World Journal of Urology

https://doi.org/10.1007/s00345-020-03115-0

ORIGINAL ARTICLE

Male genital trauma at a level 1 trauma center

Connor S. McCormick1 · Mitchell G. Dumais1 · Niels V. Johnsen1 · Bryan B. Voelzke1,2 · Judith C. Hagedorn1 

Received: 3 September 2019 / Accepted: 2 February 2020

© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Objectives  To describe our experience with men admitted to a tertiary care hospital with genital injury.
Methods  Adult men with injuries of the genitals, admitted to our institution between January 2013 and June 2018, were
identified from our institutional trauma registry. Patient charts were queried to extract mechanism, management, follow-up,
and complications.
Results  118 men met inclusion criteria. 39% and 61% sustained penetrating and blunt injuries, respectively. The most com-
mon mechanisms of penetrating trauma were external violence (48%) and self-inflicted injury (40%). The most common
mechanisms of blunt trauma were motorcycle crash (33%) and sexual injury/intercourse (22%). 38% presented with penile and
71% with scrotal injuries. 48% of men with scrotal injuries had concomitant testis injury. 9.3% presented with both a penile
and a scrotal injury. Concomitant urethral injuries were found in 17% of all genital injuries. Genital trauma was more common
in the summer months. 74% of all genital injuries were managed operatively, with surgery more common after penetrating
injury (89% vs 64%, p value < 0.01). 73% of 84 men with scrotal trauma were managed operatively. 27 men received surgical
intervention for testis rupture, with a testicular salvage rate of 44%. 60 (51%) patients presented for follow-up. The median
length of follow-up from initial injury was 29 (± 250) days. Of these, 9 (15%) patients developed one or more complications
Conclusions  Genital injuries can occur via numerous mechanisms and frequently require operative intervention. Concomitant
urethral injury is common. More work is needed to evaluate the long-term sequelae of these injuries.

Keywords  Genital · Trauma · Injuries · Male · Blunt · Penetrating

Introduction
Trauma to the male genitals is rare [1]. This is likely due to
their mobility, elasticity, shielding between the thighs and
relatively small body surface area [2–4]. However, while
uncommon, genital injuries can result in significant long-
term morbidity, including infertility, hormonal dysfunction,
impotence, voiding dysfunction, and psychological distress
[5–8]. Although potentially devastating to quality of life,
appropriate management of these injuries may minimize and
avoid these possible complications [9].
Wartime trauma to the male genitalia has been relatively
well described in both civilian and military populations, in
* Judith C. Hagedorn
judithch@uw.edu
1
Department of Urology, Harborview Medical Center,
University of Washington, 325 9th Ave, Box 359868, Seattle,
WA 98104, USA
2
Present Address: Spokane Urology, Spokane, WA, USA
many conflicts [2, 8, 10, 11]. However, these injuries tend be
caused by high-velocity, military firearms and ground-level
explosive devices, such as improvised explosive devices
(IEDs) and landmines [2, 11, 12]. Domestic, civilian patients
with genital trauma represent a distinct, poorly described
population, with diverse mechanisms of injury. While a
number of studies have examined particular subsets of inju-
ries, such as exclusively those from penetrating trauma or
exclusively injuries of the penis or testes, research in this
field has been limited by the rarity of these wounds and
there remains a paucity of literature regarding the presenta-
tion, management, and outcomes for civilian men outside
of conflict zones [1, 4, 5, 12–15]. As such, we describe here
our 5-year experience with male genital trauma at a large,
regional, level 1 trauma center. To our knowledge, this repre-
sents one of the largest civilian series of male genital trauma
in the published literature.

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 World Journal of Urology

Materials and methods of injury, associated genitourinary injuries, management,

After institutional review board approval, the institutional
trauma registry for Harborview Medical Center, a level 1
trauma center, was retrospectively reviewed using ICD-9
codes to identify adult men admitted with injuries of the
penis, scrotum, or testes, between January 2013 and June
2018.
Individual patient charts were then reviewed to extract
demographic information, admission month, mechanism
length of follow-up, and complications. Mechanisms of
injury were assigned to the categories shown in Fig. 1.
Complications were assigned to the categories listed in
Table 1.
Statistical analyses were performed with R Version
3.5.1 (The R Foundation for Statistical Computing, 2018,
Vienna, Austria). Categorical variables were analyzed
with a χ2 test, while continuous variables were analyzed
with Student’s t test. All tests were two-tailed, with a p
value < 0.05 considered statistically significant.

