Guideline sources The following summarized guidelines for the evaluation and management of penile trauma are prepared by our editorial team based on guidelines from the American Urological Association (AUA 2023; 2014), the European Association of Urology (EAU 2022), the World Society of Emergency Surgery (WSES/AAST 2019), and the British Association of Urological Surgeons (BAUS 2018). 1 2 3 4 5 6 7 Guidelines 1. Diagnostic investigations History and physical examination: As per EAU 2022 guidelines, evaluate for urethral injury in patients with penile fracture. A As per AUA 2014 guidelines: Suspect penile fracture in patients presenting with penile ecchymosis, swelling, pain cracking or snapping sound during intercourse or manipulation, and immediate detumescence. B Evaluate for concomitant urethral injury in patients with penile fracture or penetrating trauma presenting with blood at the urethral meatus, gross hematuria, or inability to void. B Ultrasound: as per AUA 2014 guidelines, consider obtaining ultrasound in patients with equivocal signs and symptoms of penile fracture. E https://web.pathway.md/diseases/recVjY18I847yQKHc 1/4 6/29/23, 11:02 PM Penile trauma Pathway Urethrography and uretheroscopy: As per AUA 2023 guidelines, obtain retrograde urethrography with voiding cystourethrogram and/or retro-antegrade cystoscopy for preoperative planning of delayed urethroplasty after pelvic fracture urethral injury. B As per WSES 2019 guidelines, obtain retrograde urethrography or selective urethroscopy for the evaluation of traumatic urethral injuries. B Prefer urethroscopy over retrograde urethrography in patients with penile lesions. B 2. Surgical interventions Indications for surgery: As per EAU 2022 guidelines, perform surgery with the closure of tunica albuginea for the treatment of patients with penile fractures. A As per AUA 2014 guidelines: Perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture. B Perform exploration and limited debridement of non-viable tissue in patients with extensive genital skin loss or injury from infection, shearing injuries, or burns (thermal, chemical, electrical). B 3. Specific circumstances Patients with penile amputation: as per AUA 2014 guidelines, perform prompt penile replantation in patients with traumatic penile amputation with the amputated appendage wrapped in saline-soaked gauze, in a plastic bag, and placed on ice during transport. B Patients with urethral injury: As per WSES 2019 guidelines, evaluate patients with post-traumatic urethral hemorrhage for urethral injuries. B Show 9 more As per AUA 2014 guidelines, obtain retrograde urethrography in patients with blood at the urethral meatus after pelvic trauma. B Show 5 more Patients with testicular trauma, evaluation: As per EAU 2022 guidelines: Obtain ultrasound for the diagnosis of testicular trauma. A Explore the injured testis in all cases of testicular rupture and in patients with inconclusive ultrasound findings. A As per BAUS 2018 guidelines: Stabilize the patient with testicular trauma and administer adequate analgesia. Examine the genitalia once the patient is stable ensuring that the degree of swelling is documented compared to the contralateral side. E https://web.pathway.md/diseases/recVjY18I847yQKHc 2/4 6/29/23, 11:02 PM Penile trauma Pathway Obtain ultrasound of the scrotum as first-line imaging for testicular trauma. Obtain repeated ultrasound within 48 hours in patients treated conservatively. E Patients with testicular trauma, management: As per BAUS 2018 guidelines, perform scrotal exploration to determine the extent of the injury, perform adequate washout and control intrascrotal hemorrhage in patients with penetrating injuries. E Show 7 more As per AUA 2014 guidelines, perform scrotal exploration and debridement with tunical closure (when possible) or orchiectomy (when non-salvageable) in patients with suspected testicular rupture. B 4. Patient education General counseling: provide psychological, interpersonal, and/or reproductive counseling and therapy in patients with genital trauma when loss of sexual, urinary, and/or reproductive function is anticipated. E Clinical findings Symptoms Past medical history Hematuria Traumatic injury Penile deformity Penile pain Urinary retention Genitourinary exam 'eggplant sign' Blood at urethral meatus Penile bruising Penile laceration Penile swelling Perineal bruising Scrotal swelling References 1. N.D. Kitrey Chair), F. Campos-Juanatey, P. Hallscheidt et al. EAU Guidelines on Urological Trauma. EAU. 2022. Open 2. Morey AF, Brandes S, Dugi DD rd et al. Urotrauma: AUA guideline. J Urol. 2014 Aug;192 2 327 35. Open 3. Rowland W Rees, Gareth Brown, Trevor Dorkin et al. British Association of Urological Surgeons BAUS consensus document for the management of male genital emergencies - penile fracture. BJU Int. 2018 Jul;122 1 26 28. Open https://web.pathway.md/diseases/recVjY18I847yQKHc 3/4 6/29/23, 11:02 PM Penile trauma Pathway 4. Federico Coccolini, Ernest E Moore, Yoram Kluger et al. Kidney and uro-trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 2;14 54. Open 5. Marc Lucky, Gareth Brown, Trevor Dorkin et al. British Association of Urological Surgeons BAUS consensus document for the management of male genital emergencies - testicular trauma. BJU Int. 2018 Jun;121 6 840 844. Open 6. Hunter Wessells, Allen Morey, Alex Vanni et al. Urethral Stricture Disease Guideline Amendment 2023 . J Urol. 2023 Apr 25;101097JU0000000000003482. Open 7. Chitranjan J Shukla, Gareth Brown, Trevor Dorkin et al. British Association of Urological Surgeons BAUS consensus document for the management of male genital emergencies - penile amputation. BJU Int. 2018 May;121 5 699 702. Open https://web.pathway.md/diseases/recVjY18I847yQKHc 4/4