Genital Trauma Repair

Genital injuries are rare but can devastate sexual, reproductive, and psychological health. They are seldom life-threatening, so stabilise other major injuries first. The goals of repair are to minimise further injury, allow micturition, prevent erectile dysfunction, preserve reproductive function, and give good cosmesis. Most injuries need wound irrigation, debridement of devitalised tissue, and a multilayered closure. Genital trauma evaluation and timing rules are covered in the Trauma topic; penile fracture has its own Penile Fracture Repair page.

General Principles

• Debride conservatively. The genitals are richly vascularised, so over-aggressive excision removes viable skin — start with a limited debridement, copiously irrigate contaminated wounds with saline, and remove foreign material. Ischemic tissue declares itself as delayed necrosis and is excised at a later trip; multiple operating-room visits are often needed.
• Manage small, clean wounds immediately; use wet-to-dry dressings to complete debridement and prepare a full-thickness defect for grafting.

Genital Skin Loss

• Lacerations and avulsions — even large, uncontaminated lacerations can be closed primarily (rich blood supply); close the dartos with 3-0 polyglactin and skin with 4-0 chromic/nylon, leaving a drain if contamination is a concern. Scrotal skin loss up to 50% closes primarily thanks to skin elasticity.
• Circumferential penile shaft skin loss disrupts the lymphatics, so any distal skin left behind becomes lymphedematous — excise all shaft skin up to the corona at debridement and plan a single uniform graft.
• Burns — thermal: 1% silver sulfadiazine, await eschar separation, then debride. Chemical: decontaminate (brush off powder, remove clothing, low-pressure warm-water irrigation, check pH with litmus) — special cases: lye is brushed off first (it reacts with water), elemental metals (sodium/lithium/potassium) are covered in mineral oil and removed manually, hydrofluoric acid needs topical calcium gluconate or magnesium (the fluoride ion penetrates tissue and risks cardiac arrest), and phenols are wiped off and treated with 50% polyethylene glycol. Electrical: delay debridement until viable–nonviable demarcation is clear. (A urethral catheter in a genital burn is removed after 72 h to prevent slough/fistula.)
• Bites — give tetanus prophylaxis and broad-spectrum antibiotics (cephalexin or doxycycline; Pasteurella multocida is the dog/cat-bite risk — penicillin V if resistance is suspected). Human bites are not closed primarily (high infection risk).

Genital Skin Grafting

• Split- vs full-thickness — a split-thickness skin graft (STSG) (epidermis + partial dermis; thin 0.15–0.3 mm, intermediate 0.3–0.45 mm, thick 0.45–0.6 mm) reepithelialises its donor site quickly and takes well but contracts more (mitigated by a thick graft). A full-thickness graft (FTSG) contracts less and is friction-resistant with better texture/colour, but revascularises slowly, takes less reliably, is prone to blebbing, and has limited donor sites. The anterolateral thigh is the ideal donor (ample area, accessible supine or lithotomy, concealed, with laterally sparse fat).
• Penis — free the shaft from basal adhesions, anchor the scrotal/pubic skin at the base at skin level (4-0 polyglactin — not too proximal, which leaves a cleft), and excise residual skin to the corona. FTSGs suit small areas; for circumferential loss use a thick STSG (~0.45 mm, ~12.5 cm wide × 15 cm) — the width covers the penile length — wrapped circumferentially, overlapped ventrally, and trimmed in a zigzag/ventral Z-plasty to prevent chordee. Expanded meshing contracts, so use an unmeshed or 1:1 meshed-but-unexpanded graft (the mesh drains fluid and prevents blebbing without expanding); secure with a tacking and bolster dressing for 5 days.
• Scrotum — close primarily if ≤ 50% is lost (dartos with 3-0 polyglactin); otherwise use a meshed STSG (1:1 or 1:1.5), secure the testes/cord in the midline, lay the graft over the posterior testes and wrap anteriorly to build a neoscrotum, or place the testes in thigh pouches temporarily.
• High-risk wounds (malnutrition, infection, diabetes) — stage the repair: cover with cadaveric allograft or porcine xenograft as a biologic dressing, removed at ~1 week when the autograft is harvested (repeat if it fails to take — a sign of a poor bed).

Penile Fracture

Suspect a fracture with a cracking sound, rapid detumescence, swelling, and ecchymosis; repair promptly, and evaluate the urethra (cystoscopy or retrograde urethrogram) with blood at the meatus, gross hematuria, or inability to void. The tunica is closed with interrupted PDS and the patient counselled on sexual abstinence. For the full operative technique, see the Penile Fracture Repair page.

Penile Reimplantation

A microsurgical emergency. Minimise warm ischemia and, if the amputation followed a psychotic episode, prevent further self-harm (psychiatric care comes postoperatively). Preserve the part by the double-bag technique (saline-soaked gauze in a bag, then that bag in ice slush); reattachment is feasible within < 16 h cold or < 6 h warm ischemia (the atlas cites up to 24 h). Use a two-team approach — urology prepares the proximal stump while the microvascular team prepares the amputated segment.

1. Prepare — under magnification, mobilise the skin edges ~1 cm to expose the dorsal neurovascular structures, control the stump with a tourniquet, debride minimally, and ligate accessory veins (keep the largest dorsal vein).
2. Urethra and corpora — over an 18-Fr catheter, repair the urethral mucosa with interrupted 5-0 PDS and a second layer through the spongiosal tunica; close the corporal tunica albuginea with interrupted 3-0 PDS (cavernosal-artery anastomosis is not routine but is advocated by some for very proximal injuries).
3. Microvascular repair — spatulate and repair the deep dorsal vein with 9-0 nylon, the dorsal nerves (epineurium) with 9-0 nylon, and the dorsal arteries with 10-0 nylon; reapproximate Buck and Colles fascia (3-0 polyglactin) and skin (4-0 chromic).
4. Postoperative — broad-spectrum antibiotics, handheld-Doppler checks of the dorsal arteries, avoidance of vasoconstrictors (nicotine), a warm room, and leeches for venous congestion; a pericatheter retrograde urethrogram at 2–3 weeks before catheter removal, and STSG for any distal necrosis/lymphedema. A crushed or unrecovered distal penis is closed like a partial penectomy.

Testicular Rupture

Disruption of the tunica albuginea after blunt or penetrating scrotal trauma — suspect it with swelling, ecchymosis, a hematocele, or a testis that is hard to palpate; consider torsion (~5% are trauma-precipitated), and a non-palpable testis suggests dislocation. Ultrasound (heterogeneous parenchyma, tunical/contour disruption) supports the diagnosis but a normal/equivocal scan should not delay exploration when the exam is suggestive.

• Indications for exploration — imaging or clear findings of rupture, equivocal imaging with suspicion, a large hematoma (explore and drain even without rupture, to prevent pressure necrosis), penetrating injury (> 50% have rupture; explore the contralateral side in gunshot wounds, ~30% of which injure both testes), and a large hematocele (up to 80% from rupture).
• Explore within 72 hours for > 90% salvage (orchiectomy rates are 3–8× higher with delay). Through a transverse or median-raphe scrotal incision, evacuate the hematocele, ligate bleeders, conservatively debride extruded tubules, and close the tunica albuginea with running 3-0 PDS; a tunica vaginalis flap covers a large defect (sparing viable parenchyma). Leave a dependent Penrose drain, and explore the contralateral testis in penetrating injury.