Fig. 1  Mechanisms of injury Blunt Violence

Penetrating 3%
in penetrating and blunt trauma
to the male genitals at a level Sexual
1 trauma center, 2013–2018. Workplace 2%
accident Firework Bicycle
MVC motor vehicle crash, MCC
4% 9% 8% MVC
motorcycle crash
15%

Sexual
Self-inflicted 22%
37%

MCC
Violence 34%
48% Workplace
accident
18%

Table 1  Complications and rates of follow-up by injury type in male genital trauma at a level 1 trauma center, 2013–2018
Penile, penetrating Penile, blunt Scrotal, penetrating Scrotal, blunt Total ­patientsa

Injury
 Total cases 22 23 31 53 118
 Number seen for any follow- 14 (64) 17 (74) 19 (61) 19 (36) 60 (51)
up (% of total)
Cases (% of follow-up group) Total
patients with
­complicationb

Complication
 Infertility 0 (0) 0 (0) 0 (0) 1 (5) 1 (2)
 Hypogonadism 1 (7) 2 (12) 3 (16) 2 (11) 5 (8)
 Impotence 1 (7) 1 (6) 1 (5) 1 (5) 2 (3)
 Voiding dysfunction 1 (7) 2 (12) 1 (5) 2 (11) 3 (5)
 Psychological distress 1 (7) 2 (12) 1 (5) 1 (5) 4 (7)
 Total patients with injury 3 (21) 3 (18) 4 (21) 3 (16) 9 (15)
and any complication
a
 11 total study patients and 9 patients seen in follow-up had a combined penile/scrotal injury and are counted in both columns
b
 4 patients with a complication had a combined penile/scrotal injury, and 4 patients had 2+ complications and counted in both columns and
rows, respectively

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World Journal of Urology
Results
Review of our institutional trauma registry identified 118
adult men admitted with genital trauma between January
2013 and June 2018. A single patient who presented two
separate times with self-inflicted penile lacerations was
treated as two separate study patients. The mean (± SD)
age was 38 (± 14.2) years. 46 (39%) of the injuries were
penetrating and 72 (61%) were blunt. The blunt injury
group tended to be older, with a mean age of 40.6 years
vs 34.1  years for penetrating injuries (p = 0.012). The
mechanisms of injury in blunt and penetrating trauma are
summarized in Fig. 1. Both penetrating and blunt injuries
to the male genitalia were more frequent in the summer
months (Fig. 2).
Of 118 total patients, 45 (38%) presented with penile
and 84 (71%) with scrotal injuries. 40 (48%) of men
with scrotal injuries had concomitant testicular inju-
ries. 11 (9.3%) of patients presented with both a penile
and a scrotal injury. Isolated scrotal injuries occurred
more frequently following blunt trauma (71% vs 29%,
p value = 0.03), while testicular injuries occurred more
frequently following penetrating trauma (57% vs 43%, p
18
16
14
12
No. of cases
10
0
Jan Feb Mar Apr May
Fig. 2  Frequency of male genital trauma at a level 1 trauma center by month, 2013–2018
value < 0.01). There was no statistically significant differ-
ence in frequency of penile injuries between the blunt and
penetrating injury groups.
Concomitant urethral injury was found in 20 (17%) men
who had sustained genital trauma. Of the 10 total patients
with penile fracture, 6 (60%) were found to have an associ-
ated urethral injury. Five other urethral injuries were due
to other blunt trauma, and four were associated with pel-
vic fracture. Eight urethral injuries were due to penetrating
penile trauma from gunshot wounds (GSW), and one was
due to a complex friction burn and avulsion sustained in an
industrial accident. The tunica albuginea was ruptured in 18
(40%) penile injuries.
Overall, 87 (74%) patients received operative interven-
tion, with operative intervention being more common in
the penetrating injury group (89% vs 64%, p value < 0.01).
Examples of operatively managed penetrating and blunt
injuries are shown in Fig. 3. Of the 84 patients with scro-
tal trauma, 63 (73%) received operative intervention.
Eleven (17%) of these had a negative scrotal exploration.
Testis rupture occurred in 28 patients, 16 (57%) due to
blunt injury, and 12 (43%) due to penetrating injury. All
testicular ruptures were treated operatively, except in
a single patient, who sustained multiple, more serious
All Injuries
Penetrating
Blunt
June July August Sept Oct Nov Dec
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 World Journal of Urology

