Male Genital Trauma: Diagnosis and

Management
Tania P. Bartkiw, BScN, RN, Bernard Goldfarb, BASc, MD, FRCS(C),
and John Trachtenberg, MD, FRCS(C), FACS

Trauma to the male external genitalia represents a serious injury that must be
managed promptly and completely. To avoid long-term loss of function, disabil-
ity, and psychologic effects, wounds should be carefully assessed, protected
from further injury, and referred for surgical and social follow-up. (INT J TRAUMA
NURS 1995;1:99-107)

he mobility and position of the male
external genitalia offer some degree of
protection from injury. 1 Most cases of
injury are associated with a direct force ap-
plied to this region. Thoughout history, the geni-
talia have been a preferred target during mili-
tary combat (e.g., rifle bullets, fragmentation
weapons, land mines, grenades) and for pun-
ishment or torture. 2 Nonmilitary male genital
trauma has b e e n associated with intentional
actions (self-mutilation, religious practices, psy-
chotic episodes) and accidental causes (agri-
cultural, industrial, sporting, automobile mis-
haps). 24 S e e Table 1 for a list of the most fre-
quent causes of injury noted in one study.
Tania Bartkiw is clinical research coordinator at The Prostate
Centre, The Toronto Hospital, University of Toronto, Toronto,
Ontario, Canada. Bernard Goldfarb is a clinical research fellow
at the same institution. John Trachtenberg is a professor of sur-
gery and director of The Prostate Centre, Division of Urology of
The Toronto Hospital and The University of Toronto, Toronto,
Ontario, Canada.
For reprints write Tania Bartkiw, BScN, RN, The Toronto Hospi-
tal, 200 Elizabeth St., EN1-231 ,Toronto, Ontario, Canada M5G
2C4.
Copyright 9 1995 by the Emergency NursesAssociation.
1075-4210/95 $5.00 + 0 6511168023
The health care team caring for genital trauma
is confronted with complex issues. The loss or
serious injury to any part of the genitalia re-
quires prompt, careful diagnosis, management,
reconstruction, and protection from complica-
tions s u c h as sepsis or loss of an organ. The
patient undergoes a psychologic and emotional
crisis. He may envision disfigurement, malfor-
mation, or loss of the part. 5
Throughout history, the
genitalia have been a
preferred target during
military combat...
ANATOMIC CONSIDERATIONS
The external genitalia of the male consists
of the penis, which contains multiple structures
including the urethra, and the scrotum with two
testicles and their accessory organs (Figure 1).
The penis has three different portions: the
root, which lies in the superficial perineal p o u c h
and provides fixation and stability; the body,
made up of three erectile bodies (two corpora

OCTOBER-DECEMBER 1995 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw 99

 iers
$crotalseptum

Tunicaalbuginea
Corpora~Buck's
cavernosa ~ ~ f a s c i a

Corpus,~~~~ fascia
spong~osum Urethra Skin

Figure 1. Top, Relationship of bladder, prostate, seminal vesicles, penis, urethra,

and scrotal contents. Lowerleft, Transverse section through penis. Paired upper struc-
tures are corpora cavernosa. Single lower body surrounding urethra is corpus
spongiosum. Lower right, Fascial planes of lower genitourinary tract. (Reprinted with
permission. From Tanagho EA. Anatomy of the genitourinary tract. In: Tanagho EA,
McAnnish JW, eds. Smith's general urology. 14th ed. Norwalk, Connecticut: Appleton
& Lange, 1995.)

cavernosa, which lie side by side on the dor-
sum of the penis and are enclosed in a dense
white fibrous coat, the tunica albuginea, and
the corpus spongiosum, which lies ventrally in
the median plane, contains the urethra, and is
enclosed in the tunica albuginea; all three cav-
ernous bodies are loosely surrounded by a
double layer of dense fibrous connective tis-
sue known as the Buck's fascia (or deep fascia
of the penis); and the glans, which is the distal
expansion of the corpus spongiosum,
The penis is highly vascular and obtains ar-
terial blood from a branch of the internal pu-
dendal artery, which is derived from the inter-
nal iliac artery. Two branches extend the length
of the penis, becoming the deep a n d d o r s a l
arteries of the penis. There are also two major
veins, the superficial dorsal vein and the deep
dorsal vein of the penis.
The penile motor and sensory nerve function
is supplied by the dorsal nerve of the penis, a
branch of the pudendal nerve. The penis is also
innervated by portions of the autonomic ner-
vous system (involuntary). Parasympathetic fi-

