GU Trauma Julian Gordon, MD FACS May 23, 2006 Julian Gordon, MD FACS May 23, 2006

PerspectivePerspective Commonly covert entity, occurs in 10% of injured patients Commonly covert entity, occurs in 10% of injured patients Diagnosis usually done in retrograde fashion, Diagnosis usually done in retrograde fashion, –i.e. urethra evaluated before bladder, etc. GU trauma divided into lower tract (bladder, urethra), upper tract (renal, ureter) or external genitalia GU trauma divided into lower tract (bladder, urethra), upper tract (renal, ureter) or external genitalia Commonly covert entity, occurs in 10% of injured patients Commonly covert entity, occurs in 10% of injured patients Diagnosis usually done in retrograde fashion, Diagnosis usually done in retrograde fashion, –i.e. urethra evaluated before bladder, etc. GU trauma divided into lower tract (bladder, urethra), upper tract (renal, ureter) or external genitalia GU trauma divided into lower tract (bladder, urethra), upper tract (renal, ureter) or external genitalia

Physical Exam Careful exam of abdomen/torso and compression of pelvic girdle/pubic symphysis Careful exam of abdomen/torso and compression of pelvic girdle/pubic symphysis Examine genitalia, looking for hematoma or blood at urethral meatus Examine genitalia, looking for hematoma or blood at urethral meatus Do not insert foley if blood at meatus until retrograde urethrogram done Do not insert foley if blood at meatus until retrograde urethrogram done Careful exam of abdomen/torso and compression of pelvic girdle/pubic symphysis Careful exam of abdomen/torso and compression of pelvic girdle/pubic symphysis Examine genitalia, looking for hematoma or blood at urethral meatus Examine genitalia, looking for hematoma or blood at urethral meatus Do not insert foley if blood at meatus until retrograde urethrogram done Do not insert foley if blood at meatus until retrograde urethrogram done

Lower Tract Injuries

Women with pelvic fractures need to have a vaginal exam as bone fragments may lacerate the vaginal vault Women with pelvic fractures need to have a vaginal exam as bone fragments may lacerate the vaginal vault OK to pass a Foley in females with pelvic fractures OK to pass a Foley in females with pelvic fractures Rectal exam to check for “high riding” prostate Rectal exam to check for “high riding” prostate Women with pelvic fractures need to have a vaginal exam as bone fragments may lacerate the vaginal vault Women with pelvic fractures need to have a vaginal exam as bone fragments may lacerate the vaginal vault OK to pass a Foley in females with pelvic fractures OK to pass a Foley in females with pelvic fractures Rectal exam to check for “high riding” prostate Rectal exam to check for “high riding” prostate Physical Exam

Foley should be placed in all major trauma patients Foley should be placed in all major trauma patients Any urine that is not clear or yellow is considered gross hematuria Any urine that is not clear or yellow is considered gross hematuria Most lower tract injuries accompanied by pelvic fracture will have blood at meatus or gross hematuria Most lower tract injuries accompanied by pelvic fracture will have blood at meatus or gross hematuria Blunt trauma to renovascular pedicle or penetrating uretral injury may not produce hematuria Blunt trauma to renovascular pedicle or penetrating uretral injury may not produce hematuria Foley should be placed in all major trauma patients Foley should be placed in all major trauma patients Any urine that is not clear or yellow is considered gross hematuria Any urine that is not clear or yellow is considered gross hematuria Most lower tract injuries accompanied by pelvic fracture will have blood at meatus or gross hematuria Most lower tract injuries accompanied by pelvic fracture will have blood at meatus or gross hematuria Blunt trauma to renovascular pedicle or penetrating uretral injury may not produce hematuria Blunt trauma to renovascular pedicle or penetrating uretral injury may not produce hematuria Foley Catheter

Urethral Trauma Anatomy: Anatomy: Divided by UG diaphragm into anterior and posterior urethra Divided by UG diaphragm into anterior and posterior urethra Pelvic fracture may result in a laceration of the prostatic or membranous urethra Pelvic fracture may result in a laceration of the prostatic or membranous urethra Anatomy: Anatomy: Divided by UG diaphragm into anterior and posterior urethra Divided by UG diaphragm into anterior and posterior urethra Pelvic fracture may result in a laceration of the prostatic or membranous urethra Pelvic fracture may result in a laceration of the prostatic or membranous urethra