Fig. 3  Operatively managed
male genital injuries. a Self-
inflicted partial penile amputa-
tion and bilateral orchiectomy;
b gunshot wound (GSW) to
left thigh and left scrotum/
crura; c motorcycle collision
(MCC) blunt scrotal trauma
with devitalized right testicle; d
and self-inflicted GSW to base
of penis

injuries and died prior to scrotal exploration. There were Discussion

15 orchiectomies and 12 orchiorrhaphies in this group,
for an overall testicular salvage rate of 44%. The differ-
ence in orchiectomy rates between the penetrating and
blunt injury groups did not reach statistical significance
(p value = 0.13).
60 (51%) men presented for follow-up of their genital
injury. The median length of follow-up from initial injury
was 29 (± 250) days. Of these, 9 (15%) men developed
one or more complications. These complications and rates
of follow-up are listed by injury type in Table 1.
Though uncommon, injury to the male genitals can occur
by a variety of mechanisms and result in significant long-
term morbidity [1, 5–8]. As a result of the rarity of these
injuries, the epidemiology, management, and outcomes of
genital injuries for civilian men are relatively unknown.
Our series demonstrated a 36% rate of urethral injury
associated with penetrating penile trauma, all due to
penile gunshot wound (GSW). This is consistent with the

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World Journal of Urology
previously reported 23–50% rate of urethral injury in pen-
etrating penile trauma [1, 4, 14]. Similar to other published
series and the European Association of Urology (EAU)
guidelines on urotrauma, our approach to penetrating
penile injuries included surgical exploration, conservative
debridement that maximizes tissue preservation, and pri-
mary repair of affected structures, with small lacerations,
superficial to Buck’s fascia, managed conservatively [1,
4, 15–17].
60% of men in our cohort who presented with a penile
fracture were found to have an associated urethral injury, a
higher proportion than has been reported elsewhere (0–38%)
[3, 18–23]. 100% of men in our study with penile fracture
were injured during sexual intercourse and penile fracture-
associated urethral injury has previously been found to be
more common in sexual intercourse as opposed to other
mechanisms such as masturbation or taqaandan, likely due
to the greater force applied to the penis [22, 23]. However, 4
(40%) men admitted with a penile fracture in our study were
referred with a known urethral injury. Therefore, our high
rate of urethral injury may also reflect the nature of our insti-
tution as a tertiary hospital with a very large catchment area.
We also evaluated the urethra of all men presenting with a
penile fracture via urethrogram, cystoscopy, and/or surgical
exploration. This is in contrast a national rate of urethral
evaluation of 23% in penile fracture, and likely increased our
rate of detection [24]. All penile fractures in our series were
operatively managed with urgent exploration and closure of
the ruptured corpora and all co-occurring urethral injuries
were primarily repaired.
The overall high rate (17%) of associated urethral injury
in our series emphasizes the need for a high index of sus-
picion for urethral injury in male genital trauma. In the
absence of a readily apparent urethral injury, blood at the
urethral meatus, difficulty voiding, and hematuria can be
indicative of urethral injury [16]. While retrograde urethrog-
raphy is considered the gold standard for the diagnosis of
urethral injury, we also frequently use cystoscopy at the time
of exploration [25]. Similar to other authors, we attempt pri-
mary repair of penetrating injuries of the anterior urethra or
injuries associated with penile fracture [16]. However, in
