Genital Trauma

BACKGROUND

Traumatic injuries to the genitourinary tract are seen in 2-10% of patients admitted to hospitals. Of these injuries, between one-third and two-thirds of cases are associates with injuries to the external genitalia. The incidence of genital trauma is higher in men than in women, not only because of anatomical differences but also due to increased exposure to violence, the performance of aggressive sports and a higher incidence of motor vehicle accidents. In addition, an increase in domestic violence has led to an increase in gunshot and stab wounds over the last several years. Approximately 35% of all gunshot wounds are affiliated with genital injuries.

Genitourinary trauma is seen in all age groups, most frequently in males between 15-40 years. However, 5% of patients are less than 10 years old.Genitourinary trauma is commonly caused by blunt injuries (80%) but the risk of associated injuries to neighbouring organs ( bladder, urethra vagina, rectum, bowel) after blunt trauma is higher in females than in males.
Penetrating external genital trauma is seen in about 20% with 40-60% of all penetrating genitourinary lesions involving the external genitalia.
In men, blunt genital trauma frequently occurs unilaterally. Only 1% present as bilateral scrotal or testicular injuries. Penetrating scrotal injuries affect both testes in 30% of cases. In both genders, penetrating genital injuries occur with other associated injuries in 70% of patients. The accurate diagnosis and treatment of patients with penetrating injuries are of utmost importance.

However, it is essential that physicians and nurses treating traum patients are aware of an increased risk of hepatitis B and/or C infection in this cohort. Recently, a 38% infection rate with hepatitis B and/or C was reported in males with penetrating gunshot or stab wounds to the external genitalia. This was significantly higher compared to normal population, and exposes emergency staff to an increased risk.

BLUNT TRAUMA

In males, a direct blow to the erct penis may cause penile fracture.Usually the penis slips out of the vagina and strikes against the symphysis pubis or perineum. This most frequently (60%) occurs during consensual intercourse . Penile fracture is caused by rupture of the cavernosal tunica albuginea, and may be associated with subcutaneous haematoma, and lesions of the corpus spongiosum or urethra in 10-22%.

Due to the thickness of the tunica albuginea in the flaccid state (appoximately 2 mm), blunt trauma to the flaccid penis does not usually cause tearing of the tunica. In these cases, only subcutaneous hematoma with intact tunica albuginea may be seen.

Blunt trauma to the scrotum can cause testicular dislocation, testicular rupture and/or subcutaneous scrotal haematoma. Traumatic dislocation of the testicle occurs rarely. Its most common in victims of motor vehicle accidents or auto-pedestrian accidents. Bilateral dislocation of the testes has been reported in up to 25% of cases. It can be classifies as:

1- Subcutaneous dislocation with epifascial displacement of the testis

2- Internal dislocation; in these cases, the testis is positioned in the superficial external inguinal ring, inguinal canal or abdominal cavity.

Testicular rupture is found in approximately 50% of cases of direct blunt scrotal trauma. It may occur under intense, traumatic compression of the testis against the inferior pubic ramus or symphysis, resulting in a rupture of the tunica albuginea of the testis. Wasko and Goldstein estimated that a force of approximately 50 kg is necessary to cause testicular rupture.
In females, blunt trauma to the vulva is rarely reported. The incidence of traumatic vulvar haematomas after vaginal deliveries has been reported as 1 in 310 deliveries. The frequency in non-obstetric vulvar haematomas is even lower, with only individual cases reported. Although blunt trauma to the female external genitals is rarely reported, the presence of vulvar haematoma is closely related to an increased risk of associated vaginal, pelvic or abdominal injuries. Goldman et al. reported that blunt injuries of the vulva and vagina were associated with pelvic trauma in 30%, after consensual intercourse in 25%, sexual assault in 20% and other blunt trauma in 15%.

PENETRATING TRAUMA

Penetrating trauma to the external genitalia is frequently associated with complex injuries of other organs, in children, penetrating injuries are most frequently seen after straddle-type fails or lacerations of gental skin due to fails on sharp objetc .

