MANAGEMENT OF PENILE GUNSHOT WOUNDS BRIAN J. MILES, M.D. RODNEY J. POFFENBERGER, M.D. RIAD N. FARAH, M.D. STEVEN MOORE, M.D. From the Department of Urology, Henry Ford Hospital, Detroit, Michigan
ABSTRACT--The management oJ 10 cases oJ penile gunshot wounds treated at Henry Ford Hospital ~tom 1982 to 1986 is reviewed. All patients were assaulted by low velocity weapons (handguns). Eight patients had associated injuries, predominantly to the genital region (thigh, pubis, and scrotum). There were 5 urethral injuries; 4 were treated with primary repair, the remaining patient underwent delayed repair, complicated by severe urethral strictures requiring reoperation. Blood at the urethral meatus was suggestive of/urethral injury but microscopic hematuria was not. Five penile injuries did not involve the urethra and were treated by debridement and primary wound closure with no immediate or delayed complications. In dealing with these injuries we recommend a high index of suspicion for urethral and regional organ injury and primary urethral closure if at all possible.
The incidence of urogenital trauma compared with other regions of the body is relatively low. Gunshot injury to the penis is unusual due to its location and size. In the literature, most penetrating injuries are reported from military combat. 1-a Isolated injuries are rare and most are accompanied by associated trauma to other areas of the body. 2 Although still relatively few in number, these injuries appear to represent an increasing pereentage of eivilian traumatie urologic injuries. Material and Methods Case records of all patients with penetrating trauma to the penis admitted to Henry Ford Hospital from the years 1989. through 1986 were reviewed. The reeords were evaluated for type of weapon used, the presence of associated injuries, general physical findings in the region of the penetrating trauma, blood at the urethral meatus, radiographie evaluations to include retrograde urethrogram, voiding cystourethrograms, intravenous urography and angiograms, urinalysis, operative findings, management, postoperative course, and long-term sequelae. 318
Results Ten gunshot wounds to the phallus were found in 9 patients. One patient sustained gunshot wounds to the penis on two different occasions. The patients' ages ranged from fifteen to forty-two years. Handguns were used by the victim's assailants in all eases. Nine of these 10 eases required open surgical management. One patient received a grazing wound to the penile shaft which required only local therapy. Eight of the 10 eases had associated injuries (Table I). As noted, most injuries involved those areas adjacent to the penis, i.e., scrotum, pubis, and thighs. Four of the patients had serotal injuries, and all of these underwent exploration and debridement. Two patients required orchiectomy for a shattered testis. All serotal wall injuries were closed primarily without sequelae. Of note, none of our patients received injuries to the ureters or kidneys. One patient had injury to his bladder treated with a suprapubic catheter (SPC) placement and primary wound closure. His postoperative course was unremarkable.
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TABLE I. Summary of gunshot wounds (GSW) in 10 patients Blood at Retrograde Angiogpt. Age Associated Injuries Meatus UA Urethrogram raphy Management Complications 1 18 GSW to thorax; N.E. Clear Not obtained Yes Local wound care None pudendal artery injury 2 20 None N.E. N.E. Transection No SPC debridement Meatal stenosis penile urethra primary repair 3 15 None N.E. N.E. Partial transection No SPC debridement None penile urethra primary repair 4 27 GSW to rt. thigh; Yes N.E. Urethral tear Yes SPC debridement; None scrotal hematoma penile urethra primary repair; scrotal explor.; right orehieetomy 5 36 FX inferior ramus; N.E. Gross Transection bulbo- Yes SPC, wound Postop. stricture right pubis hematuria membranous debridement; x 2; after urethra delayed repair reoperation, doing well 6 18 Scrotum No Micro Normal No Wound debridement; None hematuria serotal explor. 7 42 GSW ft. thigh; Yes N.E. Transection Yes SPC debridement None scrotum; buttocks penile urethra primary repair; scrota1 explor.; primary repair It. testis; ft. orchiectomy 8 18 GSW lt. thigh No N.E. Normal Yes Debridement; penile None exploration 9 29 GSW ft. thigh; N.E. N.E. Normal No Penile, scrotal explor.; None rt. wrist; debridement it. hand; scrotum 10 21 Lt. femoral vein Yes Micro Normal Yes SPC; repair bladder Occasional postlaceration; hematuria laceration; penile void dribbling G S W it. foot, b l a d d e r laceration
explor.; d e b r i d e m e n t
*KEY: UA = Urinalysis; N.E. = not evaluated; SPC = suprapubie catheter; FX = fracture.
