Penile injuries: Rare but potentially hazardous

Penetrating external genitourinary trauma is rare, occurring in only 0.57 percent of all trauma injuries and 2 percent of penetrating trauma cases.1 Historically, 49–93 percent of these injuries are caused by gunshot wounds (GSWs), and only 28 percent involved the penis.1,2 Given the proximity of the penis to the urethra and testis, penile GSWs are associated with neighboring injuries in up to 84 percent of cases.3 Isolated injuries, however, may not require extensive surgical intervention, as clinical examination can prove sufficient to rule out deeper penile injuries.1

Limited protocols

Surgery for isolated penile trauma involves minimal debridement of surrounding tissue and primary wound closure if possible while keeping a high index of suspicion for concomitant urethral and other regional organ injuries.4,5 Some series have found blood at the meatus can be a helpful predictor of possible urethral injury, while microscopic hematuria was not found helpful.5 Other series describe retrograde urethrography and abdominal imaging as the only required diagnostic studies in select patients.4

Penile GSWs remain rare; therefore, it is difficult to create guideline-directed care for such occurrences. That said, the American Urologic Association’s uro-trauma guidelines do suggest “exploration and limited debridement of non-viable tissue” and evaluation for urethral injury in the presence of “blood at the urethral meatus, gross hematuria, or the inability to void.”6 Consequently, the physical exam remains paramount in determining the treatment of men who present to the emergency department with penile GSWs.

To examine the occurrence of patients with penile gunshot wounds in the National Trauma Data Bank® (NTDB®) research admission year 2016, medical records were searched using the International Classification of Diseases, 10th Revision Clinical Modification codes. Specifically searched were records that contained one of 192 non–war-related E Codes for penetrating injury and a diagnosis code of S31.2 (open wound of penis). A total of 288 records were found, of which 243 records contained a discharge status, including 220 patients discharged to home, 13 to acute care/rehab, and three to skilled nursing facilities; seven died (see Figure 1). All of these patients were male, on average 29.9 years of age, had an average hospital length of stay of 6.2 days, an intensive care unit length of stay of 6.1 days, an average injury severity score of 10.5, and were on the ventilator for an average of 4.6 days. Of those tested, 38 percent (69 out of 180) tested positive for alcohol.

Figure 1. Hospital Discharge Status

Figure 1. Hospital Discharge Status

These injuries are rare and potentially hazardous to surrounding structures; hence, the physical exam is important. Blood at the meatus may direct one to perform a retrograde urethrogram to rule out associated injuries.

Throughout the year, NTDB data are highlighted in brief monthly reports in the Bulletin. The NTDB Annual Report can be found on the American College of Surgeons website as a PDF file. In addition, the website contains information about how to obtain NTDB data for more detailed study. To submit your trauma center’s data, contact Melanie L. Neal, Manager, NTDB.

Acknowledgment

Statistical support for this column was provided by Ryan Murphy, Data Analyst, NTDB.


References

  1. Bjurlin MA, Kim DY, Zhao LC, et al. Clinical characteristics and surgical outcomes of penetrating external genital injuries. J Trauma Acute Care Surg. 2013;74(3):839-844.
  2. Phonsombat S, Master VA, McAninch JW. Penetrating external genital trauma: A 30-year single institution experience. J Urol. 2008;180(1):192-195.
  3. Kunkle DA, Lebed BD, Mydlo JH, Pontari MA. Evaluation and management of gunshot wounds of the penis: 20-year experience at an urban trauma center. J Trauma. 2008;64(4):1038-1042.
  4. Brandes SB, Buckman RF, Chelsky MJ, Hanno PM. External genitalia gunshot wounds: A ten-year experience with fifty-six cases. J Trauma. 1995;39(2):266-271.
  5. Miles BJ, Poffenberger RJ, Farah RN, Moore S. Management of penile gunshot wounds. Urology. 1990;36(4):318-321.
  6. American Urological Association. Urotrauma. Available at: www.auanet.org/guidelines/urotrauma-(2014-amended-2017). Accessed September 30, 2018.

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