Pathophysiology Pathophysiology Most posterior urethral injuries due to pelvic fractures Most posterior urethral injuries due to pelvic fractures Most anterior injuries due to straddle injuries, GSW, self-instrumentation Most anterior injuries due to straddle injuries, GSW, self-instrumentation Pathophysiology Pathophysiology Most posterior urethral injuries due to pelvic fractures Most posterior urethral injuries due to pelvic fractures Most anterior injuries due to straddle injuries, GSW, self-instrumentation Most anterior injuries due to straddle injuries, GSW, self-instrumentation Urethral Trauma

Clinical Features Lack of pelvic tenderness, no hematomas, normal rectal exam all support an intact urethra Lack of pelvic tenderness, no hematomas, normal rectal exam all support an intact urethra Pelvic crush injury Pelvic crush injury Blood at meatus Blood at meatus Distended Bladder Distended Bladder Catheter-no urine output Catheter-no urine output Lack of pelvic tenderness, no hematomas, normal rectal exam all support an intact urethra Lack of pelvic tenderness, no hematomas, normal rectal exam all support an intact urethra Pelvic crush injury Pelvic crush injury Blood at meatus Blood at meatus Distended Bladder Distended Bladder Catheter-no urine output Catheter-no urine output

DiagnosisDiagnosis Ability to pass a Foley precludes complete urethral disruption, partial tear may exist Ability to pass a Foley precludes complete urethral disruption, partial tear may exist If partial tear exists/attempt of passage of a Foley may be done, consult urology if difficulty If partial tear exists/attempt of passage of a Foley may be done, consult urology if difficulty Consider urethral tear in any patient following unsuccessful cath followed by bleeding Consider urethral tear in any patient following unsuccessful cath followed by bleeding Ability to pass a Foley precludes complete urethral disruption, partial tear may exist Ability to pass a Foley precludes complete urethral disruption, partial tear may exist If partial tear exists/attempt of passage of a Foley may be done, consult urology if difficulty If partial tear exists/attempt of passage of a Foley may be done, consult urology if difficulty Consider urethral tear in any patient following unsuccessful cath followed by bleeding Consider urethral tear in any patient following unsuccessful cath followed by bleeding

RadiologyRadiology Retrograde urethrogram is procedure of choice is all suspected urethral injuries Retrograde urethrogram is procedure of choice is all suspected urethral injuries Perform urethrogram with patient in supine position with penis stretched obliquely over the thigh, or in oblique position Perform urethrogram with patient in supine position with penis stretched obliquely over the thigh, or in oblique position First obtain KUB, and try to do with flouro First obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of contrast into the penis over seconds Using a Toomey syringe, inject 60 ml of contrast into the penis over seconds Retrograde urethrogram is procedure of choice is all suspected urethral injuries Retrograde urethrogram is procedure of choice is all suspected urethral injuries Perform urethrogram with patient in supine position with penis stretched obliquely over the thigh, or in oblique position Perform urethrogram with patient in supine position with penis stretched obliquely over the thigh, or in oblique position First obtain KUB, and try to do with flouro First obtain KUB, and try to do with flouro Using a Toomey syringe, inject 60 ml of contrast into the penis over seconds Using a Toomey syringe, inject 60 ml of contrast into the penis over seconds

Complete vs. partial tear distinguished by the presence of contrast in the bladder Complete vs. partial tear distinguished by the presence of contrast in the bladder RadiologyRadiology

TreatmentTreatment If normal urethrogram, place a Foley If normal urethrogram, place a Foley For a partial tear, 1 attempt at Foley placement may be done For a partial tear, 1 attempt at Foley placement may be done For complete tear consult urology, may need to place suprapubic catheter, or attempt endoscopic assisted cath For complete tear consult urology, may need to place suprapubic catheter, or attempt endoscopic assisted cath If normal urethrogram, place a Foley If normal urethrogram, place a Foley For a partial tear, 1 attempt at Foley placement may be done For a partial tear, 1 attempt at Foley placement may be done For complete tear consult urology, may need to place suprapubic catheter, or attempt endoscopic assisted cath For complete tear consult urology, may need to place suprapubic catheter, or attempt endoscopic assisted cath