I n f o r m a t i o n regarding blood at the urethral meatus was obtained in 5 eases. T h r e e of the 5 patients h a d blood evident at the meatus, 2 h a d urethral injury, and 1 h a d a bladder perforation. Of the 9. patients w i t h no blood evident at the urethral meatus 1 h a d microscopic h e m a t u ria of greater t h a n 10 red blood cells/highpower field and the other did not have urinalySis p e r f o r m e d . Neither of these patients h a d urethral or bladder injuries. Of the r e m a i n i n g 5 cases not evaluated for m e a t a l blood, 1 h a d :gross h e m a t u r i a , 1 h a d a n o r m a l urinalysis, and t h e other 3 did not u n d e r g o urinalysis. The patient with gross h e m a t u r i a had a b u l b o m e m branous injury, and the other 4 patients h a d no urethral involvement. Retrograde u r e t h r o g r a m s w e r e p e r f o r m e d in 9 eases. Extravasation was noted in 5 eases. Angiography was p e r f o r m e d in 6 patients w i t h suspected significant vascular injury to the major arteries of the leg and pelvis. Arterial d a m -
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age to the p u d e n d a l artery was found in only 1 ease. T h e left f e m o r a l vein was injured in another patient and was repaired w i t h o u t incident. Cystoseopy was not done on any patient. Nine patients r e q u i r e d definitive surgery. The 4 patients w i t h no urethral invovlement u n d e r w e n t simple d e b r i d e m e n t and closure of the penile w o u n d . Two h a d corpora eavernosa injuries, w h i c h w e r e debrided and primarily closed. The other 2 patients h a d deep superficial injuries that did not involve the corpora. They, too, required simple d e b r i d e m e n t and closure. None of these patients h a d suprapubie catheters placed. Five patients h a d urethral injury. F o u r of the 5 patients with definitive urethral involvement u n d e r w e n t p r i m a r y repair. D e l a y e d urethroplasty was p e r f o r m e d on the final patient w h o h a d m e m b r a n o u s urethral involvement. All 5 of these patients h a d suprapubic catheters and small penile drains placed as p a r t of their m a n a g e m e n t .
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There were no deaths or wound infections in our patient population. Long-term follow-up was difficult to obtain in this group of individuals due to their poor compliance. Significant complications were noted in only 2 patients. Severe urethral stricture disease developed in the patient treated with delayed urethroplasty and required 2 surgieal retreatments. He is now doing well without obstructive symptoms. In another patient meatal stenosis developed whieh was treated successfully with meatotomy. No ehordee or ereetile difficulties occurred in any of the patients. Comment Approximately 40 percent of penetrating urologic wounds are to the external genitalia. 3 Our data eorroborate that most gunshot wounds to the penis are aeeompanied by injuries to other areas of the body. Eighty pereent of our patients had associated injuries to regional struetures. Four of our patients had assoeiated serotal injuries which required definitive exploration, ineluding orehieetomy in 2. In all of our patients it appeared that the external genitalia was the prime target by the patient's assailant. Therefore, most of our patients had no other significant life-threatening injuries. However, every trauma patient should be thoroughly assessed and stabilized before definitive treatment of external genitalia wounds is undertaken. Half of the patients in our series sustained urethral injuries. Urethral injuries should be suspected in all individuals with penetrating wounds to the penis. Retrograde urethrography should be obtained. Information from this simple test can be vital to patient management. It should be remembered that the extent of injury in most instanees can only be determined at the time of surgery, as the amount of extravasation noted on urethrography does not correspond to the severity of injury. 4 Blood at the meatus or gross hematuria was somewhat predietive of urethral or bladder injury, but 1 patient with meatal blood had a normal urethrogram. Microscopic hematuria was not predictive of urethral injury. Nonetheless, the presence or absence of hematuria or meatal blood should not be relied on to define urethral involvement. A high index of suspicion should always be maintained. The type of weapon used (handgun or rifle), loeation, and extent of injury determine the appropriate management. Selikowitz3 reported on