100 INTERNATIONALJOURNALOF TRAUMANURSING/Bartkiw VOLUME1, NUMBER4

 Table 1. Causes of genital injury
Event Frequency (%)*
Gunshot 35
Motor vehicle crash 1.8
Sexual intercourse 13
Industrial crush 5 Corpora fracture
Industrial metal fragment 3 Rupture
Blunt shearing 3 Strangulation or gangrene
Fall onto blunt or sharp object 3 Amputation
Fight 2 Pressure necrosis
Use of autoerotic aid <1
Emasculation <1
Human bite <1
Sporting accident <1
Other 14
*Among all causes.
Reprinted with permission. From Bertini JE, Corriere JN Jr.
Male genital trauma: evaluate promptly, treat with restraint.
Contemp Uro11993;4:7-10, 18.
bers from the second through fourth sacral nerve
roots supply the erectile tissue of the penis.
Venous engorgement and obtaining an erection
are considered to be parasympathetic responses.
The s c r o t u m is a cutaneous p o u c h devel-
o p e d from the skin of the abdomen. It consists
of an outer layer of skin and an underlying
subcutaneous layer, the tunica dartos (Figure
1). The scrotum receives its blood supply from
branches of the femoral artery. Innervation is
provided by the lumbar plexus, which supplies
the lowermost portion of the abdominal wall.
Located within the scrotum are two testicles
(responsible for the production of spermato-
zoa and testosterone), the epididymis (elon-
gated cordlike structure responsible for stor-
age, transit, and maturation of sperm), and the
vas deferens (the excretory duct of the testes).
The testicles receive arterial blood from two
testicular arteries, which arise from the abdomi-
nal aorta. The venous system essentially fol-
lows the arteries. Nerve supply to the testicles
contain both parasympathetic (vagal) and sym-
pathetic fibers (from the thoracic segment of
the spinal cord).
M E C H A N I S M S A N D PATTERNS OF
INJURY
Injuries to the male external genitalia from
numerous types of force have b e e n reported
OCTOBER-DECEMBER 1995
Table 2. Types of genital injury
Injury Frequency (%)*
Laceration or perforation 58
Contusion or hematoma 15
Skin avulsion 13
6
3
2
2
1
*Among all causes.
Reprinted with permission. From Bertini JE, Corriere JN Jr.
Male genital trauma: evaluate promptly, treat with restraint.
Contemp Urol 1993;4:7-10, 18.
(Table 1). Table 2 lists the most frequent types
of injuries identified in the same report.
It is important to determine whether an in-
jury is the result of blunt versus penetrating
forces because the pattern of injury can vary
significantly. Penetrating injuries have been re-
ported with stab wounds, gunshot w o u n d s , 1,4-7
intentional trauma, 7-1~ or with the use of a
v a c u u m cleaner for sexual stimulation. The se-
verity of injury is influenced by the amount of
force applied and the anatomy affected. Inju-
ries sustained with penetrating forces include
superficial cuts to the prepuce (foreskin) and
glans penis, partial or complete amputation of
the penis or scrotum, degloving, urethral inter-
ruption, and laceration of the erectile bodies. 1,6,m
Blunt forces producing male genital trauma
have been reported with automobile, industrial,
farm, or athletic mishaps. Penile injuries have
been reported with sexual stimulation activities
(e.g., forcible manipulation with rings, nuts,
washers, sprockets, rubber bands, thread, hair)
and with violent sexual intercourse (the cause
of penile fracture in 33% to 60% of reported
casesnq3). Other reports describe injury to an
erect penis while the male attempted to put on
pants or turned over during sleep. 1,5,n,12,14,15
Penile Injuries
A direct blunt force can produce a fracture,
usually in the distal third of the penile shaft
(Figure 2). ~ The force ruptures the tunica
a l b u g i n e a c o v e r i n g o n e or b o t h c o r p o r a
INTERNATIONALJOURNAL OF TRAUMA NURSING/Bartkiw 101