Bladder Trauma

Bladder Anatomy Lies within pelvis when empty, can reach umbilicus when full Lies within pelvis when empty, can reach umbilicus when full Consists of 3 muscle layers Consists of 3 muscle layers Blood supplied from int. iliac artery, nerve supply from lumbar and sacral plexus Blood supplied from int. iliac artery, nerve supply from lumbar and sacral plexus Bladder trauma usually associated with severe injuries, mortality 22-44% Bladder trauma usually associated with severe injuries, mortality 22-44% Lies within pelvis when empty, can reach umbilicus when full Lies within pelvis when empty, can reach umbilicus when full Consists of 3 muscle layers Consists of 3 muscle layers Blood supplied from int. iliac artery, nerve supply from lumbar and sacral plexus Blood supplied from int. iliac artery, nerve supply from lumbar and sacral plexus Bladder trauma usually associated with severe injuries, mortality 22-44% Bladder trauma usually associated with severe injuries, mortality 22-44%

PathophysiologyPathophysiology Can rupture in or outside of peritoneum, or both Can rupture in or outside of peritoneum, or both Extraperitoneal rupture usually from pelvic fracture with laceration of bladder, but may occur with blunt trauma Extraperitoneal rupture usually from pelvic fracture with laceration of bladder, but may occur with blunt trauma Can rupture in or outside of peritoneum, or both Can rupture in or outside of peritoneum, or both Extraperitoneal rupture usually from pelvic fracture with laceration of bladder, but may occur with blunt trauma Extraperitoneal rupture usually from pelvic fracture with laceration of bladder, but may occur with blunt trauma

Intraperitoneal rupture usually from blunt trauma in patients with a full bladder Intraperitoneal rupture usually from blunt trauma in patients with a full bladder Clinically will see lower abdominal pain, inability to urinate, blood at meatus Clinically will see lower abdominal pain, inability to urinate, blood at meatus Intraperitoneal rupture usually from blunt trauma in patients with a full bladder Intraperitoneal rupture usually from blunt trauma in patients with a full bladder Clinically will see lower abdominal pain, inability to urinate, blood at meatus Clinically will see lower abdominal pain, inability to urinate, blood at meatus PathophysiologyPathophysiology

DiagnosisDiagnosis

LabLab Gross hematuria indicative of urologic injury Gross hematuria indicative of urologic injury Clear urine and no pelvic fracture virtually eliminates possibility of bladder rupture Clear urine and no pelvic fracture virtually eliminates possibility of bladder rupture 98% of patients with bladder rupture have gross hematuria 98% of patients with bladder rupture have gross hematuria Gross hematuria indicative of urologic injury Gross hematuria indicative of urologic injury Clear urine and no pelvic fracture virtually eliminates possibility of bladder rupture Clear urine and no pelvic fracture virtually eliminates possibility of bladder rupture 98% of patients with bladder rupture have gross hematuria 98% of patients with bladder rupture have gross hematuria

RadiologyRadiology Retrograde cystogram is diagnostic procedure of choice Retrograde cystogram is diagnostic procedure of choice

Retrograde Cystogram Exclude urethral injury and place a Foley Exclude urethral injury and place a Foley Contrast is instilled under gravity thru a Toomey syringe without its central piston Contrast is instilled under gravity thru a Toomey syringe without its central piston Obtain KUB first Obtain KUB first Instill contrast until 100cc with x-ray evidence of extravasation, cc in patient older than 11 Instill contrast until 100cc with x-ray evidence of extravasation, cc in patient older than 11 Use flouroscopic monitoring Use flouroscopic monitoring Children (age+2)x30cc Children (age+2)x30cc Exclude urethral injury and place a Foley Exclude urethral injury and place a Foley Contrast is instilled under gravity thru a Toomey syringe without its central piston Contrast is instilled under gravity thru a Toomey syringe without its central piston Obtain KUB first Obtain KUB first Instill contrast until 100cc with x-ray evidence of extravasation, cc in patient older than 11 Instill contrast until 100cc with x-ray evidence of extravasation, cc in patient older than 11 Use flouroscopic monitoring Use flouroscopic monitoring Children (age+2)x30cc Children (age+2)x30cc

Foley is clamped and AP film taken Foley is clamped and AP film taken Then empty bladder and take post-evacuation film Then empty bladder and take post-evacuation film If extraperitoneal perforation, will see contrast in area of pubic symphysis,intraperitoneal perforation will outline abdominal contents If extraperitoneal perforation, will see contrast in area of pubic symphysis,intraperitoneal perforation will outline abdominal contents May see false negatives if less than cc of contrast used May see false negatives if less than cc of contrast used Foley is clamped and AP film taken Foley is clamped and AP film taken Then empty bladder and take post-evacuation film Then empty bladder and take post-evacuation film If extraperitoneal perforation, will see contrast in area of pubic symphysis,intraperitoneal perforation will outline abdominal contents If extraperitoneal perforation, will see contrast in area of pubic symphysis,intraperitoneal perforation will outline abdominal contents May see false negatives if less than cc of contrast used May see false negatives if less than cc of contrast used Retrograde Cystogram