his experienees in Viet Nam and found that high-veloeity injuries generally resulted in total loss of the phallus. Low-velocity missiles f r o m handguns cause mueh less tissue damage, require less debridement, and result in easier wound elosure. Debridement can also be limited in the penis beeause of its excellent blood supply. 5 All of our patients were assaulted with handguns. Signifieant destruction of tissue be-: yond the immediate path of the bullet was not encountered in any of our eases. Wounds that graze the penis may be closed like a simple laceration. Injuries that involve layers deep to the skin and the Colle fascia need surgical exploration. There are several methods of exploration, and modifieations may be needed as operative findings dictate. A circumcising incision at the: coronal suleus followed by degloving the penis to its base provides good exposure for most injuries. As suggested by Selikowitz, we found nO: difficulty in loeating the limits of viable tissue: in any of our eases. 3 Injuries to the corpora eavernosa should be explored and repaired using permanent, buried interrupted suture. 6 Penile injuries that do not involve the urethra should be treated with adequate debridement : and standard closure with absorbable suture. Onee the repair is complete, skin is reapproximated with absorbable suture. Full thiekness skin grafts, if needed, may be used for coverage.1 Skin may also be closed seeondarily and in some cases re-epithelialization may oeeur. ~ When the urethra is injured, we have found that adequate debridement of the lacerated urethra followed by primary eireumferential repair and elosure is the preferred method of) management. Blumberg, Herwig, and others: describe similar excellent results using this teeh, nique. 3,7-9 The 1 patient in our series treated with delayed repair had the most significant eomplieation, severe urethral stricture disease. However, he had membranous urethral i n volvement and primary repair was not deemed feasible. We share Selkowitz, 3 Jordan and Gilbert, 1 Guerriero's4 belief that primary r e p a i r should be performed if, after debridement and mobilization, sufficient urethral length exists to allow it. More morbidity and urethral stricture disease appear to be assoeiated with delayed repair. If minimal vaseular injury is noted, as in o u r : patient with the pudendal artery damage, re, :: pair may not be required. Signifieant vascular injury demands repair. Both dorsal arteries and at least one dorsal vein, preferably the deep : i
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dorsal, should be reapproximated to provide adequate vascularization of the penis. Many advocate the use of a small drain to decompress any drainage. ° Drains are placed routinely in our patients with urethral injury. Infections have not been a problem in our experience. Finally suprapubic cystostomy was done in all our patients with urethral injuries. This allowed for early urethral stent removal and may have contributed to the success of our urethral repairs. Not all authors believe suprapubic tubes are necessary. 1,2 Nonetheless, urinary diversion for seven to ten days is necessary, and whether this is obtained by Foley catheter alone or by suprapubic tube must be determined by the attending surgeon. In summary, although gunshot wounds to the penis are uncommon, in the current climate of urban violence and crime, the possibility of being faced with one of these injuries is very real. The guiding principles for management are a high index of suspicion for urethral and regional organ injury, adequate debridement of
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all wounds, and primary closure if at all possible. Detroit, Michigan 48202
(DR. MILES) References 1. Jordan GM, and Gilbert DA: Male Genital Trauma, AUA Update Series, 4, lesson 20, 1985. 2. Salvatierra O, Rigdon WO, Norris DM, and Brady TM: Vietnam experience with 252 urological war injuries, J Urol 10h
615 (1969).
3. Selikowitz SM: Penetrating high-velocity genitourinary injuries, Urology 9:493 (1977). 4. Guerriero WC: Trauma to the kidneys, ureters, bladder, and urethra, Surg Clin North Am 62:1047 (1982). 5. McAninch JW, et al: Major traumatic and septic genital injuries, J Trauma 24:291 (1984). 6. Peters PC, and Sagalowsky Ah Genitourinary trauma, in Walsh PC, Gittes RF, Perlmutter AD, and Stamey TA (Eds): Campbell's Urology, vol 1, 5th ed, Philadelphia, WB Saunders Co., 1986, pp 1235-1239. 7. Blumberg N: Anterior urethral injuries, J Urol 102:210
(1969). 8. Herwig KR, Blumberg N, and Hubbard H: Injuries o2 the penile and bulbous urethra, Milit Med 135:289 (1970). 9. Mitchell JP: Injuries to the urethra, Br J Uro140:649 (1968).
