506

Practical Urology: EssEntial PrinciPlEs and PracticE

is typically determined by the extent of pelvic,

can be managed with primary spatulated end-

lower extremity, and lumbar spine fractures.

to-end anastomosis over a Foley catheter after

Antibiotics should be administered prior to the

adequate irrigation and debridement, though

procedure. Antegrade access is secured through

some restraint is advisable during debride-

the existing suprapubic site with a sheath large

ment.55 If the defect is large or there are multiple

enough to accommodate the flexible cystoscope.

defects, delayed repair is recommended. Blunt

The bladder is inspected with the flexible cysto-

trauma, such as straddle injuries where the

scope and then the antegrade cystoscope is used

immobile bulbar urethra is compressed against

to guide a retrograde cystoscope into the bladder.

the underside of the pubic symphysis, are prob-

Through-and-through access is obtained with

ably best treated with suprapubic cystotomy and

a guide wire, and an 18-fr council-tip urethral

delayed repair,56 though some advocate imme-

catheter is placed over the wire. When the retro-

diate endoscopic realignment.57

grade cystoscope cannot be guided into the

bladder, a wire can be passed through the ante-

Fractured Penis

grade cystoscope into the rupture site, and can

usually be grasped with alligator forceps and

pulled out of the urethra, establishing through-

Penile fracture, or rupture of the tunica albug-

and-through access.

inea as a result of

blunt trauma to the erect

Postoperatively, suprapubic drainage should

penis, classically

occurs during intercourse

be continued for 3–4 days. Pericatheter retro-

when the penis is vigorously thrust against the

grade urethrogram can be performed at 3 weeks

pubic symphysis or perineum, though a number

after realignment by placing an 18-gauge angio-

of other causes have been reported. The diagno-

cath alongside the catheter. Alternatively, if sus-

sis is usually made based on the history and

picion of leak is low, VCUG can be performed at

physical exam, which typically reveals the clas-

6 weeks with discontinuation of the catheter if

sic “eggplant” sign in which a hematoma devel-

the study is negative. In either case, if a leak is

ops deep to Buck’s fascia. The penis is usually

demonstrated, the catheter should be left in

deviated away from the side of injury, and occa-

place and pericatheter RUG should be repeated

sionally a blood clot or defect in the tunica can

in 2–4 week intervals until there is no leak. Close

be palpated.

follow-up is necessary to assess for signs of

Retrograde urethrography is recommended

developing stricture.

to assess for concomitant urethral injury. Most

authorities recommend early surgical repair of

Anterior Urethral Trauma

the defect as the most reliable way to decrease

morbidity from this injury, which is mostly

The anterior urethra is more commonly injured

due to acquired penile angulation and poten-

tially debilitating pain. The tunica defect

than the posterior urethra, usually due to the

should be closed with interrupted 2-0 or 3-0

blunt trauma of saddle injury. The mobility of

absorbable suture. Complete urethral transec-

the penis provides excellent protection against

tions should be formally repaired over a cath-

both blunt and penetrating injury, but inju-

eter, whereas partial disruptions can be treated

ries from gunshot wounds do occur and are

with primary repair, suprapubic cystotomy, or

believed to be increasing in incidence. Finally,

urethral catheter.

the urethra is injured in 10–20% of penile frac-

tures. In all cases, immediate management of

the injury is necessary to avoid long-term mor-

Penile Amputation

bidity, which is mainly due to urethral stricture

disease.

Initial management should focus on resuscita-

All patients suspected of having a urethral

injury should undergo retrograde urethrogra-

tion of the patient and preservation of the penis.

phy. Anterior urethral injuries, as discussed pre-

The penis should be rinsed in saline solution,

viously and summarized in Table 36.1, are

wrapped in saline-soaked gauze, and placed in a

classified as partial or complete disruptions.

sealed sterile bag, which is then suspended in

Most penetrating injuries to the anterior urethra

ice-slush so as to limit direct contact of ice with