CT SCAN Obtain same anatomic info, contrast instilled in retrograde fashion Obtain same anatomic info, contrast instilled in retrograde fashion

TreatmentTreatment If no extravasation treat with or without Foley drainage If no extravasation treat with or without Foley drainage Extraperitoneal ruptures treated with Foley drainage for 7 to 15 days with 20Fr. or greater sized catheter Extraperitoneal ruptures treated with Foley drainage for 7 to 15 days with 20Fr. or greater sized catheter If no extravasation treat with or without Foley drainage If no extravasation treat with or without Foley drainage Extraperitoneal ruptures treated with Foley drainage for 7 to 15 days with 20Fr. or greater sized catheter Extraperitoneal ruptures treated with Foley drainage for 7 to 15 days with 20Fr. or greater sized catheter

Surgical repair if rupture involves bladder neck or proximal urethra Surgical repair if rupture involves bladder neck or proximal urethra Intraperitoneal ruptures always require surgical repair Intraperitoneal ruptures always require surgical repair –Children 77% –Increased Bun/Cr –Potentially lethal Surgical repair if rupture involves bladder neck or proximal urethra Surgical repair if rupture involves bladder neck or proximal urethra Intraperitoneal ruptures always require surgical repair Intraperitoneal ruptures always require surgical repair –Children 77% –Increased Bun/Cr –Potentially lethal TreatmentTreatment

Upper Tract Trauma

Renal Injury

ComplicationsComplications Renovascular HTN in 1% associated with pedicle injuries and failed arterial repairs Renovascular HTN in 1% associated with pedicle injuries and failed arterial repairs

EpidemiologyEpidemiology Blunt trauma accounts for 80-85% of all renal injuries Blunt trauma accounts for 80-85% of all renal injuries –MVA –Sports –Domestic violence Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating trauma Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating trauma Pedicle injuries due to acceleration/deceleration Pedicle injuries due to acceleration/deceleration or penetrating injury Blunt trauma accounts for 80-85% of all renal injuries Blunt trauma accounts for 80-85% of all renal injuries –MVA –Sports –Domestic violence Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating trauma Intraperitoneal injury found in 20% of blunt trauma and 80% of penetrating trauma Pedicle injuries due to acceleration/deceleration Pedicle injuries due to acceleration/deceleration or penetrating injury

DiagnosisDiagnosis

LabsLabs Degree of hematuria not indicative of severity Degree of hematuria not indicative of severity 1998 guidelines state major renal lacerations may be repaired, adults at risk for major lacerations have gross or microscopic hematuria and shock 1998 guidelines state major renal lacerations may be repaired, adults at risk for major lacerations have gross or microscopic hematuria and shock CT is procedure of choice for imaging CT is procedure of choice for imaging Degree of hematuria not indicative of severity Degree of hematuria not indicative of severity 1998 guidelines state major renal lacerations may be repaired, adults at risk for major lacerations have gross or microscopic hematuria and shock 1998 guidelines state major renal lacerations may be repaired, adults at risk for major lacerations have gross or microscopic hematuria and shock CT is procedure of choice for imaging CT is procedure of choice for imaging

PedsPeds Kidney most frequently injured organ in blunt trauma Kidney most frequently injured organ in blunt trauma Major injuries may have microscopic hematuria without shock Major injuries may have microscopic hematuria without shock If less than 50RBC/hpf, imaging can be deleted If less than 50RBC/hpf, imaging can be deleted Kidney most frequently injured organ in blunt trauma Kidney most frequently injured organ in blunt trauma Major injuries may have microscopic hematuria without shock Major injuries may have microscopic hematuria without shock If less than 50RBC/hpf, imaging can be deleted If less than 50RBC/hpf, imaging can be deleted

When is Imaging Indicated ? Penetrating trauma Penetrating trauma Pediatric trauma Pediatric trauma –Blunt > 50 rbc’s Deceleration injury Deceleration injury Adult blunt trauma Adult blunt trauma –Gross hematuria –Microhematuria & shock (sbp<90) Penetrating trauma Penetrating trauma Pediatric trauma Pediatric trauma –Blunt > 50 rbc’s Deceleration injury Deceleration injury Adult blunt trauma Adult blunt trauma –Gross hematuria –Microhematuria & shock (sbp<90)

