2 McAninch JW (2002) In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campbell \200\231s U rology, 8th edn. Philadelphia: WB Saunders pp. 3703 \200\22314. CHAPTER 11 Trauma to the urinary tract 526 Pelvic fractures: bladder and ureteric injuries Pelvic fractures are usually due to run-ove r or crush injuries where mas- sive force is applied to the pelvis. Associated head, chest, intra-abdominal (spleen, liver, mesentery of bowel), pelvic (bladder, urethra, vagina, rec - tum), and genital injuries are common and these injuries and the massive blood loss from torn pelvic veins and arteries account for the substantial (20%) mortality after pelvic fra cture. Initial assessment Pelvic fractures are often occult. Screen run-over or crush victims with a pelvic X-ray. Assess: - - Vital signs (pulse rate, systolic Neurovascular integrity of lower limb (lumbosacral plexus , peripheral nerves, and major vessels may be damaged). Examine for head, chest, abdominal, and perineal injuries. Determine stability/instability of the fracture from pelvic X-rays. BP). Is the fracture stable or unstable? See Box 11.3. Abdominal and pelvic imaging in pelvic fracture - Abdominal/pelvic CT: establishes presence/absence of associated pelvic (rectum, bladder) an d abdominal organ injury (liver, bowel, spleen). Retrograde urethrogram: perform retrograde urethrography only when blood is present at the meatus; others do this in all pelvic fract ure patients where the pubic rami have been disrupted. If the urethra is intact, a retrogra de cystogram is done to assess theintegrity of the bladder. to detect urethral injury. Some hospitals PELVIC FRACTURES: BLADDER AND URETERIC INJURIES 527 Box 11.3 Is the fracture stable or unstable? Stable = the fracture can withstand normal phy siologic forces. Unstable = the fracture cannot withstand normal physiologic forces. Instability suggests a greater degree of trauma to the pelvis and increases the likelihood of serious associated injuries. In addition, \201 xation of an unstable fracture reduces blood loss, mortality, hospital stay, leg length discrepancy, and long-term disability; mak es nursing care easier; and reduces analgesic consumption. Stability can be de \201 ned ac cording to the Tile classi \201 cation system of pelvic ring fractures (Table 11.3). Of unstable pelvic fractures, 70% are B2 and B3, 10 \200\22320% are open book type (B1), and 10 \200\22320% are type C. - Open book pelvic fracture (B1): compressio n. A dramatic rise in pelvic volume stretches vessels, nerves, and organs (e.g. bladder) (F igs. 11.7 and 11.8). Closed book pelvic fracture (B2 or B3): compression force to the pelvi s. The pubic rami fracture and overlap and the ilium and sacral wings may be fractured. Ner ves and vessels are not stretched, but the urethra is more likely to be damaged by scissors like action of overlapping pubic rami. Vertically unstable pelvic fracture (C): damaged by stretching. caused by anteroposterior caused by a lateral vessels and nerves can be Radiological determination of stability Based on inlet (for anteroposterior displacement) a nd outlet views (for vertical displacement) of the pelvis, the X-ray beam being angled acco rd- ingly. CT provides better de \201 nition of sacral, sacroiliac, and acetabular fractur es and dislocations. Is urethral catheterization of a pelvic fracture patient safe? If there is no blood present at the meatus, a gentle attempt at urethral catheterization may be made. It has been sugge sted that this could con- vert a partial urethral rupture into a complete rupture. However, lead- ing trauma centers in the United States state \200\230We and others have not seen a ny evidence that this can convert an incomplete into a complete transection \200 and we u sually make one gentle attempt to place a urethral catheter in suspected urethral disruptio n \200\231.1 If any resistance is encoun- tered, stop and obtain a retrograde urethrogram. If the retrograde ure- throgram demonstrates a normal urethra, proceed with another attempt at catheterization, using plenty of lubricant. If there is a urethral rupture, insert an S PC via a formal open approach to allow inspection of the blad- der (and repair of injuries if present). Bladder injuries associated with pelvic fractures Ten percent of male and 5% of female pelv ic fractures are associated with a bladder injury (fracture type leading to bladder injury is usually an an- teroposterior pelvic compression fracture, i.e. open book pelvic fracture ; Tile classi \201 cation B1). Sixty percent of pelvic fracture bladder ruptures are extra peritoneal, 30% intraperitoneal, and 10% combined extraperitoneal and intraperitoneal. CHAPTER 11 Trauma to the urinary tract 528 Table 11.3 The Tile classi \201 cation system of pelvic ring