anterior urethral injuries not amenable to primary repair,
such as those with significant tissue destruction or local
blast effects, we have created a urethrostomy or neomeatus
in anticipation of a later, staged reconstruction. In pelvic
fracture urethral injury (PFUI) and other blunt injuries of
the posterior urethra, we follow American Urological Asso-
ciation (AUA) guidelines and attempt early urine drainage
via endoscopic realignment or suprapubic tube, depending
on the clinical scenario, with delayed repair of the likely
urethral stricture, [25, 26].
A unique finding of the present study was the role of
firework injuries to the scrotum, which represented ~ 3%
of injuries in our series. All of these men were operatively
managed in a fashion representative of our general approach
to testis rupture. This included early exploration, conserva-
tive debridement of devitalized tissue and extruded semi-
niferous tubules, and primary closure of the tunica albug-
inea. Those with more extensive soft tissue defects are
then offered primary wound closure, if possible, or delayed
split-thickness skin grafting. In cases of testis rupture with
extensive destruction of the tunica albuginea, we have used
a free graft of the tunica vaginalis to close the testicle and
avoid orchiectomy, as advocated by Ferguson and Brandes
[27]. Our decision to remove or salvage an injured testicle
is based on the appearance of the testicle after exposure. If
there are a substantial amount of remaining viable tubules
with evidence of robust blood flow to the testicle, salvage
is attempted, knowing that progressive testicular atrophy
may occur in spite of a successful repair. Similar to our
experience with urethral injuries, the high rate of testis rup-
ture in scrotal injuries (33%) in our series emphasizes the
low threshold required for operative exploration of scrotal
trauma.
Our finding of increased blunt and penetrating genital
trauma in the summer months is consistent with other series
in the general trauma literature, which have shown increased
intentional trauma, and blunt injuries, especially due to
motorcycle collisions (MCC), in the summer [28, 29]. Cor-
respondingly, external violence and MCC were, respectively,
the most common mechanisms of penetrating and blunt
injuries in our series. Of note, while our data reflect trends
previously demonstrated in other large US urban areas, our
series also likely reflects significant seasonal variations in
industrial and recreational activities across the rural, 5-state
region served by our tertiary referral center.
This study is a retrospective review of our 5-year experi-
ence with male genital trauma and has several limitations.
Patients were identified in our institutional trauma registry
via ICD-9 codes. While the charts of all patients coded for
genital injury were reviewed, it is possible that patients with
genital injuries not coded as such were missed. This is most
likely the case in patients with polytrauma, especially those
who died of their injuries.
Similar to other trauma series, our information about
long-term outcomes is relatively limited [1]. Only half of our
patients were seen in follow-up and were only followed for a
median of 1 month from initial admission date, though this
was widely variable. Several patients with further planned,
staged reconstructive operations were additionally lost to
follow-up. While some complications occurred in short-term
follow-up, our ability to examine the effect of different mecha-
nisms of injury or management strategies on known sequelae
of genital injuries, especially long-term outcomes such as fer-
tility, is limited. To address this, a complementary follow-up
study is planned, which will administer questionnaires to men
13