RadiologyRadiology IVP: 1.5 – 2ml/kg bolus IVP preferred IVP: 1.5 – 2ml/kg bolus IVP preferred –This study is adequate 60-85% of the time –Abnormal findings often require further imaging –“single shot” IVP is discouraged CT with IV contrast is procedure of choice IVP: 1.5 – 2ml/kg bolus IVP preferred IVP: 1.5 – 2ml/kg bolus IVP preferred –This study is adequate 60-85% of the time –Abnormal findings often require further imaging –“single shot” IVP is discouraged CT with IV contrast is procedure of choice

What is the Best Imaging Study ? Computed Tomography Computed Tomography –Accurate staging –Non-invasive –Detects associated injuries –Rapid –Need contrast Computed Tomography Computed Tomography –Accurate staging –Non-invasive –Detects associated injuries –Rapid –Need contrast

RENAL INJURY SCALE I Contusion hematuria with normal studies I Contusion hematuria with normal studies II Hematoma subcapsular or perirenal II Hematoma subcapsular or perirenal III Laceration <1cm renal cortex III Laceration <1cm renal cortex IV Laceration >1cm w/o extrav or into collecting system IV Laceration >1cm w/o extrav or into collecting system V Vascular Renal artery or vein, or shattered kidney V Vascular Renal artery or vein, or shattered kidney I Contusion hematuria with normal studies I Contusion hematuria with normal studies II Hematoma subcapsular or perirenal II Hematoma subcapsular or perirenal III Laceration <1cm renal cortex III Laceration <1cm renal cortex IV Laceration >1cm w/o extrav or into collecting system IV Laceration >1cm w/o extrav or into collecting system V Vascular Renal artery or vein, or shattered kidney V Vascular Renal artery or vein, or shattered kidney

TreatmentTreatment

Blunt Injury Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf can be discharged from ED with close follow up Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf can be discharged from ED with close follow up Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-20% Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-20% Renal injuries are more common, result from deceleration tend to be partial tears Renal injuries are more common, result from deceleration tend to be partial tears Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf can be discharged from ED with close follow up Adults with less than 3-5 RBC/hpf or children with less than 50 RBC/hpf can be discharged from ED with close follow up Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-20% Only 1-2% of injuries involve the pedicle, but salvage rate is only 15-20% Renal injuries are more common, result from deceleration tend to be partial tears Renal injuries are more common, result from deceleration tend to be partial tears

Venous injuries tend to bleed more Venous injuries tend to bleed more CT scan will diagnosis most arterial injuries, venous injuries diagnosed indirectly due to large hematoma CT scan will diagnosis most arterial injuries, venous injuries diagnosed indirectly due to large hematoma Renal lacerations account for 2-4% of all renal injuries, diagnosed by CT Renal lacerations account for 2-4% of all renal injuries, diagnosed by CT Venous injuries tend to bleed more Venous injuries tend to bleed more CT scan will diagnosis most arterial injuries, venous injuries diagnosed indirectly due to large hematoma CT scan will diagnosis most arterial injuries, venous injuries diagnosed indirectly due to large hematoma Renal lacerations account for 2-4% of all renal injuries, diagnosed by CT Renal lacerations account for 2-4% of all renal injuries, diagnosed by CT Blunt Injury

Surgical repair controversial Surgical repair controversial Minor renal lacerations/contusions managed expectantly Minor renal lacerations/contusions managed expectantly Surgical repair controversial Surgical repair controversial Minor renal lacerations/contusions managed expectantly Minor renal lacerations/contusions managed expectantly Blunt Injury

Penetrating Injuries Hematuria is of no consequence as all patients need CT, most will need surgery Hematuria is of no consequence as all patients need CT, most will need surgery

Ureteral Trauma

PathophysiologyPathophysiology Rare, most due to penetrating injury or iatrogenic Rare, most due to penetrating injury or iatrogenic Most in upper 1/3 of ureter, consider in patient with recent penetrating injury and palpable flank mass Most in upper 1/3 of ureter, consider in patient with recent penetrating injury and palpable flank mass Blunt injuries often associated with other injuries Blunt injuries often associated with other injuries Rare, most due to penetrating injury or iatrogenic Rare, most due to penetrating injury or iatrogenic Most in upper 1/3 of ureter, consider in patient with recent penetrating injury and palpable flank mass Most in upper 1/3 of ureter, consider in patient with recent penetrating injury and palpable flank mass Blunt injuries often associated with other injuries Blunt injuries often associated with other injuries

