External injuries to the penis may include damage to the corporal bodies and the urethra in up to 50% of the cases despite the absence of blood at the meatus on presentation. Early surgical exploration is indicated to repair injuries to the urethra and corporal bodies and gives a significantly better long-term outcome with respect to erectile dysfunction and voiding. Use of the retrograde urethrogram is imperative prior to exploration in order to plan the surgical approach and repair.

The best way to expose the penis for penetrating or blunt injuries is through a circumcision incision. The shaft skin may be degloved from the penis and the corporal bodies and urethra directly inspected. On exploration significant hemorrhage can be controlled initially with direct compression and gauze sponges. Should bleeding be extremely brisk, control may be easily obtained through the use of a tourniquet at the base of the penis consisting of a Penrose drain held in place with a Kelley clamp. Any lacerations or injuries to the corporal bodies are closed with interrupted 2-0 Vicryl for a watertight closure. In the uncircumcised patient, a completion circumcision will usually be required to avoid phimosis and paraphimosis from the postoperative edema.

Traumatic amputation of the penis is rare but may result from explosion injuries. While reconstruction of the urethra with anastomosis of the corporal bodies and microsurgical repair of penile vessels can achieve remarkably good results, these are rarely indicated nor often possible in a deployed environment. In these cases the penile stump should be formalized by closing the corporal bodies in a watertight fashion to prevent bleeding, spatulation of the end of the urethra ventrally into a neo-meatus, and closure of the remaining skin. These injuries will require urinary diversion with a urethral catheter or suprapubic tube until medical evacuation.

Any penetrating or blunt trauma to the penis, perineum, scrotum, or pelvis may include the injury to the urethra. The urethra should be completely evaluated prior to surgery with a retrograde urethrogram. A delayed or missed diagnosis of a significant urethral injury can have devastating consequences including urinoma, abscess formation, infection, and urethral stricture. When considering isolated urethral trauma, it is best to classify these injuries based on location rather than mechanism of injury. Urethral injuries in the male can be subdivided into posterior and anterior.

The posterior urethra includes the bladder neck, prostatic urethra, and membranous urethra. In men with pelvic fracture, 10% will also have a concomitant urethral injury – so a high index of suspicion is required. In the posterior urethra, injury is most commonly from blunt trauma where the membranous urethra is distracted from the prostate at the apex, resulting in a pelvic fracture urethral distraction defect (Fig. 24.3). The membranous urethra is most commonly involved in these injuries because the prostate is protected by ligaments which secure it to the pelvis. This is what results in a high-riding prostate, the physical exam finding of a prostate that is displaced cranially and difficult to palpate. On radiographic evaluation, a high-riding prostate is otherwise known as the “pie in sky” bladder on cystogram.

Management of the prostatic or membranous urethral injury resulting from high-velocity projectiles is best achieved with suprapubic drainage and a Foley catheter placement if possible. A diverting colostomy is often required as there are frequently other injuries of the distal gastrointestinal tract. Early attempt at repair is not indicated as it may cause a significant amount of bleeding, incontinence, and erectile dysfunction. In the case of blunt trauma causing urethral distraction defect, initial management has been hotly debated in the literature. Some authors recommend early realignment of the urethra through endoscopic techniques, while others recommend early suprapubic drainage only with a delayed repair after 3–6 months of healing. Currently, our thoughts are that the latter is the more logical in the combat trauma setting as it allows acute decompression of the urinary system, convalescence of the patient, and a definitive reconstruction at a controlled time. There are, however, some cases that require early laparotomy with pelvic exploration and repair of the distraction. These include concomitant injury to the rectum or bowel, concomitant bladder neck injury requiring closure, and large distraction defect where the pelvic hematoma needs to be drained acutely. Exercise caution in exploring a pelvic hematoma with a pelvic fracture as it can cause troublesome bleeding.