Genito-Urinary Trauma PDF

**OUTLINE** I. **Introduction** II. **Renal (Kidney) Trauma** III. **Ureteral Trauma** IV. **Bladder Trauma** V. **Urethral Trauma** VI. **Testicular Trauma** VII. **Penile Trauma** VIII. **Review Questions** IX. **References** X. **Appendices** +-----------------------+---------------...

**OUTLINE** I. **Introduction** II. **Renal (Kidney) Trauma** III. **Ureteral Trauma** IV. **Bladder Trauma** V. **Urethral Trauma** VI. **Testicular Trauma** VII. **Penile Trauma** VIII. **Review Questions** IX. **References** X. **Appendices** +-----------------------+-----------------------+-----------------------+ | **LEGEND** | | | +=======================+=======================+=======================+ | ⭐ | 🖊️ | 📖 | | | | | | Must | Lecture | Book | | | | | | Know | *\[lec\]* | *\[bk\]* | +-----------------------+-----------------------+-----------------------+ I. INTRODUCTION {#i.-introduction.TransOutline} =============== A. GENITOURINARY TRAUMA {#a.-genitourinary-trauma.TransSubtopic1} ----------------------- Genitourinary: Kidney, Bladder, Urethra, Testis, Penis Initially evaluated by the **Emergency Physician** and/or the **Trauma/General Surgeon** For **acute abdomen** with **blunt or penetrating trauma**: ⭐**TRAUMA SURGEON** takes the lead in the exploration with Urological referral as needed For patients in **whom immediate exploration is not contemplated** by the general surgeon plus a **high suspicion of urologic trauma**, Initial evaluation can be done by the ⭐**UROLOGIST** ⭐**Gross hematuria: CARDINAL SYMPTOM** for suspected trauma to GU system; most especially for renal, bladder and urethra. Urothelial is histologic ⭐**Urine output (UO):** One of the standard monitoring parameters for hemodynamics Monitored by placing urethral catheters are in trauma patients ⭐CAVEAT for patients with hematuria → THE MOST IMPORTANT FEATURE of gross hematuria is to check if there is: **Blood in urethral meatus** Different from hematuria. Hematuria means blood in the urine meaning it could be from the kidney or ureter **Fresh blood in the urethral meatus** is different You see a bleeding urethra you must immediately refer to a Urologist who will be the one evaluating and performing the intervention **Inability to void** **Perineal hematoma** → Urethral Trauma 🖊️Usually butterfly shape doon sa singit ng patient minsan abot hita All of these could point out to a urethral trauma You **MUST NOT INSERT A CATHETER!** A close-up of a hairy stomach Description automatically generated **Figure 1. Bleeding Urethra** *(Source: © Lecture)* II. RENAL (KIDNEY) TRAUMA {#ii.-renal-kidney-trauma.TransOutline} =========================  **Figure 2. Renal Trauma** *(Source: © Lecture)* +-----------------------------------+-----------------------------------+ | **Table 1. Classification of | | | Renal Trauma** | | +===================================+===================================+ | **PENETRATING INJURY** | **BLUNT INJURY** | +-----------------------------------+-----------------------------------+ | - Usually due to **gunshot or | - ⭐**Most common** | | stab** to the upper abdomen | | | or flank | - 90% of all renal injuries | | | | | - ⭐**All must undergo imaging** | - The ff should undergo | | **unless unstable** | radiographic imaging: | | | | | - **If unstable do | - Major deceleration injury | | immediate exploration** | | | | - Shock | | - ⭐Most penetrating trauma will | | | require **exploration**. | - Gross hematuria | | | | | | - ⭐Most blunt trauma can be | | | **managed conservatively** | +-----------------------------------+-----------------------------------+ - Renal trauma is classified by extent of damage - **CT Scan of Whole Abdomen with contrast** is the main imaging study of choice for abdominal injuries - 🖊️Preferably **a spinal CT scan** since it is faster - Contrast CT requires a normal serum creatinine - 🖊️However, this is not always seen in all patients since normal serum creatinine requires time - 🖊️Even the best centers need at least 45 mins to 1 hour to produce results - 🖊️Hence in such patients wherein you need to immediately do radioimaging then a plain spinal CT scan of the abdomen is acceptable especially if px is for exploration immediately after the CT scan - 📖Also called CT urogram in which delayed contrast imaging delineates the upper urinary tract collecting system - Imaging is correlated with the **American Association for the Surgery of Trauma Renal Injury Scale** - 📖The first goal of renal trauma is to accurately grade the renal injury +-----------------------+-----------------------+-----------------------+ | **Table 2. Renal | | | | Trauma Scale** | | | +=======================+=======================+=======================+ | **GRADE** | **INJURY TYPE** | **DESCRIPTION** | +-----------------------+-----------------------+-----------------------+ | **GRADE 1** | Contusion | Microscopic or gross | | | | hematuria with normal | | | | imaging | +-----------------------+-----------------------+-----------------------+ | | Hematoma | Subcapsular, | | | | nonexpanding hematoma | | | | without parenchymal | | | | laceration | +-----------------------+-----------------------+-----------------------+ | **GRADE 2** | Hematoma | Non-expanding | | | | perineal hematoma | | | | confined to renal | | | | retroperitoneum \< | | | | 1cm in depth | | | | | | | | No urinary | | | | extravasation | +-----------------------+-----------------------+-----------------------+ | **GRADE 3** | Laceration | \>1 cm in depth | | | | without collecting | | | | system rupture or | | | | urinary extravasation | +-----------------------+-----------------------+-----------------------+ | **GRADE 4** | Laceration | Parenchymal | | | | laceration extending | | | | through the cortex, | | | | medulla and | | | | collecting system. | | | | Main renal artery or | | | | vein injury with | | | | contained hemorrhage | +-----------------------+-----------------------+-----------------------+ | **GRADE 5** | Laceration | Completely shattered | | | | kidney OR Avulsion of | | | | renal hilum leading | | | | to revascularized | | | | kidney | +-----------------------+-----------------------+-----------------------+ Diagram of a diagram of the kidney Description automatically generated with medium confidence **Figure 3. Renal Trauma Scale** *(Source: © Lecture)* - **Grade IV Injury** - Can be conservatively managed although **monitoring of hemodynamic parameters** (vitals, serial Hb & Hct, urine output) and **repeat imaging studies** is necessary - 🖊️You can also measure **abdominal girth** and monitor the feeling of the patient if pasakit ba ng pasakit - 🖊️Once you see **at least 1** of these parameters go south, you must **do explore-laparotomy** - 📖A repeat CT scan should be done to make certain that the urinary extravasation has resolved. Otherwise, urinoma and subsequent abscess formation may occur - If there is urinary extravasation that is persistent, **minimally invasive urinary diversion** can be done **via ureteral stent** or nephrostomy tube - 🖊️So that imbis na tumagas siya sa tissues ng kidney at least mailalabas mo siya and the urinary extravasation will not increase - **Grade V Injuries** should be considered for **immediate exploration** - Delayed intervention can result in loss of kidney - **High Grade renal injuries** all have increased risk of bleeding however stable patients **without a pulsatile or expanding hematoma** can be **managed conservatively** A. MANAGEMENT OF RENAL TRAUMA {#a.