Male genital trauma: penile fracture, scrotal and testicular injuries

Male genital trauma covers a range of injuries to the penis and scrotum, from minor bruising to true surgical emergencies such as penile fracture or testicular rupture. Some are managed by observation alone; others require immediate surgery. The key distinction is between closed injuries (no external wound) and open ones (with skin laceration), and imaging — especially ultrasound — plays a central role.

Penile trauma

Penile trauma is classified as closed or open, according to whether the tunica albuginea — the sheath of the corpora cavernosa — is ruptured.

Closed trauma and penile fracture

In closed trauma, large haematomas can form, spreading along the fascial planes with skin discoloration that may extend to the perineum and the abdomen. Diagnosis relies, beyond physical examination, on imaging: ultrasound, cavernosography, retrograde urethrography or MRI when surgery is being considered.

In most closed injuries the acute approach is conservative (observation). The exception is penile fracture: rupture of the tunica albuginea during erection is a surgical emergency and must be assessed immediately in the emergency department.

Open penile trauma

Rarer, these range from a simple skin laceration to degloving or amputation of the penis. All of these situations demand reparative or reconstructive surgery.

A late consequence: Peyronie's disease

Even traumatic or microtraumatic penile injuries that initially cause no alarm can give rise, sometimes long afterwards, to Peyronie's disease (Induratio Penis Plastica): a localised fibrosis of the tunica albuginea, with or without calcification, which alters the elasticity of the sheath and appears on erection as an abnormal curvature of the penis. Beyond the examination, dynamic ultrasound is essential; treatment may be medical, physical or surgical.

Another consequence: post-traumatic erectile dysfunction

Trauma to the nerve fibres of the perineum or to the cavernous tissue can lead to erectile dysfunction, the inability to achieve and maintain an erection sufficient for satisfactory intercourse.

Post-traumatic priapism

Blunt trauma to the perineum can produce arterio-cavernous fistulae that present with episodes of priapism (a persistent, pathological erection). This is not to be underestimated: untreated priapism can lead to necrosis of the erectile tissue, followed by fibrosis of the corpus cavernosum and loss of erectile function.

Distinguishing the two forms is crucial, because the treatment is opposite:

• Low-flow priapism (ischaemic): the dangerous one. Treatment is surgical, with the creation of shunts of various kinds
• High-flow priapism (typically post-traumatic, from a fistula): treatment may be mechanical (ice, compression bandaging), pharmacological (alpha-agonists), radiological (selective or superselective embolisation) or surgical (closure of the fistula or the cavernous artery)

For the differential diagnosis, the blood gas analysis of the corpora cavernosa, Doppler flowmetry and colour Doppler, and selective internal pudendal arteriography are useful.

Scrotal and testicular trauma

Closed scrotal trauma

This may be confined to the skin (superficial bruising and haematomas), but it can also involve the testis, with laceration of the albuginea and extrusion of testicular pulp, up to a true testicular “burst” (testicular rupture). More often it is a contusion of the parenchyma with an intratesticular haematoma. Ultrasound is the key investigation. Treatment ranges from monitoring alone to surgery, with evacuation of the haematoma and repair of the albuginea.

Open scrotal trauma

Characterised by a laceration of the scrotal wall exposing the internal structures, up to laceration of the spermatic cord or amputation of the testis. Ultrasound may help, but reparative surgery is always necessary.

Testicular torsion after exertion

In predisposed individuals — lacking the structures that fix the testis — physical exertion can trigger a torsion of the spermatic cord: the testis rotates on its axis, venous outflow is blocked, and oedema, intratesticular bleeding and sudden acute pain ensue, even out of the blue. The testis appears drawn up towards the groin and the affected side of the scrotum is swollen; the pain worsens with walking. Manual detorsion may be attempted, but if it fails, surgical scrotal exploration is required — mandatory if the diagnosis is in doubt. Surgery must be performed within the first few hours to avoid permanent damage to the testis.

Frequently asked questions about genital trauma

Is penile fracture an emergency?

Yes. Penile fracture is rupture of the tunica albuginea during erection and is a surgical emergency: it must be assessed immediately in the emergency department. Unlike many other closed penile injuries, managed acutely by observation, a fracture requires surgical repair.

Can penile trauma cause problems later on?

Yes. Even microtrauma that initially seems trivial can give rise, sometimes much later, to Peyronie's disease, with curvature of the penis on erection. Trauma to the nerve fibres of the perineum can also cause erectile dysfunction. This is why an andrological assessment after significant trauma is advisable.

What is priapism and why is it dangerous?

Priapism is a persistent, pathological erection that can follow perineal trauma. It is dangerous because, untreated, it can lead to necrosis of the erectile tissue and permanent loss of erectile function. There are two forms, low-flow and high-flow, with different treatments, so the differential diagnosis must be made quickly.

What happens if a testis "ruptures" after a blow?

A violent closed injury can tear the albuginea of the testis (testicular rupture or "burst"), with extrusion of pulp. Diagnosis is by ultrasound and, in established cases, treatment is surgical: evacuation of the haematoma and repair of the albuginea. With a significant testicular injury accompanied by pain and swelling, urgent assessment is always indicated.

After genital trauma, when should you worry?

Warning signs include intense and persistent pain, significant or rapidly increasing swelling, an extensive haematoma, blood in the urine or inability to urinate, and an erection that will not subside. With these signs the right course is to go to the emergency department, because some of these injuries are time-dependent.

After significant genital trauma, with intense pain, swelling or blood in the urine, go to the emergency department. For an andrological assessment you can ask Prof. Natali for a consultation or book an appointment at his practices in Florence and Empoli, Italy.

The information on this page is provided for general educational purposes and does not replace a medical examination, which remains the only diagnostic tool for correct and effective treatment.