Incresing civilian violence has led to a rising incidence of stab and/or gunshot injuries associated with injuries of the genitourinary tract. The extent of injuries associated with guns is related to the calibre and velocity of the missile. Handguns or pistols range from 0.22 to 0.45 calibre and produce bullet velocities of 200-300 meters/second (m/s). In addition, "magnum" handguns have larger gunpowder loads, and transmit 20-60% more energy than standard handguns due to the higher velocity of the missile. Injuries by rifles cause even more extensive lesions. Rifles have a calibre ranging form 0.17 to 0.460, with the bullet velocities up to 1000 m/s.

Missiles with a velocity of approximately 200-300 m/s are considered "low velocity". These bullets only introduce a "permanent cavity". The energy transmitted to the tissue along the projectile path is much less than in high-velocity missiles, so that tissue destruction in low-velocity guns to less extensive. High-velocity missiles(velocity of 800-1000 m/s) have an explosive effect with high-energy transmission to the tissue causing a "temporary cabity" in addition to the permanent cavity. Due to the high -energy released, gaseous tissue vaporization induces extensive damage often associated with life-threatening injuries.

Gunshot wounds are classified as penetrating, perforating or aulsive. Penetrating injuries are caused by low-velocity missiles, with bullets often rtained in the tissue and a small, ragged entry wound. Perforating gunshot wounds are frequently seen in low to high-velocity missiles. In these cases, the missile passes through the tissue with a small entry wound, but larger, exit one. Serious injuries are associated with avulsive gunshot wounds causes by high-velocity missiles, with a small entry wound comparable to the calibre but a large tissue defect at the exit wound.

In any penetrating trauma, tetanus vaccinations is mandatory and should be given using active ( tetanus toxoid booster) and passive immunization (250IE humans tetanus immunoglobulin) if the patient's last immunization was given more than 5 years ago. For current recommendations for tetanus vaccination, see information from the Robert Koch Institute, Germany (http://www.rki.de/INFEKT/INFEKT.HTM).

Although animals bites are common, bites injuring the external genital are rare. Wounds are usually minor, but have a risk of wounds infection. The most common bacterial infection by a dog bite is Pasturella Multicida, which accounts for up to 50% of infections. Other commonly involved organism are Escherichia coll, Streptococcus viridans, Staphylococcus aures, Elkenella corrodens, Cpnocytophaga canimorsus, Veillonella pavula, Bacteroides and Fusobacterium spp.

The first choise of antibiotics is penicillin-amoxiclavulanic acid followed by doxycycline, cephalosporine, or erythromycine for 10-14 days. After any animal bite, one has to consider the possibility of rables infection. Besides vaccination, local wound management is an essential part of post-exposure rables prophylaxis. If rabies infection is suspected, vaccination should be considered in relation to the animal involved, specific nature of the wound and attack (provoked, unprovoked) and the appearance of the animal (aggressive, foam at the mouth). In high risk patients, vaccination with human rabies immunoglobin and human diplod cell vaccine is recommended.

Genital bites from humans can rarely occur, but can also become infected. Wound infections in these cases may include Streptococci, Staphilococcus aereus, Haemophilus spp., Bacteroides spp. and other anaerobes. Transission of viruses (e.g. hepatitis B, hepatitis C, HIV) following human bites is much less common but should be considered especcially n risk groups. Since transmmision of viral deseases may occur, risk assessment should be made and, if appropriate, hepatitis B vaccine/immunoglobulin and/or HIV popst-exposure prophylaxis offered. For further details see Guidelines for the Management of Human Bite injuries.

Wound manangement should include cleaning with warm running water or disinfectants. Debridement should be conservative, due to the regenerative capacity of genital skin. Antibiotic therapy may be considered only in cases with infected wounds using amoxiclavulanic acid as first line therapy, or, alternatively clindamycin.