-management-of-renal-trauma.TransSubtopic1} ----------------------------- - 📖The prime goal of renal trauma management is **preservation of renal function** - 📖The management of renal injuries depends not only on the grade but also on the injury mechanism and clinical symptoms - 📖In a hemodynamically stable patient with a renal injury, renal trauma should be initially observed CONSERVATIVE MANAGEMENT {#conservative-management.TransSub-subtopic2} ----------------------- - **Restricted activity or Complete Bed Rest (CBR):** - 🖊️Pahinga without toilet privileges. Nakahiga lang yan at most tatagitagilid lang sa kama - **Prevent increases in intra-abdominal pressure or Valsalva maneuver (coughing, constipation etc):** - 🖊️Give antitussives and/or laxatives - **Hydration**: - 🖊️Hematomas resolve faster when you are well hydrated - **Close monitoring of Hb/Hct, UO and serum creatinine** - 🖊️Note that your kidneys will not produce any urine if you are hemodynamically unstable. Hence, adequate urine output means the patient is hemodynamically stable - **Serial imaging studies looking for pulsative or expanding hematoma** - 🖊️Better if done by the same radiologist; once you see it expanding then you know that you have to intervene B. RADIOIMAGING STUDIES {#b.-radioimaging-studies.TransSubtopic1} ----------------------- GRADE 1 RENAL INJURY {#grade-1-renal-injury.TransSub-subtopic2} --------------------  **Figure 4. Contrast-enhanced abdominal CT scan showing a Grade 1 Renal Injury, Contusion** *(Source: © Doc Yusi Lecture)* - Contrast-enhanced CT scan of the abdomen in a patient with **hematuria** after a motor vehicle collision shows **an ill-defined area of hypoenhancement** in the medial right kidney A close-up of an x-ray of a body Description automatically generated **Figure 5. Grade 1 Renal Injury, Subcapsular Hematoma** *(Source: © Doc Yusi Lecture)* - CT scan of the abdomen with intravenous contrast in a patient after motor vehicle collision. It shows a **crescenteric high density fluid collection** around the left kidney. Note the well-defined outer margin GRADE 2 RENAL INJURY {#grade-2-renal-injury.TransSub-subtopic2} --------------------  **Figure 6. Grade 2 Renal Injury. Perirenal vs. Subscapular hematoma; no urinary extravasation, and all fragments viable** *(Source: © Doc Yusi Lecture)* - CT imaging of acute renal injury and follow-up after 3 months for grade 2 left renal injury **associated with late onset of hypertension** - Image A is the acute CT image for grade 2 renal trauma - Note the **perineal versus subscapular hematoma** - No signs of urinary extravasation and all fragments are viable - 🖊️You can't see the laceration here, maybe it's in a different cut - Image B is a CT image 3 months post-injury - Note **perinephric subcapsular fluid collection and scarring** resulting in **PAGE KIDNEY AFFECT** - "Page kidney or Page phenomenon results from external compression of the kidney by a chronic subcapsular hematoma. It is a rare, treatable cause of secondary hypertension mediated by activation of the renin-angiotensin-aldosterone system (RAAS)." (Haydar et.al., 2003) A close up of a x-ray Description automatically generated **Figure 7. Grade 2 Renal Injury, Coronal View** *(Source: © Doc Yusi Lecture)* - CT image with coronal reconstruction - Note the **significant distortion of the renal cortex** from perinephric fluid collection - The perinephric fluid collection and cortical scar was removed with only temporary (\< 1 month) reduction in blood pressure - 🖊️In the coronal view you can see that **the hematoma is actually displacing** a lot of the renal parenchyma producing the bizarre shape of the kidney. GRADE 3 RENAL INJURY {#grade-3-renal-injury.TransSub-subtopic2} --------------------  **Figure 8. Grade 3 Renal Injury** *(Source: © Doc Yusi Lecture)* - Figure 8 is an acute CT Image of Grade 3 renal trauma showing **greater than 1 cm laceration** of the midrenal pole and perinephric hematoma A close-up of a radiograph Description automatically generated **Figure 9. Grade 3 Renal Injury, Coronal view** *(Source: © Doc Yusi Lecture)* - Acute CT coronal reconstruction of grade 3 renal trauma - Image A shows **possible devitalization** of the entire lower pole of the kidney - 🖊️This image is with contrast. You can see na may contrast enhancement yung upper pole but in the lower pole there is none. This is because of the hematoma or baka devascularized siya. You don't know yet at this point based from the imaging studies - Image B is a 2-hour delayed CT image coronal reconstruction of grade 3 renal trauma showing NO urinary extravasation. The lower pole shows questionable devitalization verses contusion.  **Figure 10. Grade 3 Renal Injury 3 months post-injury, Coronal View** *(Source: © Doc Yusi Lecture)* - CT image of a 3-months post-traumatic renal injury revealing **parenchymal scarring** at the site of laceration with **scarred but functional lower pole** consistent with healed parenchyma following severe renal contusion. Scarring of the lower pole was believed to have occurred with impoverished blood supply due to severe contusion - 🖊️This is a repeat CT done 3 months after the injury with conservative management - 🖊️You can see extensive parenchymal scarring at the site of laceration but the lower pole still looks functional although scarred. This is the healing following contusion GRADE 4 RENAL INJURY {#grade-4-renal-injury.TransSub-subtopic2} -------------------- A close-up of a scan of a person\'s body Description automatically generated **Figure 11. Acute CT Image of Grade 4 Renal Trauma** *(Source: © Doc Yusi Lecture)* - Grade 4 renal trauma with perinephric hematoma, severe (\>1cm) fractures with devitalized renal segments and urinary extravasation - 🖊️The laceration is \>1cm - 🖊️You can see that the facture goes almost through the hilum inside the collecting system - 🖊️You can see urinary extravasation (red arrow) This is a contrast study and you can see the urine coming out through the contrast - 10-minute delayed CT of the same