EXTERNAL GENITALIA

With the rise in dismounted complex battle injuries from explosive devices during combat operations in Iraq and Afghanistan and polytrauma involvement of the lower extremities, perineum, pelvis, and lower abdomen, greater attention has turned to the management of soft tissue injury to the external genitalia and urethra. Testicular injuries are easily missed due to small scrotal entry wounds in some cases and require a high index of suspicion when evaluating patients with significant blast injuries. If you are suspicious of penetrating trauma or believe it may be possible, a low threshold should be employed to explore the scrotum bilaterally. This holds true for blast injuries, as overpressure can cause testicular rupture in patients with no overt injury; a low threshold should be employed in these patients. (See Figure 8).

Figure 8. Top left: Testicular rupture seen in the setting of a blast injury. Top right: No overt testicular trauma was seen. The decision was made to explore. Bottom images: One of the testes was salvaged, where likely, both would be unsalvageable if not explored or treated early. (Images courtesy of ZRM).

For blunt trauma, and in the hands of an experienced physician, bedside ultrasonography can be considered; vascular flow settings can be used to identify testicular rupture and compromised vascular flow (Figure 9).24 Clinicians should not rely on ultrasound for penetrating trauma; most penetrating scrotal injuries should be explored due to the limited sensitivity and variable levels of skill with ultrasound.15

Initial operative management involves thoroughly assessing the injury sites, removing wound contaminants, and debriding non-viable tissue. This is done in conjunction with copious, low-pressure irrigation of the wound.7 (See External Genitalia Injuries in Appendix A: Urological Diagnosis and Treatments.)

Figure 9. Side-by-side Ultrasound with Doppler imaging. Note the decreased Doppler flow of the left testicle (LT) compared to the right. Original image by Dr. Allison Tadros (photo courtesy of WVU Department of Radiology).

In addition to arterial bleeding, vascular structures of the penis and scrotum should be addressed during the initial surgery, specifically, the corpora cavernosa, corpus spongiosum, and bilateral testes (Figure 10). Lacerations to the corpora cavernosa can be closed with absorbable sutures. Attempts should be made to avoid the dorsal neurovascular structures. If the injury is dorsal, the neurovascular structures can be elevated off the corpora cavernosum to preserve the vascular supply to the glans and sensation to the penis. Avoid aggressive over-sewing of the corpus spongiosum in favor of closure to its tunical covering reducing the risk of ischemic changes distal to the injury site in these complex wounds.24,25 Patients with penetrating scrotal wounds or evidence of testicular rupture on exam should undergo scrotal exploration. Ruptured testes are managed with irrigation and debridement of non-viable seminiferous tubules. The tunica albuginea is then closed with fine (4-0 or 5-0) absorbable suture (PDS or Vicryl), returned to the scrotum, and an orchiopexy with three-point fixation is performed.15 A tunica vaginalis flap can be used to close the defect when there is insufficient tunica to obtain a tension-free closure over the exposed tubules. A drain (e.g., Penrose) should typically be left following scrotal exploration for trauma.26 A delay in managing a testicular injury is acceptable when the patient is too unstable or there is insufficient expertise to manage it at initial exploration. Every attempt should be made to salvage viable testicular tissue, especially when both testicles are involved or a unilateral orchiectomy is required. The injured testis should be wrapped in saline-soaked gauze and protected with multiple layers of additional dressing. All findings should be documented and communicated to the next echelon of care.

Figure 10. Trauma to the external genitalia. (Images courtesy of ZRM)

The superficial fascia and skin layers of the penis can and should be left open following high-energy trauma. A loose approximation of these layers with interrupted sutures allows continued tissue evaluation and additional wound debridement. Therefore, a moist gauze or negative pressure dressing is appropriate. Alternatively, Penrose drains can be placed between loosely approximated interrupted sutures. In cases where scrotal closure is impossible, the testis can be covered with a non-adherent dressing followed by a negative pressure dressing. Creating a sub-dermal thigh pouch is rarely necessary during early surgical care.

With the recent introduction of female combatants to all roles in the military, GU injuries in female patients have risen. Of the nearly 1,500 service members in Operation Enduring Freedom and Operation Iraqi Freedom between 2001 and 2013, 1.3% were female. Injuries described in female service members thus far include bladder injury, vulvar injury, vaginal injury, and bladder and perineal injury. Currently, there is a limited evidence-based direction in managing these injuries. Initial care should focus on good exposure of the injured tissue with a complete examination to include the vaginal vault, urethra, and meatus with low-pressure irrigation and judicious debridement of devascularized tissue. Limited debridement should be practiced around the clitoris, favoring repeat examinations in the operating room with intervention as needed. This new injury pattern is being prospectively tracked to ensure the best appropriate care.28,29