RISK FACTOR

There are certain sports with an increased risk for genital trauma. Off road bicycling and motorbike riding, especially on bikes with a dominat petrol tank, accidents from in-line hokey skating and rugby footballers have been associate with blun testicular trauma. Any kind of full contact sports, without the use od necessary protective aids, may be associates with genital trauma.Besides these risk groups, self mutilation of the external genitalia have also been reported in psycotic patients and transsexuals.

DIAGNOSIS

Investigating genital trauma requires information concerningthe accident and thorough history and physical examination, if possible. Trauma to external genitalia at any age may be due to abusive asssault. In these cases, the extraordinary emotional situation of the patient must be considered and the privacy of the patient respected. In suspicious cases, a sexual assault forensic exam is necessary. Swabs or vaginal smears should be taken for detection of spermatozoa and local legal protocols followed closely. A thorough history and examination (in some cases under anaesthesia), photodocumentation, and identification of forensic material may be important. Genital injury is seen frequently (42%) after sexual abuse, and must be considered when such injuries present at any age. In a recent report, only 38% of the forensic samples tested positive for an ejaculate and/or sperm. This may be due to delayed presentation or lack of vaginal(anal ejaculation.

In patients with gunshot wounds to the genitals several pleces of information will be useful: close or far range, calibre and type of weapon. Get a urinalysis. The presence or macro-and or microhaematuria cystoscopy has been recommended to exclude urethral and bladder injury. In women with genital injuries and blood at the vaginal introitus, further gynaecologic investigation to exclude vaginal injuries. The potential for significant injury should never be discounted in those patients who also may have blood in the vaginal vault from menstruation. Complete vaginal inspection with specula is mandatory. Depending on the nature of injury, this may require sedation or general anaesthesia to be completed comfortably.

BLUNT PENILE TRAUMA

PENILE FRACTURE

Penile fracture is associated with a sudden cracking or popping sound, pain and immediate detumescence. Local swelling of the penile shaft develops quickly, due to enlarging haematoma. Bleeding may spread along the fascial layers of the penile shaft and extend to the lower abdominal wall if Buck's fascia is also ruptured. The rupture of the tunica may be palpable if the haematoma is not too large. Physical exam and history usually confirm the diagnosis, but in rare cases imaging may be required.

Cavernosography or magnetc resonance imaging (MRI) can identify lacerations of the tunica albuginea in unclear cases. In case of tunical laceration, surgical correction with suturing of the ruptured area is indicated.


BLUNT TESTICULAR TRAUMA

Testicular rupture is associates with immediatre pain, nausea, vomiting and sometimes fainting. The hemiscrotum is tender, swollen, and eccymotic. The testis itself may be difficult to palpate. High-resolution, real-time ultrasonography with a high resolution probe (minimum 7.5 MHz or higher) should be performed to determine intra-and/or extratesticular haematoma, testicular contusion or rupture. In children, scrotal ultrasonography must be performed with a 10-12 MHz probe.

The literature is contradictory as to the real usefulness of ultrasound over exam alone. Some studies report convincing results with accuracy of 94%. Others reported poor specificity (78%) and sensitivity (28%) for differentiation of testicular rupture or haematocele, and accuracy as low as 56%.

Colour doppler-duplex ultrasonography may provide useful information when used to evaluate testicular perfusion. In case of inconclusive scrotal sonography, testicular computed tomography (CT) or MRI may be helpul. However, these techniques did not specifically increase the detection of testicular rupture. It may be most prudent to surgically explore these equivocal patients. it imaging studies cannot definitively exclude testicular rupture, surgical exploration is indicated.


PENETRATING TRAUMA

In penetrating trauma of the external genital in men, urethrography should be performed in all patients (irrespective of urinalysis). Associated pelvic or abdominal trauma may also require an abdominal CT. CT cystography should be performed in pelvic injuries associate with microhaematuria. In females, the use of diagnostic laparoscopy for identification of intraperitoneal injuries has been reported prior to explorative laparotomy. This approach is only reasonable in haemodynamic stable patients, in whom CT cannot exclude presence of accociated bowel injuries or significant intra-abdominal bleeding.

