External genital injuries are uncommon thanks to the mobility of the penis and scrotum. This tab covers penile fracture and other penile injuries, testicular trauma, and reconstruction of genital skin loss. Two timing rules anchor management: a penile fracture can be repaired up to 7 days out, but testicular rupture should be explored within 72 hours.
Penile Fracture
A penile fracture is disruption of the tunica albuginea with rupture of the corpus cavernosum, most often during vigorous intercourse when the rigid penis buckles against the perineum or pubic bone (in the Middle East, forcible bending — taqaandan — predominates). The tear is usually on the proximal shaft distal to the suspensory ligament, transverse, unilateral (both corpora in 10%), and ventral or lateral (the tunica is thinnest at 5–7 o'clock — contrast Peyronie's, which is dorsal).
- Diagnosis is usually clinical — a cracking/popping sound with immediate detumescence, then swelling and ecchymosis. With Buck's fascia intact, an "eggplant deformity" results; if disrupted, the hematoma spreads as a butterfly pattern, and the penis deviates away from the tear. Imaging is usually unnecessary but, when H&P is equivocal, ultrasound is preferred (MRI is the most accurate); Doppler and cavernosography have high false-negative rates. Evaluate the urethra (urethroscopy or RUG) — urethral injury occurs in 10–22% (more with bilateral corporeal injury) and is suggested by blood at the meatus, gross hematuria, or inability to void.
- Management is prompt surgical exploration and repair, which gives faster recovery and lower rates of ED, curvature, cavernosal diverticulum, and chronic pain; delay up to 7 days does not worsen outcomes. A penoscrotal or distal circumcising incision exposes the defect (an artificial erection with dye locates it); the tunica is closed with interrupted 2-0/3-0 PDS, with any partial urethral injury oversewn and a complete injury repaired tension-free over a catheter. Postoperatively: antibiotics and 1 month of sexual abstinence. For the full operative technique, see the Penile Fracture Repair procedure page.
Other Penile Injuries
- Gunshot wounds — immediate exploration, irrigation, debridement, antibiotics, and closure; low-velocity urethral injuries are closed primarily, while high-velocity/shotgun blasts may need staged repair with suprapubic diversion.
- Bites — dog bites are irrigated, debrided, and closed primarily over a drain with broad-spectrum antibiotics (amoxicillin-clavulanate, cefoxitin/cefotetan, or clindamycin + ciprofloxacin) plus tetanus/rabies cover; human bites are contaminated and usually not closed primarily.
- Amputation — preserve the severed part by the double-bag technique (saline-wrapped in a sterile bag, then a bag on ice) and transfer to a microsurgical centre. Macrovascular repair preserves erectile function, glans vascularity, and urethral continuity; microvascular repair is needed for skin (dorsal artery/vein) and sensation (dorsal nerve). Reimplantation is possible within <16 h cold or <6 h warm ischemia.
- Zipper injuries — after a penile block, lubricate with mineral oil and attempt a single unzip; if it fails, cut the slider with a bone cutter.
Testicular Trauma
Testicular rupture must be considered in all blunt scrotal trauma (rupture of the tunica albuginea). Patients have exquisite pain and nausea — and since ~5% of cord torsions are trauma-precipitated, consider torsion with significant pain but minimal injury signs. A non-palpable testis suggests dislocation (needs reduction).
- Ultrasound reliably diagnoses rupture in blunt trauma; suggestive findings are a heterogeneous parenchyma and disruption of the tunica/contour. A normal or equivocal US should not delay exploration when the exam suggests injury.
- Indications for scrotal exploration: imaging or clear physical 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; ligate the injured vas, and explore the contralateral side in gunshot wounds since ~30% injure both testes), and significant hematoceles (up to 80% are from rupture).
- Early exploration within 72 h achieves >90% salvage (orchiectomy rates are 3–8× higher with delay). Repair via a transverse scrotal incision — debride extruded tubules, close the tunica albuginea (a tunica vaginalis flap can cover a large defect), and reserve orchiectomy for a non-salvageable testis.
Genital Skin Loss and Reconstruction
The most common cause of extensive genital skin loss is Fournier gangrene. Manage with exploration and limited debridement (genital skin is well vascularised, so marginally viable tissue may survive), often over multiple procedures. A urethral catheter in a genital burn should be removed after 72 h to prevent urethral slough and fistula.
- Penile reconstruction — thick, non-meshed split-thickness skin grafts are preferred (meshed grafts contract); shaft grafts never regain normal sensation, though sexual function is preserved via glans sensation.
- Scrotal reconstruction — defects up to 50% can be closed directly; otherwise meshed split-thickness grafts are preferred, and the testes can be placed in thigh pouches temporarily (avoided initially if infected).
Self-Test
1. What are the benefits of surgically repairing a penile fracture, and how long after injury can repair still be considered? Faster recovery and lower rates of ED, penile curvature, cavernosal diverticulum, and chronic pain — and repair can be undertaken up to 7 days after injury.
2. What are the benefits of early exploration and repair of testicular injury? Higher testicular salvage (>90% within 72 h), reduced ischemic atrophy and infection, preserved fertility and hormonal function, and faster recovery.