Keywords

10.1 Introduction

Fabrizio Palumbo, Francesco Sebastiani

Acute genital injuries are a peculiar occurrence which demands specific attentions from the specialist in both the diagnostic and therapeutic approach to the patient.

Thorough history taking is mandatory when first assessing the patient, but it is important to keep in mind several important aspects pertaining to the high emotional impact usually associated with such afflictions. Sensibility is required when discussing the issue with the patient, especially when there is the possibility of permanent functional consequences in relation to sexual function and fertility. Furthermore, in some cases, a psychiatric origin of the event can be considered.

The physical examination should take place in a quiet, reserved office, and should always include a complete evaluation of penis and testicles, as well as the abdominal and perineal area. Potential concomitant injury to other relevant organs should be taken into consideration, and therefore, the physical examination can be extended accordingly.

There are situations in which photographic documentation and forensic material acquisition may be advisable, for example, in the case of potential sexual abuse or violence. The specialist should refer to local legal protocols when assessing possible victims.

Key points of the assessment of an andrological emergency patient are listed in Table 10.1.

Table 10.1 Key points when assessing an andrological emergency patient
Full size table

The aim of this chapter is to review the clinical and therapeutic aspects of major andrological emergencies.

10.2 Paraphimosis

Fabrizio Palumbo, Francesco Sebastiani

10.2.1 Clinical Presentation

Paraphimosis is defined by the entrapment of the foreskin behind the corona of the glans penis, with consequent impossibility to restore its usual anatomic position by moving it distally to cover the glans [1]. It is considered a true andrological emergency because if the retracted foreskin remains trapped behind the coronal sulcus for a significant amount of time, venous and lymphatic drainage can be gradually impaired, as well as arterial blood flow—though the latter usually occurs in a matter of hours to days. The end result is glans ischemia and consequent necrosis which may also affect the distal portion of the urethra [2, 3].

Clinical presentation is typical: the patient complains of distal penile swelling with or without pain. Engorgement of the foreskin, in which a tight ring of constrictive tissue is usually detectable, is another distinctive finding. It is advisable to pay close attention to the colour of the glans penis, since pale or dark hues may be indicative of ischemia or even imminent necrosis. The diagnosis is confirmed when manual retraction of the foreskin proves to be difficult or impossible [4]. The history of the patient also aids in completing the diagnosis, since catheterization, intercourse, cleaning manoeuvres, and penile instrumentation are typically found to be triggering events, as well as the presence of genital piercings and dermatologic afflictions [5].

Paraphimosis usually affects uncircumcised males, even though it is still a possible occurrence in circumcised patients if removal of the foreskin was incomplete [6]. The most affected age groups are children (0.2%), teenagers, and the elderly (1%) [7]: this is thought to be due to the lower frequency of physiologically occurring preputial dilation in the case of lacking daily hygiene and regular sexual activity. In general, every male for whom genital hygiene presents difficulties attributable to a poor elasticity of the foreskin is at risk of developing paraphimosis [4].

10.2.2 Management

Immediate action must be taken to restore the foreskin to its normal position and prevent ischemia and necrosis of the glans penis. Various techniques have been described to minimize the oedema of the skin before attempting the reduction manoeuvre.

Simple manual compression of the oedematous foreskin while gently pulling the penile shaft upwards is the most commonly used approach. The compression can be carried out for several minutes before attempting foreskin reduction, and can be repeated. If the swelling has subsided, the thumbs can be pressed on the tip of the glans while the other fingers gently pull the foreskin upwards. Lubrication can be applied as needed [8].

Other methods are described in the literature, though often reported in small case series. Some authors obtain compression by means of applying gauze pad and an elastic bandage to the distal portion of the penis for 10 to 20 min in order to reduce the swelling before the manual reduction manoeuvre [9]. A “sleeve” obtained by cutting the thumb of a surgical glove and filled with local anaesthetic cream can be placed over the penis for about 30 min with the intent of softening the oedematous skin and providing analgesia [10].

Osmotic methods have also been described: the rationale is to create a gradient to allow fluids to leave the oedematous areas through the skin. This is achieved with the application of granulated sugar or gauze soaked in mannitol solution around the skin [11, 12].

Injection of hyaluronidase directly in the swollen foreskin has been described to disperse the trapped fluids within the constrictive foreskin, allowing easy resolution of the paraphimosis [13]. Some practitioners have also described a technique involving multiple punctures of the foreskin to decrease the oedema [14].

It should be noted that the patient may not always be compliant to reduction manoeuvres because of discomfort and pain, especially when managing a prolonged, severe paraphimosis with multiple attempts at reduction. Local anaesthesia with a standard penile block can be considered in selected cases [15].

If manual reduction attempts are unsuccessful, surgical treatment of the paraphimosis is necessary. A dorsal slit or full circumcision provides resolution of the emergency and prevention of future recurrences [16].

10.3 Penile Strangulation Injury

Fabrizio Palumbo, Francesco Sebastiani

10.3.1 Clinical Presentation

Penile strangulation occurs as a compartment syndrome in which the penile shaft is circumferentially constricted and trapped by an object, resulting in venous and arterial flow impairment and consequent vasculogenic damage to the corpora cavernosa [17]. Prolonged and unresolved strangulation may lead to oedema, ischemia, urethrocutaneous fistula, and tissue necrosis with penile amputation [18].

Penile strangulation injury is a rare clinical entity, not commonly encountered during daily practice, but it can be challenging to manage for the treating specialist. In infants, the causing object is often identified to be maternal hair. This is also known as “hair tourniquet syndrome” and usually occurs between 2 and 6 months of age. Hormonal post-partum changes in the mother are linked to increased hair loss. During hygiene manoeuvres, it is possible that this excess hair accidentally coils around the infant’s penis (or other appendages as well) without the parent noticing, especially in the presence of skin folds [19]. Hair tourniquet syndrome is rarer in children, for whom toys or other house objects are more likely to cause injury. Adolescent and adults often report penile strangulation injuries due to various kinds of rings employed for sexual gratification or even sexual abuse: wedding rings, rubber bands, metallic plumbing, bottle necks, etc [20]. Due to the social stigma, it is possible that medical attention-seeking is delayed in this age group, potentially worsening the clinical presentation.

Bhat et al. proposed a detailed classification of severity for penile strangulation injury clinical presentation and symptoms [21]:

  • