5. TRAUMATIC UROLOGICAL EMERGENCIES 117
Indications for Exploration in Scrotal Trauma
Penetrating trauma should be explored, since structures such as the vas deferens may have been severed and can be repaired. Blunt trauma resulting in testicular rupture (altered echo pattern due to intraparenchymal haemorrhage) should also be explored, so that the haematoma can be evacuated, the extruded seminiferous tubules excised, and the tear in the tunica albuginea repaired. We use a 3/0 or 4/0 Vicryl for closure of the tunica albuginea.
Causes and Mechanisms
These occur as a result of penile amputation (accidental or self-inflicted), knife and gunshot wounds, penile fracture, and other self-inflicted injuries. The diagnosis is usually obvious.
If the penis has been retrieved (sometimes in self-inflicted wounds it has been thrown away by the patient), place it in a wet swab inside a plastic bag, which is then placed inside another bag containing ice ('bag in a bag'). (Aboseif et al. 1993) The penis may survive for up to 24 hours if so preserved, though clearly the shorter the ischaemia time, the more likely it will survive. Blood loss can be severe, and resuscitation with intravenous fluids and blood should be used in the shocked patient.
The urethra should be repaired first, over a catheter, to provide a stable base for subsequent neurovascular repair. Next close the tunica albuginea of the corpora with a 4/0 absorbable suture (repair of the cavernosal arteries is technically very dificult and does not improve outcome in terms of viability of the penis). Next, the dorsal artery of the penis should be anastomosed (11/0 nylon), followed by the dorsal vein (9/0 nylon) to provide venous drainage, and then the dorsal penile nerve (10/0 nylon). A supra-pubic catheter provides additional security in draining the bladder.
Knife and Gunshot Wounds to the Penis
Associated injuries are common (e.g., scrotum, major vessels of the lower limb).