Figure 2. Hematoma overlying fracture of corpus
cavernosum. Penis has distorted appearance. (Re-
printed with permission. From Bertini JE, Corriere
JN Jr. Male genital trauma: evaluate promptly, treat
with restraint. Contemp Urol 1993;4:10.)
cavernosa. The tunica albuginea is especially
vulnerable to injury in an erect penis because
it b e c o m e s inelastic and distended (changes
from a thickness of 2 m m to approximately 0.25
tO 0.50 ram). n'16 A penile fracture is suspected
w h e n the patient describes hearing a "crack-
ing" or p o p p i n g s o u n d a c c o m p a n i e d by imme-
The male with genital injury
may have intense physical
pain and psychologic distress.
diate pain a n d rapid loss of erection. 2,1~ A
h e m a t o m a develops along the shaft of the pe-
nis, causing swelling, discoloration, and devia-
tion of the penis a w a y from the defect. ~,lr If
confined, the h e m a t o m a spreads along the shaft
w h e r e it can cause external urethral compres-
sion leading to obstructive urinary retention. ~
In some cases Buck's fascia is torn, allowing
blood and urine to extravasate along the fascial
planes into the scrotum and perineum. 2,11
Anterior urethral injuries are c o m m o n compli-
102 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw
cations associated with blunt trauma to the exter-
nal genitalia. 2,11,12 The bulbous urethra is forced
against the ischial rami, causing urethral wall con-
tusion and partial or complete disruption. 8,18
Scrotal Injuries
Blunt scrotal injuries are not common, but
have b e e n r e p o r t e d w h e n the p e r i n e u m has
b e e n forced against handlebars, motorcycle
tank, or pa}allel bar. 8,18 It occurs nearly always
in m e n <50 years old. TM Blunt injuries to the
scrotum can be classified into one of five cat-
egories to aid in proper management:
9 Superficial contusion
9 Superficial contusion with skin laceration
9 Severe contusions with intrascrotal injury (in-
cluding hematocele, laceration or rupture of
the testes)
9 Testicular dislocation
9 Partial or c o m p l e t e avulsion of the scro-
tum. 8
Avulsion Injuries
The skin o v e r the male genitalia can be
avulsed with a shearing action, forcing the
genitalia against a stationary object. This has
b e e n the r e p o r t e d m e c h a n i s m in falls and pe-
destrian-car crashes. It has also b e e n n o t e d
w i t h stab w o u n d s , g u n s h o t w o u n d s , a n d
burns. 2,19 The injury can be partial (Figures 3
and 4) or c o m p l e t e (Figure 5). The avulsed
skin usually s e p a r a t e s along the relatively
bloodless planes over Buck's fascia of the pe-
nis or the dartos fascia of the scrotum. The
shaft of the penis and the testicles remain rela-
tively intact and u n c o n t a m i n a t e d . 2
CARE OF' THE MALE PATIENT WITH
EXTERNAL GENITAL TRAUMA
The male with genital injury will experience
intense physical pain along with psychologic
distress. Loss or serious injury to the genitalia
has b e e n described as similar to the loss of a
breast for a w o m a n . 2 Not only must the patient's
care provide m a n a g e m e n t for physical changes,
the health care providers must be sensitive to
the patient's fears or threat to his sense of "man-
hood." Psychologic support is a critical com-
p o n e n t of treatment.
VOLUME 1, NUMBER 4
 Figure 3. Gunshot wound causing injury to scrotum; damage to tes-
ticular contents can be seen.
Emergency Care
Patients with external genital injury may have
localized or multisystem trauma. The patient
should be assessed for other, more serious, or
life-threatening disorders before definitive care
is started.
H i s t o r y . The patient or reliable other source
should be asked for details regarding the in-
jury. The injury may be the result of a poten-
tially embarrassing situation or to an act of in-
terpersonal violence. The patient's right to pri-
vacy is important to ensure an accurate history
and to protect him from further emotional stress.
If the injury was due to an action that requires
police investigation, the nurse will n e e d to care-
fully d o c u m e n t statements and clinical findings
to help provide evidence. Additional evidence
such as clothing, bullet fragments, or foreign
matter will n e e d to be handled per protocol.
The patient should be questioned about the
cause of injury and the circumstances in w h i c h
it occurred; the b o d y area involved (especially
the point of impact); time since injury; symp-
toms since injury, including tenderness, ability
to void, characteristics of urine; past and present
health; history of previous genital injury, sur-
gery, or other genitourinary conditions.
Physical Examination. Isolated trauma t o
the external genitalia is not generally life-threat-
OCTOBER-DECEMBER 1995 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw
ening; however, a victim of blunt trauma m a y
have other injuries that can p r o d u c e airway
compromise or significant blood loss. A care-
ful primary and s e c o n d a r y survey are d o n e to
rule out conditions that m a y be m o r e serious.