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321
ABSTRACT--The management oJ 10 cases oJ penile gunshot wounds treated at Henry Ford Hospital ~tom 1982 to 1986 is reviewed. All patients were assaulted by low velocity weapons (handguns). Eight patients had associated injuries, predominantly to the genital region (thigh, pubis, and scrotum). There were 5 urethral injuries; 4 were treated with primary repair, the remaining patient underwent delayed repair, complicated by severe urethral strictures requiring reoperation. Blood at the urethral meatus was suggestive of/urethral injury but microscopic hematuria was not. Five penile injuries did not involve the urethra and were treated by debridement and primary wound closure with no immediate or delayed complications. In dealing with these injuries we recommend a high index of suspicion for urethral and regional organ injury and primary urethral closure if at all possible.
The incidence of urogenital trauma compared with other regions of the body is relatively low. Gunshot injury to the penis is unusual due to its location and size. In the literature, most penetrating injuries are reported from military combat. 1-a Isolated injuries are rare and most are accompanied by associated trauma to other areas of the body. 2 Although still relatively few in number, these injuries appear to represent an increasing pereentage of eivilian traumatie urologic injuries. Material and Methods Case records of all patients with penetrating trauma to the penis admitted to Henry Ford Hospital from the years 1989. through 1986 were reviewed. The reeords were evaluated for type of weapon used, the presence of associated injuries, general physical findings in the region of the penetrating trauma, blood at the urethral meatus, radiographie evaluations to include retrograde urethrogram, voiding cystourethrograms, intravenous urography and angiograms, urinalysis, operative findings, management, postoperative course, and long-term sequelae. 318
Results Ten gunshot wounds to the phallus were found in 9 patients. One patient sustained gunshot wounds to the penis on two different occasions. The patients' ages ranged from fifteen to forty-two years. Handguns were used by the victim's assailants in all eases. Nine of these 10 eases required open surgical management. One patient received a grazing wound to the penile shaft which required only local therapy. Eight of the 10 eases had associated injuries (Table I). As noted, most injuries involved those areas adjacent to the penis, i.e., scrotum, pubis, and thighs. Four of the patients had serotal injuries, and all of these underwent exploration and debridement. Two patients required orchiectomy for a shattered testis. All serotal wall injuries were closed primarily without sequelae. Of note, none of our patients received injuries to the ureters or kidneys. One patient had injury to his bladder treated with a suprapubic catheter (SPC) placement and primary wound closure. His postoperative course was unremarkable.
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TABLE I. Summary of gunshot wounds (GSW) in 10 patients Blood at Retrograde Angiogpt. Age Associated Injuries Meatus UA Urethrogram raphy Management Complications 1 18 GSW to thorax; N.E. Clear Not obtained Yes Local wound care None pudendal artery injury 2 20 None N.E. N.E. Transection No SPC debridement Meatal stenosis penile urethra primary repair 3 15 None N.E. N.E. Partial transection No SPC debridement None penile urethra primary repair 4 27 GSW to rt. thigh; Yes N.E. Urethral tear Yes SPC debridement; None scrotal hematoma penile urethra primary repair; scrotal explor.; right orehieetomy 5 36 FX inferior ramus; N.E. Gross Transection bulbo- Yes SPC, wound Postop. stricture right pubis hematuria membranous debridement; x 2; after urethra delayed repair reoperation, doing well 6 18 Scrotum No Micro Normal No Wound debridement; None hematuria serotal explor. 7 42 GSW ft. thigh; Yes N.E. Transection Yes SPC debridement None scrotum; buttocks penile urethra primary repair; scrota1 explor.; primary repair It. testis; ft. orchiectomy 8 18 GSW lt. thigh No N.E. Normal Yes Debridement; penile None exploration 9 29 GSW ft. thigh; N.E. N.E. Normal No Penile, scrotal explor.; None rt. wrist; debridement it. hand; scrotum 10 21 Lt. femoral vein Yes Micro Normal Yes SPC; repair bladder Occasional postlaceration; hematuria laceration; penile void dribbling G S W it. foot, b l a d d e r laceration
explor.; d e b r i d e m e n t
*KEY: UA = Urinalysis; N.E. = not evaluated; SPC = suprapubie catheter; FX = fracture.