fractures Type A \200\224stable A1: fracture of pelvis not involving the pelvic ring A2: minimal displacement of pelvic ring with no instability Type B \200\224rotationally (horizontally) unstable B1: open book B2: closed book Lateral compression: ipsilateral fracture B3 closed book Lateral compression: contralateral fracture (bucket handle fracture) Type C \200\224rotationally (horizontally) and vertically unstable C1: unilateral C2: bilateral C3: with acetabular fracture Urethral injuries associated with pelvic fractures The posterior urethra (essentially the m embranous urethra) is injured with roughly the same frequency as the bladder in subjects wh o sustain a pelvic fracture, occurring in 5 \200\22315% of such cases. Most posterior ureth ral injuries occur in association with pelvic fractures.2 Cass found bladder ruptures in 6% of pelvic fractures, urethral rupture in 2%, and combined bladder and urethral rupture in 0.5%.3 Combined bladder and posterior urethral injuries following pelvic fracture One-third of pat ients with a traumatic bladder rupture have injuries to other urinary structures, most comm only the urethra. Ten to twenty per- cent of patients with a pelvic fracture and bladder ru pture also have a posterior urethral rupture. Symptoms and signs of bladder or urethral injury in pelvic fracture - Blood at meatus \200\224in 40 \200\22350% of patients (no blood at meatus in 50 \200\22360% ). Gross haematuria. Inability to pass urine. Perineal or scrotal bruising. \200\230High r iding \200\231 prostate. Inability to pass a urethral catheter. - - - \200\230High riding prostate \200\231 The prostate and bladder become detached from the me mbranous ure- thra and are pushed upwards by the expanding pelvic haematoma. The high ridin g prostate is said to be a classic sign of posterior urethral rupture. Traditional teaching states that a DRE should be done in cases of pelvic PELVIC FRACTURES: BLADDER AND URETERIC INJURIES 529 trauma to determine prostatic position. However, the presence of a high riding prostate is an unreliable sign.4 The pelvic haematoma may make it impossible to feel the prostate so th e patient may be thought to have a high riding prostate when, in fact, it is in a normal po sition. Conversely, what may be thought to be a normal prostate in a normal position may ac tually be the palpable pelvic haematoma. In pelvic fracture, a DRE is done not to identify a high riding prostate, but rather to establish the pres- ence of an associated rectal inju ry (blood seen on the examining \201 nger). However, rectal injury can still occur in the absence of rectal blood. Fig. 11.7 An open book pelvic fracture before \201 xation. Fig. 11.8 An open book pelvic fracture after \201 xation. CHAPTER 11 Trauma to the urinary tract 530 Management of bladder injuries associated with pelvic fractures Extraperitoneal: urethral c atheter until the bladder has healed (usually 2 \200\2233 weeks). Intraperitoneal: open sur gical repair. Management of urethral injuries associated with pelvic fractures Suprapubic catheter: place ment via an open approach is generally bet- ter than a percutaneous approach, partly becaus e it allows inspection of the bladder for associated injuries which may require repair, but also because the catheter may inadvertently be placed into the large pelvic haematoma whic h always accompanies such fractures. Not only does this mean that the bladder is not being drained (so urine will leak into the pelvic haematoma and fracture site), but the suprapubi c can also act as a potential source of infection of the pelvic haematoma, which can lead t o life-threatening sepsis. Management of combined urethral and bladder injuries associated with pelvic fractures If a urethral catheter can be passed and a cystogram shows an extraperi- toneal bladder rupture, leave a urethral catheter in place until the bladder has healed (usually 2 \200\2233 weeks ). If a urethral catheter cannot be passed (because of a complete urethral rupture), a suprapu bic catheter should be placed via an open approach (rather than percutaneously) to allow in spection of the bladder (and repair if the bladder has been torn) at the same time that the suprapubic catheter is placed. The urethral rupture will prevent a cystogram from being do ne so direct inspection of the bladder is required to establish the presence/absence of a b ladder injury. 1 McAninch JW (2002) In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds) Campbell \200\231s U rology, 8th edn. Philadelphia: WB Saunders pp. 3703 \200\22314. 2 Cass AS (1984) Simultanous bladder and prostato membranous urethral rupture from external trauma. J Urol 132:907 \200\2238. 3 Cass AS (1988) Genitourinary Trauma. Boston: Blackwell Scienti \201 c Publications. 