Grade 4 renal trauma revealing flow of contrast in the ureter distal to the injury thus confirming patency of distal ureter - 🖊️This is a 10-minute delay CT revealing the flow of contrast through the ureter distal to the injury. So even though there is extravasation of urine, kahit papano yung ihi nakakarating parin sa ureter - The patient was treated with observation only. No stent nor drainage was necessary GRADE 5 RENAL INJURY {#grade-5-renal-injury.TransSub-subtopic2} --------------------  **Figure 12. Grade 5 Renal Injury** *(Source: © Doc Yusi Lecture)* - Image A shows a Grade 5 renal injury with a **shattered left kidney** - Contrast-enhanced CT scan of the abdomen of a patient with hematuria after a motor vehicle collision - Showed several deep lacerations extending into the collecting system of the left kidney with separation of the fragments - Image B shows a Grade 5 renal injury with **ureteropelvic junction avulsion** - Contrast-enhanced CT scan of the abdomen of a \[different\] patient involved in a motor vehicle collision shows fairly normal appearing right kidney with perinephric fluid extending into the renal hilum - Delayed image shows urinary contrast extravasation - 🖊️Napunit yung renal pelvis niya C. RENAL SURGERY {#c.-renal-surgery.TransSubtopic1} ---------------- ABSOLUTE INDICATIONS {#absolute-indications.TransSub-subtopic2} -------------------- - Persistent, life-threatening hemorrhage from probable renal injury - Renal pedicle avulsion (Grade 5 Injury) - Expanding, pulsatile or uncontained retroperitoneal hematoma RELATIVE INDICATIONS {#relative-indications.TransSub-subtopic2} -------------------- A close-up of a scan of a body Description automatically generated **Figure 13. CT scan showing a lot of urinary extravasations;** **Thrombotic vessel and a devascularized kidney** *(Source: © Doc Yusi Lecture)* - Large laceration of the **renal pelvis or avulsion of the ureteropelvic junction** - 🖊️Some of these patients need not be explored - Coexisting **bowel or pancreatic injuries** - 🖊️Bubuksan din naman ng GS yung bowel, might as well repair whatever you can - Persistent **urinary leakage**, post injury **urinoma** or perinephric **abscess** with failed percutaneous or endoscopic management - 🖊️You are not able to put in a nephrostomy tube or a stent then you may have to open up and repair the leakage - Abnormal intraoperative **one-shot IV urogram** - 🖊️When the surgeons open the patient up and the hemodynamics are stable, while they are working you can do an intra-op IV urogram. This is very easy. Put the film behind the patient, put on x-ray one shot, inject dye and wait for 10 minutes then do a single shot. You can see if the kidneys are intact and if they are urinating - **Devitalized parenchymal segment** with associated urine leak - 🖊️Since it is devitalized, that urine leak probably won't heal - **Complete renal artery thrombosis** of both kidneys or of a solitary kidney when renal perfusion appears preserved - 🖊️Mukang preserved naman, may vessel an yet bakit itim siya. (Refer to Figure 13) - Renal vascular injuries after **failed angiographic management** - **Renovascular hypertension** - 🖊️Which develops after the injury; documented through a captopril nuclear renal scan - 🖊️Intervention is usually done by vascular surgeons using transluminal stenting of renal artery or renal vessels SURGERY {#surgery.TransSub-subtopic2} ------- - **📖Nephrectomy:** The most common surgery for renal surgery in modern times - 📖If uncontrolled bleeding is encountered once the hematoma is opened, occlusion of the renal vasculature can be performed - At that time, a **renorrhaphy** can be safely done as can a nephrectomy in the setting of a grade 5 renal injury - Bleeding is usually **confined in the retroperitoneum** which can tamponade most bleeding - 🖊️Because that is where your kidneys are - 🖊️The retroperitoneum is **only a potential space** and not a very large one - When it bleeds it eventually stops because of the limited space → become stable and will clot - With **hemodynamic instability, immediate surgery** is required with grading done intra-op - 🖊️Containment in the retroperitoneum is not always true because if sobrang laki na nung bleeding --- patients would show hemodynamic instability and would require immediate surgery with grading done intra-op - 🖊️The surgery is not done by a urologist. Rather, the **surgery is done by a general surgeon** - It is approached with a **midline exploratory laparotomy incision** - Want to make sure that there are no other injuries - Identify the retroperitoneum which is in tamponade - Don't have to open/release it early - Can request for blood, stabilize the patient --- then you can open the retroperitoneum when you're ready - If more information is required, an **intra-op-one-shot 10-min IVP** can be done just before entering the retroperitoneum - 🖊️If the exploration cannot provide enough information, you can do an intra-op one shot 10-min IVP - **You can tell what is grading** via this procedure  **Figure 14. Serial illustration of renal trauma surgery** *(Source: © Doc Yusi Lecture)* - 🖊️You don't go into the **retroperitoneal hematoma** straight → This is to avoid massive bleeding that cannot be controlled - 🖊️After the general surgeon has inspected the entire abdominal contents, the intestines are taken out and is swung over the patient. The patient is covered properly and then the ff structures are exposed (Figure 14, A): - **Inferior mesenteric vein** - **Aorta** - 🖊️We make an incision somewhere in between and just above the **inferior mesenteric artery** very carefully **exposing the great vessels** behind. It is at this level where we can see the all the different renal vessels, aorta, and vena cava. (Figure 14, B) - 🖊️If you're handling a **left renal injury** such as in this case (Figure 14, C) - Put **vessel loops** on the **left renal artery** and **left renal vein** pero wag mo muna iipitin. These are placed so that we may simply re-access - Open up the **White Line of Toldt**, start opening up the retroperitoneum and swing the descending colon and splenic flexure to the medial para makita yan - The **lateral peritoneal reflection** of posterior parietal pleura of abdomen over the mesentery of the ascending and descending colon. It is the junction of parietal peritoneum with Denonvilliers fascia. (Medical Dictionary and Schwartz's) - 🖊️If it is a **shattered kidney**, and you open this up, this is going to bleed profusely and within a few minutes mamamatay ang patient pag nag strangulate yan - 🖊️So if you see this, you should **clamp the renal artery and renal vein.