, reddening and swelling of the tissues of the penis are noted. With a deeper burn (grade II), blisters are formed on the skin, the tissue is edematous. This can lead to a delay in urine. At the third degree of a burn, necrosis of the skin comes  , and at the 4th degree not only the skin but also the spongy bodies die.

When frostbite of the penis in most cases, the foreskin is affected, but it is possible and frostbite of the body of the penis. Immediately after frostbite, the skin of the affected area becomes purple-blue, itching appears. Burning, stitching pain, impaired sensitivity (paresthesia), swelling. After a few days these symptoms disappear. With a deeper lesion on the necrotic areas of the skin appear ulcers with a purulent discharge, which heal within 3 months.

Diagnostics of the open trauma to the penis

Collecting anamnesis, you should collect complete information about the characteristics of the factor leading to damage to the penis, and the circumstances of injury. In addition to the general principles of the treatment of injuries, it must be remembered that with traumas of external genitalia, it is often necessary to pay attention also to the intimate side of the question.

Diagnosis of open lesions of the penis is based on the history of the lesion, the examination (localization, the nature of the wound, the direction of the wound channel, the presence of the outlet), palpation (defects in the corpus cavernosum, foreign body),  ultrasound  and survey radiography (to determine the presence and location of foreign bodies) . Recognizing the open wound of the penis, as a rule, is not difficult. The nature of the damage is established after stopping bleeding and revision of the wound.

Intensive bleeding when injured cavernous bodies of the penis persists in the first hours after injury. After 0.5-2 h after the injury, hematomas are formed, and bleeding stops. Blood, gibbing the subcutaneous tissue, blocks the lymphatic ways and often causes a significant edema of the penis.

[15], [16], [17], [18], [19]

Treatment of the open trauma to the penis

When combined wounds of the penis simultaneously with activities aimed at stopping bleeding and removing the wounded from shock, it is necessary to perform the most sparing surgical treatment of the wound of the penis with excision of necrotic tissues in order to prevent scar deformation of the organ in the future. When processing the wound of the penis, it is necessary to remove foreign bodies. Which can subsequently cause pain during erection. For this purpose, the wounded are shown performing an x-ray examination. When treating the wounds of the penis, the urologist must take into account that even to a large extent traumatized and blood-soaked tissues can restore their viability in a few days.

When manipulating the cavernous bodies should be gentle, since they can expand the area of damage: they should be carried out after determining the zone of necrosis. Economical excision of damaged tissues at the stages of rendering qualified medical care reduces the need for dermal plastic surgery to 1.6%. In 1.2% of cases observed crushing of the penis, requiring amputation of the body.

Treatment of open lesions of the penis at the prehospital stage begins with a protective aseptic, and if necessary pressing, bandage on the penis and, if possible, a tourniquet. Begin antibacterial therapy, inject painkillers and tetanus toxoid. In the treatment of infected wounds of the penis, the drugs of choice are cephalosporins and macrolides (erythromycin).

Surgical treatment includes primary surgical treatment of the wound, the final stop of bleeding, the removal of urine from the bladder. With partial separation of the penis, primary surgical treatment of the wound with economical excision of tissues and restoration of parts of the injured organ is performed. Amputation and excision of the skin of the penis are possible only with necrosis. Plastic operations for the replacement of skin defects and operations for the restoration of the penis are carried out in a specialized department.

With full traumatic amputation of the penis, the cut off organ must be preserved, since it can be sewn into the stump within the first 18-24 hours after the trauma. To maintain the viability of the amputated organ, it is washed with a solution of povidone-iodine, packed in a sterile bag filled with sodium lactate with a complex solution (Ringer Lactate Viaflo solution) and stored on ice before the operation. When amputation of the penis is often required plastic surgery to restore the penile phalloplasty. The amputated part of the penis is replaced with the Filatov stalk, which is cut out from the skin of the abdomen and thighs. To give the neofallus functional rigidity in the dermal stem implant phalloprosthesis of various designs.

In view of the abundant blood supply and high regenerative abilities of the tissues of the penis, therapeutic tactics should be maximally organ-preserving. In all cases of almost complete amputation of the penis, stitching of its ends is mandatory. In this case, it should be borne in mind that even to a large extent traumatized and blood-soaked blood flaps in a few days can restore their viability. To ensure peace of the wound, the patient is prescribed funds that prevent erection.

With extensive wound skin defects and scalp wounds of the penis, missing skin areas are filled with skin plasty. The wounded with the preserved foreskin are used plastic by the method of Dittel. The operation consists in separating the outer layer of the foreskin from the inner one, and the cutaneous flap enlarged in this way is pulled on the wound surface and fixed to the edges of the remaining skin.

In the complete absence of skin of the penis, plastic is used according to the Reich method - replacement of the defect with the skin of the scrotum. For these purposes, at the root and bottom of the scrotum, two horizontal incisions are made at a distance from each other, corresponding to the wound surface on the penis. The skin between the incisions is peeled off, and the penile is placed in the wound wound tunnel thus formed. Stitch the skin between the head and root of the penis and the lower and upper edges of the dermal bridge of the scrotum. After 2-3 weeks, alternately or immediately on both sides, parallel to the penis, cuts cut the formed skin bridge and its edges are sewn on the posterior surface of the penis. The wound of the scrotum is sutured.

In cases where it is not possible to use the skin of the scrotum for the plasty of the penis, the skin defect of the penis is filled with a bridge flap from the skin of the pubic region and the lower half of the abdomen (Bessel-Hagen technique) or the inner surface of the hips (LB Zagorodny's technique). Plasticity of skin defects of the penis can be carried out and free skin grafts.

If the integrity of the gallow shell is damaged, knotty catgut sutures are applied to it in the transverse direction to the axis of the penis, avoiding the stitching of large vessels, which prevents the cell bodies from escaping. At the same time, one should strive not to deform the cavernous body. When one cavernous body is injured with a complete break, the ends of the cavernous body are brought together and restored to its integrity by catgut sutures, seizing the tissue of the cavernous body and the belly. In the same way, they act in case of damage to both cavernous bodies.

With a simultaneous damage to the urethra, a suprapubic urinary fistula is superimposed.

In cases of crushing of the peripheral part of the penis, when the necrosis of the tissues is clearly revealed, amputation of this part of the penis takes place. Amputation in the destruction of both cavernous bodies is carried out only after the establishment of the demarcation line of gangrene. Later, such a patient shows the reconstruction of the penis. Operative treatment of thermal lesions of the penis is carried out according to general principles; it is aimed at removing necrotic tissue, replacing skin defects and cavernous bodies, restoring the function of the penis. In the case of pronounced changes localized in the foreskin region, circumcision is performed.