Objectives
To guide the management of acute isolated penile injuries in the deployed operational environment.
Scope
This guideline will focus on the investigation and management of acute isolated penile injuries. This guideline covers the following conditions:
1) Penile fracture
2) Torn frenulum
3) Penile laceration
4) Phimosis
5) Paraphimosis
6) Fournier's gangrene
Clinicians should be aware that there is a separate guideline for priapism and separate guidance on injuries sustained from blast.
Audience
This guideline is intended for the use of registered healthcare professionals fulfilling a general role in a forward medical location or in an Emergency Department on deployed operations.
Initial Assessment & Management
Penile Fracture
Suspect a penile fracture if the patient describes an audible "pop" of erect penis, with or without pain. Rapid swelling and bruising is common, and may spread to scrotum and lower abdomen. Penile deviation may be seen.
Pain may be significant, requiring intravenous analgesia.
Early surgical repair is a priority to prevent long-term complications. If there is an unavoidable delay to surgical repair then administer intravenous antibiotics as per current deployed antimicrobial guidelines.
Torn Frenulum
Presents with localised bleeding, pain at the frenulum, minor laceration at the frenulum.
Apply direct pressure with sterile gauze to control bleeding. This injury is usually self-limiting, although the frenular artery (if involved) can continue to bleed - rarely, a suture may be needed.
Penile Laceration
Clean wound with sterile saline and assess the depth of wound to distinguish between a superficial or a deep laceration.
For a superficial laceration, simply apply a sterile dressing and consider topical antibiotic if high risk mechanism (for example, a dirty blade). Give tetanus prophylaxis if indicated (see CGO).
Deep laceration, control bleeding with pressure dressing but take care not to tourniquet the penis.
See guidance below for advice on wound closure.
Phimosis
Phimosis presents as a tight foreskin preventing retraction, possible pain or urinary obstruction. This is usually a congenital problem but may be caused (or exacerbated) by recurrent infection or scarring including recurrent balanitis.
Attempt gentle retraction with lubrication; avoid forceful attempts.
Topical corticosteroid cream (such as betamethasone 0.05%) may be helpful, if available, and use warm saline soaks to reduce discomfort.
Difficulty in passing urine may rarely progress into full urinary retention, requiring catheterisation which can be challenging. If unable to catheterise then a suprapubic approach may be needed, for which surgical advice should be sought.
Paraphimosis
Paraphimosis occurs when a swollen foreskin is trapped behind glans. It most often occurs in patients with a pre-existing (but often undiagnosed) phimosis, especially following sexual activity but also after urethral catheterisation. The longer it has persisted, the more difficult the reduction.
Give good analgesia – either oral or intravenous; a dorsal penile nerve block if appropriately trained. Entonox/methoxyflurane may also be very effective.
Reduce oedema by compressing the glans and foreskin. Grasp the distal penis in the palm of a gloved hand and squeeze snugly for at least 10 minutes before reassessing - up to 30 minutes of firm continuous pressure may be needed.
Attempt to reduce the phimosis by pushing the glans proximally through the phimotic ring. Using both hands, hold the penis securely between the index and middle fingers bilaterally, just proximal to the phimotic ring. Then, with your thumbs, use slow, steady pressure to push the glans proximally through the ring, while milking the foreskin distally to reduce it fully over the glans.
A successful reduction will appear as a foreskin reduced over a swollen glans.
Fournier's Gangrene
Forunier's gangrene is a rare, rapidly progressive, and life-threatening necrotizing fasciitis of the perineal, genital, or perianal regions.
Suspect in patients presenting with disproportionate perineal/genital pain, oedema or erythema in the perineum, scrotum (or labia in female patients). Note that early signs may be subtle and there are rarely firm demarcation lines.
Although onset can be very fast (hours), gradual progression over days does not exclude the diagnosis
Patients may be septic - follow guidance in Immediate Management of Sepsis CGO including the administration of broad-spectrum antibiotics to cover Gram-positive, Gram-negative and anaerobic pathogens, as per current deployed antimicrobial guidelines.
Urgent evacuation for surgical review is essential - Fournier's gangrene may be rapidly progressive and mortality may be as high as 40%.
See also content in Cellulitis CGO.
Advanced Assessment & Management
Penile Fracture
Penile fractures will require evacuation at the earliest opportunity to a facility able to offer specialist urological intervention. This is especially urgent if there is any evidence of penile ischaemia. Signs and symptoms include penile discolouration, reduced sensation (particularly at the glans) or a feeling of coldness in the penis. Reach back for advice if immediate evacuation is not possible.
Consider local anaesthetic block if pain not well controlled by IV pain relief. See dorsal penile block (below) for further guidance.
Avoid catheterisation unless clear signs of urinary retention – the risk of urethral damage is high. A single attempt with a 16Ch urinary catheter is acceptable providing it passes easily and there is urine coming out before the balloon is inflated.
Torn Frenulum
Suturing rarely required, but large tears may need absorbable sutures. If the frenular artery is involved then care should be taken to avoid the distal urethra, which is very superficial. Avoid the use of diathermy due to the risk of an iatrogenic fistula.
Penile Laceration
If significant dehiscence then consider primary closure, ideally with steristrips, or with absorbable sutures if not otherwise possible. If presentation is delayed then avoid primary closure.
Deep lacerations require dorsal penile block and surgical review (or urology, if available) for exploration with washout.
In the deployed operational environment, give prophylactic antibiotics due to the heightened risk of wound contamination.
Phimosis
As per initial management. Referral to a urologist for definitive treatment is needed but can be undertaken routinely if acute symptoms have been effectively managed.
Paraphimosis
If simple analgesia has not facilitated reduction then proceed to a local anaesthetic block (see below), seeking specialist advice if available.
Seek urgent surgical review (urology, if available) if reduction cannot be achieved.
If reduction is achieved then referral to a urologist for definitive treatment is needed to prevent recurrence, but this can be undertaken routinely if acute presentation has been effectively resolved.
Fournier's Gangrene
As described above, early signs may be subtle but develop – a low index of suspicion regarding any infection in the groin or perineum is required. Classically, there is diffuse oedema, erythema and bullae. There may be fluctuance or crepitus. Blood tests may support, but the diagnosis is clinical.
Note that although historically considered a male disease, prevalence in females is increasing.
Urgent surgical review is essential - debridement is aggressive and radical to avoid mortality, which may be as high as 40%.
Prolonged Casualty Care
In patient's with suspected Fournier's gangrene, emergency evacuation is required. If delayed - treat aggressively with broad spectrum antibiotics and follow guidance in immediate management of sepsis CGO.
Paediatric Considerations
Anatomical Differences:
Physiologic phimosis can be normal up to age of 10 years and does not always require treatment; forced retraction should be avoided.
The glans and foreskin are more delicate, making them more prone to minor trauma and oedema.
Pain Management:
Use weight-based analgesia and consider topical pain relief before attempting all manual reductions or interventions.
If performing a dorsal penile block on children under 10kg, then use 0.2-0.4 mL 1% lidocaine with absolute maximum of 3 mg/kg.
Urinary Retention Considerations:
If catheterisation is needed, use the smallest appropriate catheter.
Avoid forceful attempts at catheterisation and consider suprapubic catheterisation in extreme cases.