** Then go back to the kidney, clean everything up and start fixing it - 🖊️Kung ganitong klase baka i-nephrectomy mo nalang. Since na clamp mo na yung renal artery and vein you are almost half done because the **major problem in doing the nephrectomy is finding the vessels** Diagram of a diagram of a kidney Description automatically generated **Figure 15. Lacerated renal trauma case** *(Source: © 2025 Trans)* - Here you see a very large laceration (Figure 15, A) and that's going to bleed a lot. So, you want to have control over the renal vessels. - So, you can either clamp the renal artery and vein or locate the specific bleeding vessel and ligate that - 🖊️Once bleeding is controlled you can now do (in this case) a partial nephrectomy. (Figure 15, B) - Ligate the vessels that are connected to the inferior pole, repair the collecting system (Figure 15, C) - Place an omentum pedicle flap (Figure 15, D) - This will help decrease the bleeding without any tension when you try to suture it as compared to when trying to repair the defect by suturing one end of the renal capsule to the other end of the renal capsule  **Figure 16. Gunshot wound renal trauma** *(Source: © 2025 Trans)* - 🖊️This one is a gunshot wound causing a deep midrenal laceration almost up to the pelvis. (Figure 16) - 🖊️Essentially, we do the same thing. **Control the bleeding then repair** - 🖊️You can put in Gelfoam bolsters inside (Figure 16D), Surgicel or even retroperitoneal fat so that when you tighten up the threads hindi siya pupunit sa renal parenchyma A diagram of a kidney Description automatically generated **Figure 17. Renal Vein Bleed** *(Source: © Doc Yusi Lecture)* - In this patient (Figure 17), nagdugo lang ang renal vein. You just clamp it and maybe even the artery distal to the injury then repair it GOALS OF RECONSTRUCTION {#goals-of-reconstruction.TransSub-subtopic2} ----------------------- - Complete renal exposure - Debridement of nonviable tissue - Hemostasis of individual suture ligation of bleeding vessels - Watertight closure of the collecting system - 🖊️The renal pelvis, infundibula, and calyces - 🖊️Repair them separately from the parenchyma so that they are watertight. Kasi pag nagleak yan may tendency for infection - Coverage or approximation of the parenchymal defect - 🖊️Sometimes the defect is so large that we put in bolsters from fat or Surgicel - Partial nephrectomy for polar injuries that cannot be reconstructed INDICATIONS FOR NEPHRECTOMY {#indications-for-nephrectomy.TransSub-subtopic2} --------------------------- - Grade 5 Renal Injuries - Unstable patient with low body temperature and poor coagulation - Cannot risk an attempt at renal repair if a normal contralateral kidney is present - Extensive renal injuries when the patient's life would be threatened by attempted renal repair - 🖊️As long as normal yung kabilang kidney. III. URETERAL TRAUMA {#iii.-ureteral-trauma.TransOutline} ====================  **Figure 18. Common Sites of Injury for ureteral trauma** *(Source: © Doc Yusi Lecture)* Common sites of injury for ureteral trauma: \(1) Uterosacral ligaments \(2) Pelvic brim \(3) Crossing of the uterine artery \(4) Tunnel of Wertheim \(5) Near the uretero-vesical junction Retroperitoneal location of ureter protects it from external trauma. **Blunt injury is rare** but can occur with rapid deceleration injuries. Penetrating trauma may occur, but a high index of clinical suspicion is required to make the appropriate diagnosis. Most ureteral trauma referrals to Urologists are **iatrogenic** during operative procedures. ⭐Most common cause of ureteral trauma. Intra-op recognition of the injury is crucial, since immediate repair is easier with greater chance of success. *Failure of identification may lead to litigation cases.* Ex: Hysterectomy, low-anterior colon resections, aortic surgeries The uterine artery is very close to the ureters, thus, **easy to injure** the latter during dissection. Non-iatrogenic ureteral trauma is rarely an isolated event, \ | | | | | | - *You direct it inside the | | | bladder itself; you do not | | | connect it anymore. It is | | | found that when you perform | | | ureteroureterostomy on the | | | distal portion, incidence of | | | stricture formation post-op | | | is very high*. | | | | | | | | | | | | - Psoas-hitch | | | | | | | | | | | | - *If hindi abot via | | | reimplantation, you do a | | | "Psoas hitch". What we do in | | | psoas hitch is that you | | | mobilize the bladder para | | | siya yung lumapit then you | | | will hitch it in the psoas | | | muscle, and reimplant this | | | portion on the bladder na | | | pinalapit mo*. | +-----------------------------------+-----------------------------------+  **Figure 20. Transureteroureterostomy (TransUU).** ***(A)**You mobilize the ureter then idadaan mo behind the great vessels, and anastomose it, end-to-side to the contralateral ureter; done for very long injuries. There is a shorter distance when going right to left, or vice versa than going right (ureter) - down*. ***(B)*** *You swing the ureter across retroperitoneally with no tension, sometimes above the inferior mesenteric artery (IMA). So, you bring it anterior (behind the great vessels accdg to Dr. Yusi sa prior page) to the great vessels. If you have the IMA, wag ka pupunta sa kili-kili kasi baka siya maipit. You have to be very cognizant as to where the inferior mesenteric artery is -- make sure you don't go below it. Then you anastomose it to the contralateral ureter in an end-to-side fashion.* *(Source: © Doc Yusi Lecture)* IV. BLADDER TRAUMA {#iv.-bladder-trauma.TransOutline} ================== - Like the ureter, the bladder's location within the bony pelvis protects it from most harm. - Usually associated with **other severe injuries.** - **Iatrogenic trauma** from pelvic surgery, especially gynecological procedures are more common. - Intraperitoneal ruptures are less common than retroperitoneal. - Intraperitoneal ruptures are seen when the trauma occurs on a full bladder. - Ruptures can be intraperitoneal or retroperitoneal. - Intraperitoneal means the bladder ruptured **its portion that is within the peritoneal cavity.** - Retroperitoneal rupture is where the rupture occurs not intraperitoneally but retroperitoneally. A diagram of a human body Description automatically generated **Figure 21. (A) Intraperitoneal vs. (B) Extraperitoneal bladder rupture.** ***(A)** If there is an instance wherein you were hit by a car or punched in the abdomen when you have a full bladder, there is a tendency of the bladder rupturing intraperitoneally. So, you will have urine in the intraperitoneal cavity. When this happens,*⭐***acute abdomen** yan. So, you explore and repair this. Mas complicated ang course na ito. **(B)** In extraperitoneal rupture, blunt trauma occurred when your BLADDER WAS NOT FULL. When it does rupture, it will tend to rupture retroperitoneally. Since it's retroperitoneal, it does not enter the peritoneum so you won't have an acute abdomen. You will feel a* ⭐***suprapubic tenderness and swelling**. So, kung maraming ihi, then you must **explore**. Pero kung kaunti lang naman, then you can **TREAT THIS CONSERVATIVELY**. Often are associated with pelvic fractures and when so, frequently occur in conjunction with urethral injuries.