4 Elliott DS, Barrett DM (1997) Long-term follow-up and evaluation of primary realignment o f posterior urethral disruptions. J Urol 157:814 \200\2236. This page intentionally left blank CHAPTER 11 Trauma to the urinary tract 532 Bladder injuries Situations in which the bladder may be injured TURBT (Figs. 11.9 and 11.10 ), cystoscopic bladder biopsy, TURP, cysto- litholapaxy, penetrating trauma to the lower ab domen or back, Cesarean section (especially as an emergency), blunt pelvic trauma \200\224i n association with pelvic fracture or \200\230minor \200\231 trauma in the inebriated pati ent, rapid de- celeration injury (e.g. seat belt injury with full bladder in the absence of a pelvic fracture), spontaneous rupture after bladder augmentation, total hip replacement (very rare). Types of perforation - Intraperitoneal perforation: breached, allowing urine to escape into the peritoneal cavity. Extraperitoneal perforation: escapes into the space around the bladder, but not into the p eritoneal cavity. the peritoneum overlying the bladder is the peritoneum is intact and urine Making the diagnosis During endoscopic urological operations (e.g. TURBT, cystolitholapaxy) , the diagnosis is usually obvious on visual inspection alone \200\224a dark hole is seen i n the bladder and loops of bowel may be seen on the other side. No further diagnostic tests are required. In cases of trauma, the classic triad of symptoms and signs suggesting a bladder rupture is: - - - Suprapubic pain and tenderness. Dif \201 culty or inability in passing urine. Haematuria. Additional signs: - - Abdominal distension. Absent bowel sounds (indicating an ileus from urine in the peritoneal cavity). These symptoms and signs are an indication for a retrograde cystogram. The diagnosis may be made only at operation for \201 xation of a pelvic fracture. Imaging studies Retrograde cystography or CT cystography - Ensure the bladder is adequately distended with contrast. With inadequate distension, a clo t, omentum, or small bowel may \200\230plug \200\231 the perforation,which may not, theref ore, be diagnosed. Use at least 400mL of contrast in an adult and 60mL plus 30mL per year o f age in children up to a maximum of 400mL in children. Obtain images after the contrast ag ent has been completely drained from the bladder (a post-drainage \201 lm). A whisper of contrast from a posterior perforation may be obscured by a bladder distended with contrast. In extraperitoneal perforations, extravasation of contrast is limited to the immediate area surrounding the bladder. In intraperitoneal perforations, loops of bowel may be outlined b y the contrast. BLADDER INJURIES 533 Fig. 11.9 An intraperitoneal bladder perforation following a TURBT, as demonstrated on a cy stogram (anteroposterior view). Fig. 11.10 A bladder perforation following a TURBT, as demonstrated on a cystogram (lateral view). CHAPTER 11 Trauma to the urinary tract 534 Treatment of bladder rupture Extraperitoneal: bladder drainage with a urethral catheter for 2 weeks followed by a cystogram to con \201 rm the perforation has healed. Indications for surgical repair of extraperitoneal bladder perforation: If you have opened the bladder to place a suprapubic catheter for a urethral injury. A bone spike protruding i nto the bladder on Associated rectal or vaginal perforation. Where the patient is undergoin g open \201 xation of a pelvic fracture, the bladder can be simultaneously repaired. - CT. Intraperitoneal: usually repaired surgically to prevent complications from leakage of urine into the peritoneal cavity. Spontaneous rupture after bladder augmentation: spontaneous bladder rupture occasionally oc curs months or years after bladder augmentation and usually with no history of trauma. If t he patient has spina bi \201 da or a spinal cord injury, they usually have limited awarene ss of bladder full- ness and pelvic pain. Their abdominal pain may, therefore, be mild and vague in onset and nature. Fever or other signs of sepsis may be pres- ent. Have a high ind ex of suspicion in patients with augmentation who present with non-speci \201 c signs of i llness. A cystogram usually, although not always, con \201 rms the diagnosis. If doubt exi sts, consider exploratory laparotomy. POSTERIOR URETHRAL INJURIES 535 Posterior urethral injuries in males and urethral injuries in females Mechanisms - External blunt height, crush injuries \200\224most common cause. External penetrating Inter nal, iatrogenic (more likely with vascular prostate, prostate cancer, inexperienced surgeon ). Internal, self-in \202 icted : pelvic fracture \200\224road traf \201 c accidents, falls from a : gunshot \200\224rare; stab \200\224rare. : endoscopic surgery; radical prostatectomy; TURP : foreign bodies inserted into urethra \200\224rare. Male posterior urethral injuries The great majority of posterior urethral injuries are an a ssociated injury following pelvic fracture, and their diagnosis and initial management are discussed on b p. 530. Immediate (within 48h) open repair of posterior urethral injuries is associated with a high incidence of urethral strictures (70%) and subsequent restenosis af ter stricture repair, incontinence (20%), and impotence (40%). The surrounding haematoma an d tissue swelling make it dif \201 cult to identify structures and to mobilize the two end s of the urethra to allow tension-free anastomosis. In the majority of male posterior urethral injuries, treatment should be deferred for 3 mon ths to allow the oedema and haematoma to com- pletely resolve. As this occurs, the two dist racted ends of the urethra come closer together, thereby reducing the amount of mobilizatio n that the surgeon has to do. Most such injuries can be repaired by an anasto- motic urethr oplasty. Optical urethrotomy (division of the stricture using an endoscopic knife or laser via a cystoscope inserted into the urethra) is generally not recommended. Immediate repair is indicated where there is an open wound as long as the urethral ends are close (i.e. not distracted by a large haematoma). Urethral injuries in females Rare because the female urethra is short and its attachments t o the pubic bone are weak such that it is less prone to tearing during pubic bone frac- tur e. When they do occur, such injuries are usually associated with rectal or vaginal injuries . In developing countries, prolonged labor can cause ischaemic injury to the urethra and bl adder neck, leading to urethrovaginal or vesicovaginal \201 stula formation. CHAPTER 11 Trauma to the urinary tract 536 Anterior urethral injuries These injuries are uncommon. Mechanisms - External blunt: straddle injury (e.g. forceful contact of perineum with bicycle cross-bar*) \200\224most common cause of injury; kick to perineum; penile fracture. External penetrati ng: gunshot; stab. Internal, iatrogenic: catheter balloon in \202 ated in urethra; endosco pic surgery; penile surgery. Internal, self-in \202 icted: foreign bodies inserted into ur ethra. History and examination The patient usually presents with dif \201 culty in passing urine and frank hae- maturia in the context of a straddle injury. Blood may be present at the end of the penis and a haematoma around the site of the rupture. If Buck \200\231s fascia has been ruptured (the deep layer of the super \201 cial fascia of penis), urine and blood tra ck into the scrotum causing swelling and a \200\230butter \202 y wing \200\231 pattern of bruising, re \202 ecting the anatomical attachments of Colles \200\231 fascia \200\224the membranous layer of the super \201 cial fascia of the groin and perineum(see Fig. 11.11). Con \201 rming the diagnosis and subsequent management Retrograde urethrography delineates the extent of urethral injury. Extravasation of urine can create a collection of urine around the ure- thra (a urinoma) an d generates an in \202 ammatory reaction, with subsequent stricture formation. Superadded infection can lead to abscess formation which may burst onto the surface of the skin, leadi ng to a urethrocutane- ous \201 stula. More rarely, Fournier \200\231s gangrene supervene s. Urinary diversion (urethral or suprapubic catheter) prevents further extravasation of ur ine and antibiotics may reduce the likelihood of superadded infection. Anterior urethral contusion Typical history: blood at meatus, no extravasation of contrast on retro- grade urethrogram. Pass a small gauge urethral catheter (12 Ch in an adult) and r emove a week or so later. Partial rupture of anterior urethra Leak of contrast from urethra with retrograde \202 ow into bladder. Most can be managed by a period of suprapubic urinary diversion. Seventy per cent heal without stricture formation (primary closure can be dif \201 cult because of oed ema and of haematoma at the site of injury and can convert a short area of urethral injury into a longer one). Give a broad-spectrum antibiotic to prevent infection of extravasated u rine and blood. If a voiding cysto- gram 2 weeks later con \201 rms urethral healing, remo ve SPC. If contrast still extravasates, leave it in place a little longer. Bulbar urethra being crushed against pubic bone. ANTERIOR URETHRAL INJURIES 537 Fig. 11.11 Butter \202 y bruising following rupture of Buck \200\231s fascia. Suprapubic catheterization (percutaneously) is preferred over urethral catheterization beca use a partial rupture can be converted to a complete rupture. If the bladder cannot be palp ated such that an SPC cannot be safely inserted, then perform open suprapubic cystostomy (u nder general anesthetic). Complete rupture