TREATMENT

PENILE TRAUMA

Blunt trauma
Subcutaneous haematoma, without associated rupture of the cavernosal tunica albuginea does not require surgical intervention. In these cases, nonsteridal analgesics and ice-packs are recommended.
Benign penile injuries can be distinguished from penile fracture, because fracture is always associated with rapid post-traumatic detumescence. In penile fracture, surgical intervention with closure of the tunica albugines is recommended.Closure can be obtained by using either absorbable or non-absorbable sutures, with good long-term outcome and protecton and potency. Post-operative complications were reported in 9% including superficial wound infection and impotence in 1.3%. Conservative management of penile fracture is not recommended. It increases complications such as penile abscess, missed urethral disruption, penile curvature and persistent haematoma requiring delayed surgical intervention. Late complications after conservative management were fibrosis and angulations in 35% and impotence in up to 63%.

Penetrating Trauma
In penetrating penile trauma, surgical exploration and conservative debridement of necrotic tissue is recommended in most severe injuries.
Non-operative management is recommended in small superficial injuries with intact Buck's fascia. Even in extended injuries of the penis, primary alignment of the disrupted tissues may allow for acceptable healing because of the robust penile blood supply. In extended loss of penile shaft skin, split-thickness grafts can be placed, either acutely or after the wound bed has been prepared by several days of wet/dry dressing changes and infection is under control. McAninch et al. reccomended the use of a skin graft thickness of at least 0.015 inch in order to reduce the risk of contraction.

TESTICULAR TRAUMA

Blunt trauma
Blunt trauma to the scrotum can cause significant hematocele even without testicular rupture. Conservative management is recommended in haematoceles smaller than three times the size of the contralateral testis.
In large haematoceles, non-operative management often fils, and often requires delayed surgery (>3days). These patiens suffer from a higher rate of orchiectomy than acutely-operated patients, even in nonruptured testis.
Early surgical intervention resulted in >90% preservation of the testis whereas delayed surgery necessitates orchiectomy in 45-55%. Additionally, non-operative managment is associated with prolonged hospital stays. Large hematocoles should be trated surgically, irrespective of testicle contusion rupture. At the very least, the blood-clot should be evacuated from the tunica vaginalis sac to relieve disability and hasten recovery. Patients initially treated nonoperatively may need delayed surgery if they develop infection or undue pain.
In testicular rupture, surgical exploration with excision of necrotic testicular tubules and closure of the tunica albuginea is indicated. This results in a high rate of testicular preservation an normal endocrine fuction. Traumatic dislocation of the testis is treates by manual replacement and secondary orchidopexy. If primary manual reposition cannot be performed, immediate orchidopexy is indicated.

PENETRATING TRAUMA

Penetrating injuries to the scrotum require surgical exploration with conservative debridement of non-viable tissue. Depending on the extent of the injury, primary reconstruction of testis and scrotum can be performed in most cases. In complete disruption of the spermatic cord, realignment without vaso-vasostomy may be consideredif surgicallly feasible. If there is extensive destruction of the tunica albuginea, mobilization of a free tunica vaginalis flap can be performed for testicular closure. If the patient is unstable or reconstruction cannot be achieved, orchiectomy is indicated.
Prophilactic antibiotics are recommended by experts after scrotal penetrating trauma, although data to support this approach is lacking. Tetanus prophylaxis is mandatory. Postoperative complications were reported in 8% of patients who underwent testicular repair after penetrating trauma.
Extended laceration of scrotal skin requires surgical intervention for skin closure. Due to the elasticity of the scrotum, most defects can be primaly closed, even if the lacerated skin is only minimally attached to scrotum. Local wound management with extensive initial woun d debridement and washout is important for scrotal convalescence.

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