* *(Source: © Doc Yusi Lecture)* A. CLINICAL PRESENTATION {#a.-clinical-presentation.TransSubtopic1} ------------------------ - Presentation can be delayed due to intoxication. *Maraming mga pasyente na nagkakaroon ng ganitong kalseng injury ay mga lasing. May pelvic fracture na pala sila kaso umuwi muna at natulog. Pagkagising nila doon na nila naramdaman na masakit na ang balakang nila, may mga hematoma, hindi maka-ihi. So delayed ang pagkonsulta nila sa ER.* - **Gross hematuria** is the most common presentation. - There may be **derangements due to urine reabsorption**. - Leukocytosis: *Urine is very irritating to the peritoneum leading to inflammation.* - Electrolyte imbalance. *A lot of stuff you want to excrete goes back into your system.* - Azotemia. *If you have urine in the peritoneal cavity because toxins are accumulated presenting similarly to renal failure.* - **Fever** and **prolonged ileus** B. IMAGING {#b.-imaging.TransSubtopic1} ---------- CYSTOGRAM {#cystogram.TransSub-subtopic2} --------- **Table 5. Figure Reviews** ----------------------------- -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Imaging** **Description**  **Extraperitoneal rupture cystogram**. *This is a cystogram film using a suprapubic tube showing rupture of the bladder. In fact, the rupture separated with extravasation into the scrotum. The extravasation is all here, underneath, but the extravasated urine is still within the peritoneum and the peritoneal cavity is clean. **Dense flame-shaped pattern of contrast extravasation.*** **Intraperitoneal rupture cystogram.** *You can see the dye going into the belly. You can see the shape of the intestine as filling defects within that contrast.* C. MANAGEMENT OF BLADDER TRAUMA {#c.-management-of-bladder-trauma.TransSubtopic1} ------------------------------- +-----------------------------------+-----------------------------------+ | **Table 6. Management** | | +===================================+===================================+ | **EXTRAPERITONEAL BLADDER | **INTRAPERITONEAL BLADDER | | TRAUMA** | TRAUMA** | +-----------------------------------+-----------------------------------+ | - Typically managed with a | - ⭐**Explored immediately** and | | ⭐**Catheter Drainage** for 7 | **repaired**. | | to 10 days (*7 to 14 days*) | | | | - **Suprapubic tube** for large | | - If exploration is done for | ruptures. | | other injuries, repair can be | | | performed. *Exploration is | - **Cystogram** should be done | | usually not done for | prior to catheter removal, | | extraperitoneal/retroperitone | especially for non-operative | | al | cases. *Just to be sure that | | bladder trauma but if for | it is not ruptured, | | example exploration will be | especially if the repair is | | done for other injuries like | extensive. Sometimes you can | | orthopedics trying to | do non-operative management | | stabilize a pelvic fracture, | such as putting in a catheter | | might as well go in, repair, | but that is risky especially | | and clean up the urine.* | if you have an acute | | | abdomen.* | | - For pelvic injuries that | | | require placement of **metal | | | hardware, repair is | | | essential.** *You don't want | | | the prosthesis in there with | | | the urine. that is very | | | harmful.* | | +-----------------------------------+-----------------------------------+ V. URETHRAL TRAUMA {#v.-urethral-trauma.TransOutline} ================== A. OVERVIEW {#a.-overview.TransSubtopic1} ----------- - Urethral trauma is suspected in: - Blunt pelvic trauma - Blood present at the urethral meatus - Hematuria - Inability to void - Perineal hematoma - ⭐Such patients should be considered to have urethral injury until proven otherwise. - Urethral injuries should be anticipated **with pubic ramus fractures** and occur in 10% of unilateral and 20% of bilateral Injuries. - *If may injury ka sa symphysis pubis or in that area, the chance of urethral trauma is high.* B. CLINICAL FEATURES AND DIAGNOSTICS {#b.-clinical-features-and-diagnostics.TransSubtopic1} ------------------------------------ - Most common presentation is **fresh blood on the urethra** after the injury. - Clinical hallmark: Blood at the meatus. - This is different from hematuria (no urine). - Do not attempt catheterization as it may result in causing more damage. - An immediate **Retrograde Urethrogram** is indicated. RETROGRADE URETHROGRAM (RUG) {#retrograde-urethrogram-rug.TransSub-subtopic2} ---------------------------- Evaluation is performed by **Retrograde Urethrogram (RUG)** Patient is supine in the oblique position and a Fr12 (French 12) catheter placed in the urethral meatus. With the penis placed on traction, 30 cc of contrast (usually diluted with NSS, 1:1 ratio) is instilled while an X-ray is obtained during filling. A partial or complete disruption can be diagnosed based on extravasation or filling of the proximal urethra. Patients with partial urethral injuries can have an attempt at catheter placement by a Urologist. Those with complete disruptions should have a placement of suprapubic tube. C. THE ANATOMY OF A MALE URETHRA {#c.-the-anatomy-of-a-male-urethra.TransSubtopic1} --------------------------------  **Figure 22. Anatomy of Male Urethra. Correlate with Table 7 below.** *(Source: © Doc Yusi Lecture)* +-----------------------------------+-----------------------------------+ | **Table 7. Segments of Male | | | Urethra** | | +===================================+===================================+ | **Segment of Urethra** | **Description** | +-----------------------------------+-----------------------------------+ | **Prostatic** | - part of the urethra that is | | | engulfed by the prostate | +-----------------------------------+-----------------------------------+ | **Membranous** | - very short and the portion of | | | the urethra with the | | | sphincter | | | | | | - at this portion you have the | | | continence mechanism | +-----------------------------------+-----------------------------------+ | **Bulbous** | - part of the penis that is | | | still inside the body that's | | | because this area has the | | | bulb of the penis | +-----------------------------------+-----------------------------------+ | **Penile or Pendulous** | - starts when the urethra goes | | | externally outside. | +-----------------------------------+-----------------------------------+ The urethra is also divided into: Anterior urethra (distal part) Posterior urethra In describing injuries, you can use anterior urethral injury and posterior urethral injury, treatment of which are completely different D. ANTERIOR VS. POSTERIOR URETHRAL TRAUMA {#d.