Examination of the external genitalia involves
careful inspection and palpation. Patients usu-
ally have intense pain, especially if the scro-
tum has b e e n injured. Caution should be used
to prevent a suboptimal examination because
of the patient's d i s c o m f o r t . 2,18,19 Analgesics (if
not contraindicated because of other injuries)
and palliative measures m a y be u s e d to r e d u c e
pain and e n c o u r a g e the patient's cooperation.
The skin over the genitalia should be in-
spected for o p e n w o u n d s , loss of skin, pat-
terns of ecchymosis, and constricting objects.
The general appearance of the structures should
be observed to detect deformity. Subcutane-
ous h e m a t o m a s can form because of the elas-
ticity of the tissue, and e d e m a and bleeding
can grossly distort the normal form of the or-
gan (Figure 2). 2'17 The c i r c u m f e r e n c e of the
penis should be assessed to determine the de-
gree of edema. The scrotum m a y enlarge to
several times its n o r m a l size a n d b e c o m e
ecchymotic, making it m o r e difficult to evalu-
ate the testicles inside. The area a r o u n d the
genitalia should be e x a m i n e d for evidence of
103
Figure 4. Avulsion to scrotum causing partial
deg!oving of scrotal skin.
injury to the p e r i n e u m , l o w e r a b d o m e n , or
u p p e r thighs. Any drainage is assessed for
a m o u n t and source. The meatus of the penis is
inspected for blood, an indicator of urethral
injury. The patient's ability to spontaneously
void is evaluated. No attempt should be m a d e
to pass a urinary catheter until the physician
has b e e n able to determine w h e t h e r a urethral
injury is present.
The genitalia are inspected for signs of in-
jury. If intrascrotal pathology is suspected, the
scrotum m a y be further assessed with a bright
light placed on one side, facing toward the scro-
tum. If the light can pass through the swollen
tissue, a less s e v e r e c o n d i t i o n , s u c h as a
h y d r o c e l e or spermatocele, m a y be present.
Nontransillumination suggests a m o r e serious
injury, such as a hematocele with or without
gonadal fracture. 11
Because of the discomfort to the patient,
palpation should be deferred to the physician.
104 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw
Figure 5. Avulsion of scrotal and penile skin, com-
plete degloving of male genitalia. (Reprinted with
permission. From Bertini JE, Corriere JN Jr. Male
genital trauma: evaluate promptly, treat with re-
straint. Contemp Urol 1993;4:10.)
During routine care, however, the nurse m a y
note unusual tenderness or swelling. Signs of a
penile fracture include a palpable defect over
the fracture site in the tunica albuginea and
sometimes a blood clot lying directly over the
fracture site (discrete, firm, immobile, tender
swelling over w h i c h the penile skin can be
rolled, referred to as the "rolling sign"2~
A rectal examination is used to determine
the presence of h e m a t o m a s and the position
of the prostate gland. W h e n necessary, a ten-
d e r s c r o t u m can b e p a l p a t e d by injecting
lidocaine hydrochloride in the spermatic cord
to block sensation.
Initial Care. Initial care is directed toward
VOLUME 1, NUMBER 4
 F/gure 6
F/gure 7
Figures 6 and 7. Restoration of form and function after microsurgical
reimplantation of penis.
preserving genitourinary function and prevent-
ing complications. Because the genitalia have
a rich blood supply, acute injury usually pro-
duces immediate edema and some degree of
bleeding. Ice packs, splints, and scrotal sup-
ports can be used to relieve pain and promote
lymphatic and venous drainage. TM
Open wounds are evaluated for evidence of
foreign matter and, if indicated, are irrigated
with warm sterile normal saline solution. The
possibility of preserving evidence if the patient
has been involved in a crime should be kept in
mind. Avulsed areas are covered with dress-
ings soaked in sterile normal saline solution to
protect the skin from contamination and ex-
cess drying. An amputated penis should be
wrapped in a dressing moistened with sterile
OCTOBER-DECEMBER 1995 INTERNATIONALJOURNAL OF TRAUMA NURSING/Bartkiw
normal saline solution and placed in a plastic
container (to protect the amputated part from
contact with liquids), and then the container
should be placed in an iced bath to increase
ischemia time and the potential for anastomo-
sis. Primar3~ anastomosis is considered if the
distal segment is in good condition and the
ischemia time is <18 hours Figures 6 and 7. 21 If
anastomosis is not possible, the remaining pe-
nis can be reshaped by closing the open cor-
pora and performing a meatoplasy.
Providing safe and comfortable urinary drain-
age will need to be considered early, especially
if the patient had been consuming fluids or
has an intravenous infusion. The physician will
determine whether urethral catheterization is
safe or appropriate. Urine should be obtained
105
 Table 3. Diagnostic studies used to recognize genitourinary trauma