I n f o r m a t i o n regarding blood at the urethral meatus was obtained in 5 eases. T h r e e of the 5 patients h a d blood evident at the meatus, 2 h a d urethral injury, and 1 h a d a bladder perforation. Of the 9. patients w i t h no blood evident at the urethral meatus 1 h a d microscopic h e m a t u ria of greater t h a n 10 red blood cells/highpower field and the other did not have urinalySis p e r f o r m e d . Neither of these patients h a d urethral or bladder injuries. Of the r e m a i n i n g 5 cases not evaluated for m e a t a l blood, 1 h a d :gross h e m a t u r i a , 1 h a d a n o r m a l urinalysis, and t h e other 3 did not u n d e r g o urinalysis. The patient with gross h e m a t u r i a had a b u l b o m e m branous injury, and the other 4 patients h a d no urethral involvement. Retrograde u r e t h r o g r a m s w e r e p e r f o r m e d in 9 eases. Extravasation was noted in 5 eases. Angiography was p e r f o r m e d in 6 patients w i t h suspected significant vascular injury to the major arteries of the leg and pelvis. Arterial d a m -
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age to the p u d e n d a l artery was found in only 1 ease. T h e left f e m o r a l vein was injured in another patient and was repaired w i t h o u t incident. Cystoseopy was not done on any patient. Nine patients r e q u i r e d definitive surgery. The 4 patients w i t h no urethral invovlement u n d e r w e n t simple d e b r i d e m e n t and closure of the penile w o u n d . Two h a d corpora eavernosa injuries, w h i c h w e r e debrided and primarily closed. The other 2 patients h a d deep superficial injuries that did not involve the corpora. They, too, required simple d e b r i d e m e n t and closure. None of these patients h a d suprapubie catheters placed. Five patients h a d urethral injury. F o u r of the 5 patients with definitive urethral involvement u n d e r w e n t p r i m a r y repair. D e l a y e d urethroplasty was p e r f o r m e d on the final patient w h o h a d m e m b r a n o u s urethral involvement. All 5 of these patients h a d suprapubic catheters and small penile drains placed as p a r t of their m a n a g e m e n t .
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There were no deaths or wound infections in our patient population. Long-term follow-up was difficult to obtain in this group of individuals due to their poor compliance. Significant complications were noted in only 2 patients. Severe urethral stricture disease developed in the patient treated with delayed urethroplasty and required 2 surgieal retreatments. He is now doing well without obstructive symptoms. In another patient meatal stenosis developed whieh was treated successfully with meatotomy. No ehordee or ereetile difficulties occurred in any of the patients. Comment Approximately 40 percent of penetrating urologic wounds are to the external genitalia. 3 Our data eorroborate that most gunshot wounds to the penis are aeeompanied by injuries to other areas of the body. Eighty pereent of our patients had associated injuries to regional struetures. Four of our patients had assoeiated serotal injuries which required definitive exploration, ineluding orehieetomy in 2. In all of our patients it appeared that the external genitalia was the prime target by the patient's assailant. Therefore, most of our patients had no other significant life-threatening injuries. However, every trauma patient should be thoroughly assessed and stabilized before definitive treatment of external genitalia wounds is undertaken. Half of the patients in our series sustained urethral injuries. Urethral injuries should be suspected in all individuals with penetrating wounds to the penis. Retrograde urethrography should be obtained. Information from this simple test can be vital to patient management. It should be remembered that the extent of injury in most instanees can only be determined at the time of surgery, as the amount of extravasation noted on urethrography does not correspond to the severity of injury. 4 Blood at the meatus or gross hematuria was somewhat predietive of urethral or bladder injury, but 1 patient with meatal blood had a normal urethrogram. Microscopic hematuria was not predictive of urethral injury. Nonetheless, the presence or absence of hematuria or meatal blood should not be relied on to define urethral involvement. A high index of suspicion should always be maintained. The type of weapon used (handgun or rifle), loeation, and extent of injury determine the appropriate management. Selikowitz3 reported on