-anterior-vs.-posterior-urethral-trauma.TransSubtopic1} ----------------------------------------- +-----------------------------------+-----------------------------------+ | **Table 8. Anterior vs. Posterior | | | Urethral Trauma** | | +===================================+===================================+ | **Anterior Urethral Trauma** | **Posterior Urethral Trauma** | +-----------------------------------+-----------------------------------+ | - Anterior injuries often are | - Usually from ⭐ **pelvic crush | | related to ⭐ **blunt straddle | injuries and shearing | | injuries and penetrating | forces** causing a | | trauma.** | prostatomembranous | | | disruption. | | - Immediate surgical repair is | | | not recommended in the acute | - The other injuries, which are | | setting except for low | usually more severe, dictate | | velocity penetrating | the urologic management. | | injuries. | | | | - The Urologic problem can be | | - If patient is stable w/ | temporized by **placement of | | minimal hematoma formation, | a suprapubic tube.** | | repair should be considered, | | | esp. for short defects (1-2 | | | cm). | | +-----------------------------------+-----------------------------------+ **Table 9. Figure Review** ---------------------------- ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Figure** **Description** *Disruption of the anterior urethra (bulbous urethra) occurs with straddle-type injuries in the male (especially in injuries in corpus spongiosum or cavernosa). Blood will extravasate in the pelvic area going to the subcutaneous tissue of the perineum or scrotum even going up to the pubis. These are the layers delineated by the Colle's fascia and the Darton's fascia in which pwede mong makita yung perineum na may butterfly shaped hematoma. Take note that in this diagram the Buck's fascia has been penetrated Dense flame-shaped pattern of contrast extravasation.* E. TREATMENTS {#e.-treatments.TransSubtopic1} ------------- VISUAL INTERNAL URETHROTOMY {#visual-internal-urethrotomy.TransSub-subtopic2} --------------------------- *Once you have these kind of injury usually may scar formation then magkakaroon ng strictures and we treat this most commonly by Visual Internal Urethrotomy* Minimally invasive option using a cystourethroscope, incising the stricture with a knife or laser (fiber) ⭐ Used only for short strictures that haven't closed completely **Table 10. Figure Reviews** ------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Figure** **Description**  *This is a what urethral stricture looks like. You can see the wall --- a very fibrotic wall that's called spongiofibrosis. **Spongiofibrosis** is caused by a urethral injury with a scar formation. Parang keloid na palaki ng palaki up to the point na hindi na makaihi si patient. In order to do this procedure, the patient must have this communication because once it becomes a solid wall you cannot do this procedure anymore. Infrequently we slip in a guide wire before incising. So, we incise at the 12 o'clock position, incise until it opens up.* *Upper picture: When you go beyond the stricture portion, you can see the normal appearance. Take note that there is NO BLEEDING WHEN INCISING. WE KEEP ON INCISING UP UNTIL MAGDUGO SIYA then we put a catheter on it and keep it there for 2-4 weeks until it heals over the big catheter. Unfortunately, urethral stricture can recur because when you create an incision, gumawa ka ng panibagong sugat then mag-scar ulit yan. Most patients are advised to do self-urethral dilation. (Bottom picture) So you keep cutting until this thing is supposed to bleed* URETHROPLASTY {#urethroplasty.TransSub-subtopic2} ------------- *If you're not able to do Visual Internal Urethrotomy, you can perform Urethroplasty*. Open procedure where the urethra is exposed, the strictures are excised, and ends are reconnected either directly or via grafts, flaps or patches. **Table 11. Figure Reviews** ------------------------------ --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- **Figure** **Description**  *Serial illustration on how to perform Urethroplasty/ Urethroplasty depends on the location of the injury. In this diagram, the stricture is located at the level of the bulbous urethra. Therefore, the incision will be at the perineum (sa ilalim ng bayag). Once you open that you can access the urethra there, excise the stricture portion, spatulate both ends then suture then together* *If you have longer strictures, you can have the option NOT TO EXCISE because if you excise this long one, baka hindi mo na mapagdugtong. What we do here rather is that we DO NOT EXCISE, and we make an incision throughout the stricture. We get flap or a piece of skin from somewhere to create a graft para walang tension then close the spongiosum over the graft*  *Degloving Procedure. We get flap or a piece of skin from somewhere to create a graft para walang tension then close the spongiosum over the graft. Make a circumcising incision underneath the glans then peel down the skin. Please note that this very mobile. You can get a piece of the grafted skin then graft it there; the rest are pulled upwards then sutured* *Longitudinal incision. In here you create an island flap, open it up, place the flap inside then close it over. Problema dito is the skin is from the penis itself, baka mahigpit yung skin and mahirapan ka iclose* VI. TESTICULAR TRAUMA {#vi.-testicular-trauma.TransOutline} =====================  **Figure 23. Visual comparison of normal Testis with testicular traumas.** *(Source: © Doc Yusi Lecture)* Penetrating trauma is usually associated with other more severe injuries Most commonly from blunt injuries when the testicle is forcibly compresses against the thigh or pubic bone, enough to rupture the tunica albuginea Blunt injury can have delayed presentation Rupture of the tunica albuginea must be considered in all cases of blunt testicular trauma. *This is a cause for surgical exploration. You have to rule it out first before you do conservative management* **Figure 24. Tunica Albuginea.** *The tunica albuginea is the covering of the testicle itself. So if this is lacerated or ruptured due to blunt trauma, this is going to bleed profusely since the testicle has a rich blood supply. In addition, the structures inside are pressured, therefore when they rupture, these tubules can go out and becomes exvaginated. So, when repairing this, you need to push these tubules back as well* *(Source: © Doc Yusi Lecture)* +-----------------------------------+-----------------------------------+ | **Table 12. Testicular Trauma** | | +===================================+===================================+ | **Clinical Presentation** | - **Swelling and ecchymosis** | | | | | | - Hematoma severity does not | | | correlate with the severity | | | of the injury. *In addition, | | | absence of which does not | | | rule out rupture.