Diagnosis/TreatmentDiagnosis/Treatment Usually made by finding urine in surgical wounds/dressings or the development of a urinoma Usually made by finding urine in surgical wounds/dressings or the development of a urinoma Contrast CT or bolus IVP will delineate the injury Contrast CT or bolus IVP will delineate the injury Retrograde pyelography will aid in diagnosis Retrograde pyelography will aid in diagnosis All injuries need surgical repair All injuries need surgical repair Usually made by finding urine in surgical wounds/dressings or the development of a urinoma Usually made by finding urine in surgical wounds/dressings or the development of a urinoma Contrast CT or bolus IVP will delineate the injury Contrast CT or bolus IVP will delineate the injury Retrograde pyelography will aid in diagnosis Retrograde pyelography will aid in diagnosis All injuries need surgical repair All injuries need surgical repair

External Genital Trauma Penile Trauma

Clinical Features Strangulation with string or hair seen in kids Strangulation with string or hair seen in kids Adolescents /adults may have incarceration injuries with metal rings, bottles, etc Adolescents /adults may have incarceration injuries with metal rings, bottles, etc Consider abuse in children Consider abuse in children Strangulation with string or hair seen in kids Strangulation with string or hair seen in kids Adolescents /adults may have incarceration injuries with metal rings, bottles, etc Adolescents /adults may have incarceration injuries with metal rings, bottles, etc Consider abuse in children Consider abuse in children

Penile Fracture During an erection During an erection Loud crack and detumescence Loud crack and detumescence Penile hematoma Penile hematoma Urethral injury in 20%(blood at meatus) Urethral injury in 20%(blood at meatus) R/O dorsal vein or artery laceration R/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration ? Cavernosogram, MRI, exploration During an erection During an erection Loud crack and detumescence Loud crack and detumescence Penile hematoma Penile hematoma Urethral injury in 20%(blood at meatus) Urethral injury in 20%(blood at meatus) R/O dorsal vein or artery laceration R/O dorsal vein or artery laceration ? Cavernosogram, MRI, exploration ? Cavernosogram, MRI, exploration

Penile Trauma Treatment Superficial lacerations repaired with 4.0 absorbable suture Superficial lacerations repaired with 4.0 absorbable suture Degloving injuries need to go to the OR Degloving injuries need to go to the OR Penile amputation may be reattached within 6 hours (preserve in saline & pack in ice) Penile amputation may be reattached within 6 hours (preserve in saline & pack in ice) Most penile fractures need operative repair Most penile fractures need operative repair Human bites to penis treated same as other body areas Human bites to penis treated same as other body areas Superficial lacerations repaired with 4.0 absorbable suture Superficial lacerations repaired with 4.0 absorbable suture Degloving injuries need to go to the OR Degloving injuries need to go to the OR Penile amputation may be reattached within 6 hours (preserve in saline & pack in ice) Penile amputation may be reattached within 6 hours (preserve in saline & pack in ice) Most penile fractures need operative repair Most penile fractures need operative repair Human bites to penis treated same as other body areas Human bites to penis treated same as other body areas

Testicular Trauma

Usually caused by a fall or kick Usually caused by a fall or kick Will see pain, n/v, occasional urinary retention Will see pain, n/v, occasional urinary retention Testicle may be swollen, or small hematoma felt Testicle may be swollen, or small hematoma felt All patients need color doppler ultrasound All patients need color doppler ultrasound Usually caused by a fall or kick Usually caused by a fall or kick Will see pain, n/v, occasional urinary retention Will see pain, n/v, occasional urinary retention Testicle may be swollen, or small hematoma felt Testicle may be swollen, or small hematoma felt All patients need color doppler ultrasound All patients need color doppler ultrasound

TreatmentTreatment Contusion Contusion –Ice –Rest –NSAIDs Dislocations, lacerations, disruption Dislocations, lacerations, disruption –Surgery Contusion Contusion –Ice –Rest –NSAIDs Dislocations, lacerations, disruption Dislocations, lacerations, disruption –Surgery

Necrotizing Skin Infections Predisposing factors –ETOH abuse –Diabetes mellitus –Prolonged bed rest –Etiology: perirectal, periurethral, cutaneous abcesses Predisposing factors –ETOH abuse –Diabetes mellitus –Prolonged bed rest –Etiology: perirectal, periurethral, cutaneous abcesses