Study Indication
Urinalysis Gross or microscopic hematuria (considered significant if >40 red blood
cells per high-power field)
Urethrogram Blood at penile meatus, difficulty inserting urethral catheter, "high-riding"
prostate gland, scrotal hematoma, or history of penetrating injury involving
genitalia, fracture of penis, blunt trauma to lower abdomen
Ultrasonography Assist in diagnosis of testicular rupture with disruption of tunica
albuginea lr
Excretory urography Hematuria or significant injuries involving lower abdomen or external
genitalia (penetrating wounds, falls, deceleration). If findings are
normal, patient may be observed; if abnormal or questionable,
computed tomography may be needed.
Computed tomography Noninvasive method to evaluate patients with crush injuries, hema-
toma, lack of urinary tract function (can detect associated injury
to genitourinary and other abdominal structures)
Isotope flow scan May be used to diagnose testicular rupture associated with blunt
scrotal trauma (limited by its lack of availability in emergency setting)
Soft tissue films To determine whether foreign metallic particles are present in soft
tissue around genitalia or inside urethra or anus

for laboratory analysis and examined for gross 9 Patients will have pain from edema, tissue
or microscopic hematuria. If blood is present, damage, and other injuries. Palliative measures,
radiographic studies are indicated to determine such as ice packs and scrotal supports that keep
the source and extent of injury 18 (Table 3). the scrotum elevated slightly, can be used along
The potential for infection is high w h e n there with judicious use of analgesics. Initially, pa-
is injury to the genital region. Broad-spectrum tient-controlled analgesia with morphine sul-
antibiotics are administered intravenously in the fate may be n e e d e d for adequate pain relief.
acute resuscitation. The patient's tetanus im- After an analgesia has been provided, the pa-
munization history should be evaluated, and if tient should be instructed to contact the physi-
it is not k n o w n to be up-to-date, tetanus im- cian if he has onset of n e w or different pain,
m u n e globulin and toxoid should be given. Di- either in the hospital or after discharge.
agnostic studies used to make a definitive di- 9 The potential complications associated with
agnosis are discussed in Table 3. genital trauma include infection, poor surgical
In a number of cases of genital trauma, emer- results, and altered genitourinary function. In-
gency surgical intervention will be indicated. fection may be in the tissue or urinary tract.
Resuscitation nurses can The w o u n d s a n d inci-
anticipate the need for s i o n s s h o u l d be in-
expediting preparations Strict aseptic techniques is s p e c t e d for r e d n e s s ,
and contacting surgeons essential for dressing edema, and drainage
and notifying perioper- a r o u n d sutures. Drains
changes and when caring for p l a c e d d u r i n g snrgery
ative nurses.
I n - P a t i e n t Manage-
drainage systems. should be c h e c k e d for
m e n t . The patient with patency and a m o u n t of
genital trauma will need drainage. Strict aseptic
adequate pain relief, monitoring for signs and technique is essential for dressing changes and
symptoms of complications, education regard- w h e n caring for drainage, systems. Daily care
ing self-care activities, and psychosocial sup- of an indwelling catheter s h o u l d be done ac-
port for himself and significant others. cording to institutional protocol. The patient's

106 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw VOLUME 1, NUMBER 4

fluid intake and output should be measured.
The urine should be evaluated for changes in
color or odor that are suspicious of a urinary
tract infection. If a urinary catheter is required
for >7 days, a suprapubic catheter should be
considered to avoid urethritis, stricture, and
epididymitis. 17
Poor surgical results can be due to seepage
of urine, failure to control edema, and local-
ized tissue infection. Pressure dressings are used
w h e n e v e r skin grafts are p l a c e d b e c a u s e
h e m a t o m a s can easily form in the tissue, caus-
ing the loss of the graft. 1: D e b r i d e m e n t of ex-
posed tissue can be facilitated with the use of
gentle wet-to-dry dressings.
Patients w h o require a long-term indwelling
urinary catheter should be instructed on cath-
eter care and signs and symptoms of urinary
tract infection. It m a y be necessary to refer the
patient to a rehabilitation Service for long-term
genitourinary management.
SUMMARY
Male genital t r a u m a is g e n e r a l l y not life
threatening yet has the potential to p r o d u c e
long-term genitourinary dysfunction and seri-
ous psychosocial consequences. Trauma care
providers n e e d to be aware of h o w to diag-
nose injuries, protect the patient from further
injury or complications, and assist the patient
to achieve optimal function.
ACKNOWLEDGMENTS
We thank Dr. J. Honey, staff urologist at St.
Michael's Hospital, Toronto, Ontario, Canada, for
the use of clinical pictures of genital trauma.
OCTOBER-DECEMBER 1995 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Bartkiw
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