* | | | | | | - Contusion without fracture | | | can present as significant | | | bleeding | | | | | | - Can have associated urethral | | | injury | +-----------------------------------+-----------------------------------+ | **Diagnostics** | - ⭐**Ultrasonography**: | | | Mainstay of diagnosis | | | | | | - Assess integrity and | | | vascularity, Useful in | | | equivocal cases | | | | | | - Fracture shows a | | | **heterogenous echo pattern** | | | of the **testicular | | | parenchyma and disruption** | | | of the albuginea | | | | | | - A normal or equivocal utz | | | study should not delay | | | surgery when PE findings | | | suggest testicular damage | | | | | | - *When in doubt, explore! | | | Since this an emergency, | | | exploring is better than | | | doing nothing* | +-----------------------------------+-----------------------------------+ | **Management** | - Decision to explore: **mostly | | | clinical** | | | | | | - ⭐Early exploration and repair | | | are associated with**: | | | Increased testicular salvage, | | | Reduced convalescence and | | | disability, & Preservation of | | | fertility and hormone | | | function** | | | | | | - Minor injury w/o damage can | | | be treated w/⭐ **ice, | | | elevation, analgesics and | | | irrigation;** and closure in | | | some cases | | | | | | - Objectives of exploration | | | are: **Testicular salvage , | | | Prevention of infection, | | | Bleeding control, & Reduced | | | convalescence** | | | | | | - **Transverse scrotal | | | incision** *is what we | | | usually do* | | | | | | - T. albuginea is closed with | | | small absorbable sutures | | | after debridement | | | | | | - Even small defects must be | | | closed; T. vaginalis flap or | | | graft may be used | | | | | | - Intratesticular hematomas | | | have to be drained to prevent | | | pressure necrosis and | | | atrophy. *Very challenging to | | | identify and drain them | | | without causing more injury | | | and making the hematoma | | | worse* | +-----------------------------------+-----------------------------------+ VII. PENILE TRAUMA {#vii.-penile-trauma.TransOutline} ================== A. PENILE AMPUTATION {#a.-penile-amputation.TransSubtopic1} --------------------  **Figure 25. (A) Amputated Penis & (B) Preserving Amputation method.** *(Source: © Doc Yusi Lecture)* Usually the result of self-mutilation. Repair is usually done at a tertiary center with microsurgical capabilities. Thus, **preservation of the amputated organ is paramount.** Suprapubic tube is inserted if needed. The organ should be cleaned & preserved in a "double-bag" technique. **Rinsed in saline solution**, wrapped in sterile saline-soaked gauze, sealed in a sterile plastic bag. The bag should be placed in another sterile plastic bag with ice or slush. TREATMENT {#treatment.TransSub-subtopic2} --------- Reconstruction of the urethra & re-anastomosis of the corporeal bodies with microsurgical repair of the dorsal penile vessels & nerves. Microvascular reconstruction of the dorsal arteries, vein & nerves. +-----------------------------------+-----------------------------------+ | **Table 13. Figure Review** | | +===================================+===================================+ | **Figure** | **Description** | +-----------------------------------+-----------------------------------+ | | *A. The typical appearance of a | | | penile amputation injury* | | | | | | A. *B. The urethra, corpora | | | cavernosa, and dorsal | | | neurovascular structures are | | | exposed and minimally | | | debrided.* | | | | | | *C. A two-layer spatulated | | | urethral anastomosis is | | | completed. Microvascular | | | coaptation of the dorsal vein, | | | dorsal artery, and dorsal nerves | | | is accomplished.* | | | | | | *D. Coverage is accomplished with | | | the native skin. If the patient | | | is circumcised, the sleeve of the | | | skin between the amputation | | | injury and the old circumcision | | | scar should not be discarded. | | | Should chronic edema develop, | | | revision can be accomplished at a | | | later date. Diversion is by way | | | of a suprapubic cystostomy tube. | | | A stent is inserted in the | | | reconstructed urethra* | +-----------------------------------+-----------------------------------+ *Napakamabusisi nito. This operation takes a long time. Unfortunately, the result is always not good For example one case at NKTI, may pumunta amputated penis. Sabi namin asan yung penis? Nandito po. Saan yan nakababad? Alcohol po. Ay patay. So binabad ng mga kasama sa alcohol. It make sense sa layman, but obviously you do that it's not gonna live anymore. Alcohol kills bacteria, but it kills the cells also* Management **depends on the length** of the penis that was left behind: **At least 3cm:** Will allow urinate standing up We just repair the wound, make sure the urethra is open, put in a catheter until it heals. The patient can urinate while standing and he has a penis **Shorter than 3cm:** Useless already since kakalat lang yan, tatapon lang yan sa perinium and sa bayag mo We do **perineal urethrostomy:** *We open up the perineum, pull the urethra, then exteriorize the urethra sa ilalim ng bayag. So the patient can urinate with the urethra behind the testis. So paupo na siyang iihi kasi wala na siyang stump sa harap, sarado na yun. It is a better alternative than putting the urethra in that area tas pag iihi mo kakalat kalat lang. You have to wear diapers and have the smell all around him at all times* B. ZIPPER INJURIES {#b.-zipper-injuries.TransSubtopic1} ------------------ Impatient boys or intoxicated adults. *Pumasok yung balat ng penis mo sa zipper* **Penile block** (anesthesia) is done first to these kinds of patients. *We prep the patient, and sterilize the area; Next is we cut the zipper out* Zipper slide & skin is lubricated with **mineral oil** then attempt to unzip & untangle skin *only if it is possible* **Cut the cloth** between zipper teeth **Bone cutter** can be used on the median bar Not really easy to do; *Sometimes we put in a screwdriver sa loob then squeeze then break* Skin can be incised or circumcised under anesthesia *If you can't cut the zipper, then cut the skin. Penile block is usually enough pero minsan dahil natagalan, mas maganda i-sedate then reblock again* *Note: **See Appendix B** for Other Penile Injuries from additional resource readings.*  VIII. REVIEW QUESTIONS {#viii.