of anterior urethra Leak of contrast from the urethra on retrograde urethr ogram, no \201 lling of the posterior urethra or bladder. The urethra may either be immed iately repaired (if a surgeon with suf \201 cient experience is available) or an SPC can b e placed with delayed repair. Penetrating partial and complete anterior urethral injuries Knife or gunshot wound: primary (i.e. immediate) repair may be carried out if a surgeon experienced in these techniques is available; if not,suprapubic diversion and subsequent repair by an appropriate surgeon. Immediate surgical repair of anterior urethral injuries is only done in the context of penile fracture or where there is an open wound. CHAPTER 11 Trauma to the urinary tract 538 The anatomical explanation for \200\230butter \202 y wing \200\231 pattern of bruising in anterior urethral rupture Fascial layers of penis from super \201 cial to deep: - - Penile skin. Super \201 cial fascia of the penis (= dartos fascia) \200\224continuous with the membranous layer of the super \201 cial fascia of the groin and perineum (= Colles \200\231 fascia). Buck \200\231s fascia (= the deep layer of the super \201 cial fascia). Deep fascia of the penis (the tunica albuginea) which covers the two dorsal rods of erectil e tissue, the corpora cavernosa, and the ventrally located corpus spongiosum that surrounds the urethra (Fig. 11.12). If Buck \200\231s fascia is intact, bruising from a urethral rupture is con \201 ned in a sleeve-like con \201 guration along the length of the penis. If Buck \200\231s fascia has ruptured, the extravasation of blood, and thus the subsequent bruising, is limited by the a ttachments of Colles \200\231 fascia which forms a \200\230butter \202 y \200\231- like p attern in the perineum and is continuous in the upper abdomen and chest with Scarpa \200 \231s fascia. How to perform a retrograde urethrogram - - Aseptic technique. (sodium amidotrizoate and meglumine Urogra \201 n 150 amidotrizoate) , but other contrast agents can be used. Position the patient at an oblique angle (bottom l eg \202 exed at the hip and knee) A 12 Ch catheter is placed in the fossa navicularis of the penis 1 \200\2232cm from the external meatus, with the catheter balloon with 2mL of wat er or with a penile clamp applied to prevent contrast spilling out of the urethra and to ho ld the catheter in place. Continuous screening ( \202 uoroscopy) is done as contrast is in stilled until the entire length of the urethra is demonstrated. Remember, as the urethra pa sses through the pelvic \202 oor (the membranous urethra), there is a normal narrowing an d similarly, the prostatic urethra is narrower than the bulbar urethra. ANTERIOR URETHRAL INJURIES 539 Superficial penile a., v. Deep dorsal v. Superficial penile fascia Dorsal a. Dorsal n. Buck \200\231s fascia Superficial penile n. Cavernous a. Circumflex a., v. Subalbugineal venular plexus Emissary v. Tunica albuginea Skin Sinusoid Helicine a. Bulbourethral v. Urethra Urethral a. Tunica albuginea Corpus spongiosum Fig. 11.12 The fascial layers of the penis. CHAPTER 11 Trauma to the urinary tract 540 Testicular injuries Testicular injuries are uncommon. Mechanisms Blunt or penetrating. Most in civilian practice are blunt, a blow forcing the te sticle against the pubis or the thigh. Bleeding occurs into the parenchy- ma of the testis and if suf \201 cient force is applied, the tunica albuginea of the testis (the tough \201 brous coat surrounding the parenchyma) ruptures, allowing extrusion of seminiferous tu bules. Penetrating injuries occur as a consequence of gunshot and knife wounds and from bomb blast s; associated limb (e.g. femoral vessel), perineal (penis, urethra, rectum), pelvic, abdomi nal, and chest wounds may occur. Where bleeding is con \201 ned by the tunica vaginalis, a haematocele is said to exist. In traparenchymal (intratesticular) hemorrhage and bleeding beneath the parietal layer of tuni ca vaginalis will cause the testis to enlarge slightly. The testis may be under great press ure as a consequence of the intratesticular hemorrhage con \201 ned by the tunica vaginali s. This can lead to ischaemia, necrosis, and atrophy of the testis. The force is usually suf \201 cient to rupture the tunica albuginea and the tunica vaginal is and the seminiferous tubules and blood extrude into the layers of the scrotum. This is a haematoma. History and examination Severe pain is common as are nausea and vomiting. If the testis is sur- rounded by haematoma, it will not be palpable. If it is possible to palpate the testis , it is usually very tender. The resulting scrotal haematoma can be very large and the brui sing and swelling so caused may spread into the inguinal region and lower abdomen. Testicular ultrasound in cases of blunt