in this cohort to evaluate sexual and voiding function, as well
as quality of life.
Our study is also limited by the flaws inherent in a ret-
rospective design and the relatively small number of geni-
tal injuries. In addition, our cohort reflects the population
admitted to our tertiary care center, and this may differ
from the population in a community emergency depart-
ment, or tertiary hospitals in other regions. A multi-center
study across several regions, including patients who were
not admitted to the hospital, could address this limitation
and the overall rarity of these injuries. This may also help
capture less-severely injured patients who were treated con-
servatively in the outpatient setting.
Conclusions
This study represents one of the largest series of genital
trauma in civilian men in the published literature and dem-
onstrates that genital injuries can occur as the result of a
wide variety of mechanisms and frequently requires opera-
tive intervention. Our study also illustrates that the urethra is
frequently injured in genital trauma, requiring a low thresh-
old for imaging or operative exploration of the urethra. More
work is needed to evaluate the long-term sequelae of trau-
matic genital injuries in these men.
Acknowledgements  Hunter B. Wessells for his contribution of patients
to our study. Harborview Injury Prevention & Research Center.
Author contributions  CSM manuscript writing, data collection, data
analysis. MGD manuscript writing, data collection. NVJ manuscript
writing, data collection, data analysis. BBV project development.
JCH project development, data collection. All: critical revision of the
manuscript.
Funding None.
Compliance with ethical standards  14. Simhan J, Rothman J, Canter D, Reyes JM, Jaffe WI, Pontari
Conflict of interest None.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the Uni-
versity of Washington Institutional Review Board (approval number:
49684; 9/5/2018-9/4/2021) and with the 1964 Helsinki declaration and
its later amendments or comparable ethical standards.
Informed consent  This study was a retrospective chart review, used to
compile a de-identified database. No identifying personal information
or characteristics were collected.
References
1. Bjurlin MA, Kim DY, Zhao LC, Palmer CJ, Cohn MR, Vidal
PP, Bokhari F, Hollowell CM (2013) Clinical characteristics
and surgical outcomes of penetrating external genital injuries.
13
World Journal of Urology
J Trauma Acute Care Surg 74:839–844. https​://doi.org/10.1097/
TA.0b013​e3182​7e1b8​a
2. Etabbal AM, Hussain FF, Benkhadoura MO, Banni AM (2018)
War-related penile injuries in Libya: single-institution expe-
rience. Arab J Urol 16:250–256. https​: //doi.org/10.1016/j.
aju.2018.01.005
3. Lee SH, Bak CW, Choi MH, Lee HS, Lee MS, Yoon SJ (2008)
Trauma to male genital organs: a 10-year review of 156 patients,
including 118 treated by surgery. BJU Int 101:211–215. https​://
doi.org/10.1111/j.1464-410X.2007.07265​.x
4. Kunkle DA, Lebed BD, Mydlo JH, Pontari MA (2008) Evalua-
tion and management of gunshot wounds of the penis: 20-year
experience at an urban trauma center. J Trauma 64:1038–1042.
https​://doi.org/10.1097/TA.0b013​e3180​34203​6
5. Cass AS, Luxenberg M (1991) Testicular injuries. Urology
37:528–530
6. Frappell-Cooke W, Wink P, Wood A (2013) The psychological
challenge of genital injury. J R Army Med Corps 159(Suppl
1):i52–i56
7. Lin WW, Kim ED, Quesada ET, Lipshultz LI, Coburn M (1998)
Unilateral testicular injury from external trauma: evaluation of
semen quality and endocrine parameters. J Urol 159:841–843
8. Al-Azzawi IS, Koraitim MM (2014) Lower genitourinary
trauma in modern warfare: the experience from civil violence
in Iraq. Injury 45:885–889. https​: //doi.org/10.1016/j.injur​
y.2014.01.005
9. Furr J, Culkin D (2017) Injury to the male external genitalia: a
comprehensive review. Int Urol Nephrol 49:553–561. https​://doi.
org/10.1007/s1125​5-017-1526-x
10. Janak JC, Orman JA, Soderdahl DW, Hudak SJ (2017) Epidemi-
ology of genitourinary injuries among male U.S. Service Mem-