-review-questions.TransOutline} ====================== Shortest segment of the Male Urethra: Prostatic Membranous Bulbous Penile \_\_\_\_\_\_\_\_\_\_ injuries often are related to blunt straddle injuries and penetrating trauma. Anterior Urethral Posterior Urethral Medial Urethral Lateral Urethral Blunt renal trauma injury management: Conservative Exploration Laparoscopic Nephrectomy *baa* IX. REFERENCES {#ix.-references.TransOutline} ============== - 2025COM-Transcription - Schwartz's Principles of General Surgery 11^th^ Edition. McGraw-Hill Education - Yusi, G. (2024). MODULE 4 - General Urology (AY 2024-25), DR YUSI PART 1, 2, 3 PDF \[Lecture PPT\] X. APPENDICES ============= Appendix A: Radioimaging Studies of the Ureter {#appendix-a-radioimaging-studies-of-the-ureter.TransSubtopic1} ---------------------------------------------- +-----------+-----------+-----------+-----------+-----------+-----------+ | **Table | | | | | | | 14. | | | | | | | Imaging | | | | | | | Studies** | | | | | | +===========+===========+===========+===========+===========+===========+ | **Imaging | | | | | | | ** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | |  | | png) | | png) | +-----------+-----------+-----------+-----------+-----------+-----------+ | *CT Scan | *Iatrogen | *Ureteral | *Multiple | *Semi-rig | *Ureteral | | showing | ic | injury | CT scans | id | Injuries. | | extravasa | Injury. | from | showing | ureteral | You can | | tion | Appears | microscop | extravasa | scope. | see | | of urine; | as really | y. | tion | You | ureteral | | Blunt | bad due | A | of the | insert | stricture | | renal | to | urologic | urine.* | the | s | | injury | obstructi | procedure | | ureterosc | happening | | with | on | where you | 1. *From | ope | as a | | ureteral | of | do the | iatro | retrograd | consequen | | trauma.* | ureter; | ureteral | genic | ely | ce | | | showing | pyrogram. | urete | through | of pelvic | | | signs of | You | ral | the | surgery. | | | moderate | inject | injur | urethra, | There is | | | ureter | dye and | y. | enter the | devascula | | | hydroneph | see the | If | ureteral | rization | | | rosis. | extravasa | you | orifice, | of the | | | In this | tion*. | do | then you | ureter. | | | contrast | | the | work your | Doing a | | | study, | | retro | way up to | retrograd | | | external | | grade | the | e | | | iliac | | pyelo | kidney. | you can | | | artery | | gram, | Usually, | see that | | | can be | | you | we don't | you have | | | seen and | | can | force | bilateral | | | some of | | see | this | hydrouret | | | the urine | | the | since it | eronephro | | | is going | | extra | can | sis | | | to the | | vasation | easily | that is | | | blood | | on | injure | moderate | | | vessel. | | your | the | to | | | So you | | radio | ureter | severe.* | | | need to | | graphs.* | because | | | | ligate*. | | | it is | | | | | | | semi-rigi | | | | | | | d.* | | +-----------+-----------+-----------+-----------+-----------+-----------+ Appendix B: Other Penile Injuries {#appendix-b-other-penile-injuries.TransSubtopic1} --------------------------------- +-----------------------------------+-----------------------------------+ | **Table 15. Other Penile | | | Injuries** | | +===================================+===================================+ | **From Schwartz's** | | +-----------------------------------+-----------------------------------+ | **Penile Fractures** | - Classically occur with | | | excessive torqueing of the | | | erect penis | | | | | | - This excessive torqueing | | | results in rupture of the | | | tunica albuginea, the fascial | | | coating of the erectile | | | bodies | | | | | | - Common symptoms include | | | immediate detumescence with | | | subsequent development of a | | | hematoma | | | | | | - Clinical history and | | | examination alone are | | | sufficient to warrant | | | surgical exploration with | | | primary suture repair of the | | | corporal body laceration | | | | | | - For equivocal cases, | | | ultrasonography or an MRI may | | | be done | | | | | | - Up to 10% of penile fractures | | | are associated with urethral | | | injuries | | | | | | - Blood at the meatus signifies | | | the possibility of a | | | coexisting urethral injury. | | | This should be evaluated with | | | either a retrograde | | | urethrogram or cystoscopy at | | | the time of repair | +-----------------------------------+-----------------------------------+ | **Scrotal Trauma** | - Generally, occurs from a | | | blunt mechanism | | | | | | - Injuries to the testis, | | | epididymis, and spermatic | | | cord may occur | | | | | | - Hematomas with subsequent | | | ecchymosis are common with | | | such injuries | | | | | | - Testicular rupture occurs | | | with fracture of the fascial | | | coating of the testicle, | | | called the tunica albuginea. | | | This may occur with blunt or | | | penetrating mechanisms | | | | | | - The most specific findings on | | | ultrasonography are loss of | | | testicular contour and | | | heterogeneous echotexture of | | | parenchyma. The highest | | | reported sensitivity for | | | testicular rupture on | | | ultrasound is 93% | | | | | | - With diagnosis of a | | | testicular rupture or when a | | | high index of suspicion is | | | present (especially with | | | penetrating trauma), | | | exploration should be | | | performed | | | | | | - Testicular salvage rates are | | | high in modern times and | | | involve suture repair of the | | | site of rupture. When primary | | | repair is not possible, a | | | simple orchiectomy should be | | | performed | +-----------------------------------+-----------------------------------+ | **From Smith and Tanagho's | | | General Surgery** | | +-----------------------------------+-----------------------------------+ | - Disruption of the tunica | | | albuginea of the penis | | | (penile fracture) can occur | | | during sexual intercourse. At | | | presentation, the patient has | | | penile and hematoma. This | | | injury should be surgically | | | corrected | | | | | | - Gangrene and urethral injury | | | may be caused by obstructing | | | rings placed around the base | | | of the penis. These objects | | | must be removed without | | | causing further damage. | | | Penile amputation is seen | | | occasionally, and in a few | | | patients, the penis can be | | | surgically replaced | | | successfully by microsurgical | | | techniques | | | | | | - Total avulsion of the penile | | | skin occurs from machinery | | | injuries. Immediate | | | debridement and skin grafting | | | are usually successful in | | | salvage. Injuries to the | | | penis should suggest possible | | | urethral damage, which should | | | be investigated by | | | urethrography. | | +-----------------------------------+-----------------------------------+