trauma A normal parenchymal echo pattern suggests t here is no signi \201 cant testic- ular injury (i.e. no testicular rupture). Hypoechoic ar eas within the testis (indicating intraparenchymal hemorrhage) suggests testicular rupture. Indications for exploration in scrotal trauma - Testicular rupture: exploration allows evacuation of the haematoma, excision of extruded se miniferous tubules, and repair of the tear in the tunica albuginea. Penetrating trauma: (e. g. the vas deferens may have been severed and can be repaired). exploration allows repair to damaged structures This page intentionally left blank CHAPTER 11 Trauma to the urinary tract 542 Penile injuries Amputation Blood loss can be severe; resuscitate the shocked patient and cr oss-match blood. Place the penis, if found, in a wet swab inside a plastic bag which is the n placed inside another bag containing ice ( \200\230bag in a bag \200\231). It can sur- vi ve for 24h. Knife and gunshot wounds Associated injuries are common (e.g. scrotum, major vessels of the low- er limb). Most injuries, other than minor ones, should undergo primary repair. Remove debris from wound (e.g. particles of clothing) and debride necrotic tissue and repair as f or penile fractures (Box 11.4). Penile fracture Rupture of the tunica albuginea of the erect penis (i.e. rupture of one or both corpora cavernosa 9 rupture of the corpus spongiosum with rupture of the urethra). The tunica albuginea is 2mm thick in the \202 accid penis. It thins to 0.25mm during erectio n and is, therefore, vulnerable to rup- ture if the penis is forcibly bent (e.g. during vig orous sexual intercourse). The patient usually reports a sudden \200\230snapping \200\231 or \200\230popping \200\231 sound and/or sensation with sudden penile pain and detumescenc e of the erection. The penis is swollen and bruised, sometimes resembling an aubergine. If Buck \200\231s fasc ia has ruptured, bruising extends onto the lower abdominal wall and into the perineum and s crotum. A tender, palpable defect may be felt over the site of the tear in the tunica albug inea. If the urethra is damaged, there may be blood at the meatus or haematuria (dipstick/ microscopic or macroscopic) and pain on voiding or urinary retention. Arrange a retro- grad e urethrogram in such cases. Treatment There has been a trend away from conservative management towards surgical repair (lower complication rate, e.g. reduced penile deformity, less chance of penile scar tissue, and prolonged penile pain). Conservative: application of cold compresses to the penis; analgesics and anti-in \202 amm atory drugs; abstinence from sexual activity for 6 \200\2238 weeks to allow healing. Surgery: expose the fracture site in the tunica albuginea, evacuate the haematoma, and clos e the defect in the tunica. PENILE INJURIES 543 Box 11.4 Surgical re-implantation of amputated penis Repair the urethra \201 rst over a c atheter to provide a stable base for sub- sequent neurovascular repair. Close the tunica al buginea of the corpora (4/0 absorbable suture). Cavernosal artery repair is technically ver y dif \201 - cult and does not improve penile viability. Anastomose the dorsal artery of t he penis (11/0 nylon), then the dorsal vein (9/0 nylon) to provide venous drainage, and \201 nally, the dorsal penile nerve (10/0 nylon). Surgical repair of penile fracture Expose the fracture site by degloving the penis via a ci rcumcising incision around the subcoronal sulcus or by an incision directly over the defect , if palpable. A degloving incision allows better exposure of the urethra for associated ur ethral injuries. Alternatively, use a midline incision ex- tending distally from the midlin e raphe of the scrotum along the shaft of the penis. This latter incision, along with a deg loving incision, allows excellent exposure of both corpora cavernosa so that an unexpected bilateral injury can be repaired easily as can a urethral injury should this have occurred. Close the defect in the tunica with absorbable sutures or by non- absorbable sutures (bury the knots so that the patient is unable to pal- pate them). Non-absorbable sutures may poss ibly be associated with prolonged post-operative pain. Leave a urethral catheter (voiding c an be dif \201 cult immediately post-operatively). Repair a urethral rupture, if present, with a spatulated single or two-layer urethral anastomosis and splint repair with a urethra l catheter for 3 weeks. Penile bites Clean the wound. Give broad-spectrum antibiotics (e.g. cephalosporin and amoxi cillin). Zipper injuries If the penis is still caught in the zipper, use lubricant jelly and gently attempt to open it. The zipper may have to be cut with orthopedic cut- ters or prised apart with a pair of surgical clips on either side of the zipper.