bers deployed to Iraq and Afghanistan: early findings from the
Trauma Outcomes and Urogenital Health (TOUGH) Project. J
Urol 197:414–419. https​://doi.org/10.1016/j.juro.2016.08.005
11. Waxman S, Beekley A, Morey A, Soderdahl D (2009) Penetrating
trauma to the external genitalia in Operation Iraqi Freedom. Int J
Impot Res 21:145–148. https​://doi.org/10.1038/ijir.2008.59
12. Cerwinka WH, Block NL (2009) Civilian gunshot injuries of the
penis: the Miami experience. Urology 73:877–880. https​://doi.
org/10.1016/j.urolo​gy.2008.10.057
13. Phonsombat S, Master VA, McAninch JW (2008) Penetrating
external genital trauma: a 30-year single institution experience.
J Urol 180:192–195. https​://doi.org/10.1016/j.juro.2008.03.041
(discussion 195–196)
MA, Doumanian LR, Mydlo JH (2012) Gunshot wounds to the
scrotum: a large single-institutional 20-year experience. BJU Int
109:1704–1707. https:​ //doi.org/10.1111/j.1464-410X.2011.10631​
.x
15. Brandes SB, Buckman RF, Chelsky MJ, Hanno PM (1995) Exter-
nal genitalia gunshot wounds: a ten-year experience with fifty-six
cases. J Trauma 39:266–271 (discussion 262–271)
16. Chang AJ, Brandes SB (2013) Advances in diagnosis and manage-
ment of genital injuries. Urol Clin N Am 40:427–438. https​://doi.
org/10.1016/j.ucl.2013.04.013
17. Lynch TH, Martínez-Piñeiro L, Plas E, Serafetinides E, Türk-
eri L, Santucci RA, Hohenfellner M, Urology EAo (2005) EAU
guidelines on urological trauma. Eur Urol 47:1–15. https​://doi.
org/10.1016/j.eurur​o.2004.07.028
18. Ahmadnia H, Younesi Rostami M, Kamalati A, Imani MM (2014)
Penile fracture and its treatment: is retrograde urethrograghy
necessary for management of penile fracture? Chin J Traumatol
17:338–340
19. Fergany AF, Angermeier KW, Montague DK (1999) Review
of Cleveland Clinic experience with penile fracture. Urology
54:352–355
World Journal of Urology
20. Gedik A, Kayan D, Yamiş S, Yılmaz Y, Bircan K (2011) The
diagnosis and treatment of penile fracture: our 19-year experience.
Ulus Travma Acil Cerrahi Derg 17:57–60
21. Koifman L, Barros R, Júnior RA, Cavalcanti AG, Favorito LA
(2010) Penile fracture: diagnosis, treatment and outcomes of 150
patients. Urology 76:1488–1492. https​://doi.org/10.1016/j.urolo​
gy.2010.05.043
22. Phillips EA, Esposito AJ, Munarriz R (2015) Acute penile trauma
and associated morbidity: 9-year experience at a tertiary care
center. Andrology 3:632–636. https:​ //doi.org/10.1111/andr.12043​
23. Pavan N, Tezzot G, Liguori G, Napoli R, Umari P, Rizzo M,
Chiriacò G, Chiapparrone G, Vedovo F, Bertolotto M et al (2014)
Penile fracture: retrospective analysis of our case history with
long-term assessment of the erectile and sexological outcome.
Arch Ital Urol Androl 86:359–370. https​://doi.org/10.4081/
aiua.2014.4.359
24. Pariser JJ, Pearce SM, Patel SG, Bales GT (2015) National pat-
terns of urethral evaluation and risk factors for urethral injury
in patients with penile fracture. Urology 86:181–185. https​://doi.
org/10.1016/j.urolo​gy.2015.03.039
25. Santucci RA, Bartley JM (2010) Urologic trauma guidelines:
a 21st century update. Nat Rev Urol 7:510–519. https​ ://doi.
org/10.1038/nruro​l.2010.119
26. Morey AF, Brandes S, Dugi DD, Armstrong JH, Breyer BN, Brog-
hammer JA, Erickson BA, Holzbeierlein J, Hudak SJ, Pruitt JH
et al (2014) Urotrauma: AUA guideline. J Urol 192:327–335. https​
://doi.org/10.1016/j.juro.2014.05.004
27. Ferguson GG, Brandes SB (2007) Gunshot wound injury of
the testis: the use of tunica vaginalis and polytetrafluoroethyl-
ene grafts for reconstruction. J Urol 178:2462–2465. https​://doi.
org/10.1016/j.juro.2007.08.021
28. Nahmias J, Poola S, Doben A, Garb J, Gross RI (2017) Sea-
sonal variation of trauma in western Massachusetts: fact or
folklore? Trauma Surg Acute Care Open 2:e000120. https​://doi.
org/10.1136/tsaco​-2017-00012​0
29. Michel SJ, Wang H, Selvarajah S, Canner JK, Murrill M, Chi
A, Efron DT, Schneider EB (2016) Investigating the relationship
between weather and violence in Baltimore, Maryland, USA.
Injury 47:272–276. https​://doi.org/10.1016/j.injur​y.2015.07.006
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