his experienees in Viet Nam and found that high-veloeity injuries generally resulted in total loss of the phallus. Low-velocity missiles f r o m handguns cause mueh less tissue damage, require less debridement, and result in easier wound elosure. Debridement can also be limited in the penis beeause of its excellent blood supply. 5 All of our patients were assaulted with handguns. Signifieant destruction of tissue be-: yond the immediate path of the bullet was not encountered in any of our eases. Wounds that graze the penis may be closed like a simple laceration. Injuries that involve layers deep to the skin and the Colle fascia need surgical exploration. There are several methods of exploration, and modifieations may be needed as operative findings dictate. A circumcising incision at the: coronal suleus followed by degloving the penis to its base provides good exposure for most injuries. As suggested by Selikowitz, we found nO: difficulty in loeating the limits of viable tissue: in any of our eases. 3 Injuries to the corpora eavernosa should be explored and repaired using permanent, buried interrupted suture. 6 Penile injuries that do not involve the urethra should be treated with adequate debridement : and standard closure with absorbable suture. Onee the repair is complete, skin is reapproximated with absorbable suture. Full thiekness skin grafts, if needed, may be used for coverage.1 Skin may also be closed seeondarily and in some cases re-epithelialization may oeeur. ~ When the urethra is injured, we have found that adequate debridement of the lacerated urethra followed by primary eireumferential repair and elosure is the preferred method of) management. Blumberg, Herwig, and others: describe similar excellent results using this teeh, nique. 3,7-9 The 1 patient in our series treated with delayed repair had the most significant eomplieation, severe urethral stricture disease. However, he had membranous urethral i n volvement and primary repair was not deemed feasible. We share Selkowitz, 3 Jordan and Gilbert, 1 Guerriero's4 belief that primary r e p a i r should be performed if, after debridement and mobilization, sufficient urethral length exists to allow it. More morbidity and urethral stricture disease appear to be assoeiated with delayed repair. If minimal vaseular injury is noted, as in o u r : patient with the pudendal artery damage, re, :: pair may not be required. Signifieant vascular injury demands repair. Both dorsal arteries and at least one dorsal vein, preferably the deep : i
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dorsal, should be reapproximated to provide adequate vascularization of the penis. Many advocate the use of a small drain to decompress any drainage. ° Drains are placed routinely in our patients with urethral injury. Infections have not been a problem in our experience. Finally suprapubic cystostomy was done in all our patients with urethral injuries. This allowed for early urethral stent removal and may have contributed to the success of our urethral repairs. Not all authors believe suprapubic tubes are necessary. 1,2 Nonetheless, urinary diversion for seven to ten days is necessary, and whether this is obtained by Foley catheter alone or by suprapubic tube must be determined by the attending surgeon. In summary, although gunshot wounds to the penis are uncommon, in the current climate of urban violence and crime, the possibility of being faced with one of these injuries is very real. The guiding principles for management are a high index of suspicion for urethral and regional organ injury, adequate debridement of
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all wounds, and primary closure if at all possible. Detroit, Michigan 48202
(DR. MILES) References 1. Jordan GM, and Gilbert DA: Male Genital Trauma, AUA Update Series, 4, lesson 20, 1985. 2. Salvatierra O, Rigdon WO, Norris DM, and Brady TM: Vietnam experience with 252 urological war injuries, J Urol 10h
615 (1969).
3. Selikowitz SM: Penetrating high-velocity genitourinary injuries, Urology 9:493 (1977). 4. Guerriero WC: Trauma to the kidneys, ureters, bladder, and urethra, Surg Clin North Am 62:1047 (1982). 5. McAninch JW, et al: Major traumatic and septic genital injuries, J Trauma 24:291 (1984). 6. Peters PC, and Sagalowsky Ah Genitourinary trauma, in Walsh PC, Gittes RF, Perlmutter AD, and Stamey TA (Eds): Campbell's Urology, vol 1, 5th ed, Philadelphia, WB Saunders Co., 1986, pp 1235-1239. 7. Blumberg N: Anterior urethral injuries, J Urol 102:210
(1969). 8. Herwig KR, Blumberg N, and Hubbard H: Injuries o2 the penile and bulbous urethra, Milit Med 135:289 (1970). 9. Mitchell JP: Injuries to the urethra, Br J Uro140:649 (1968).
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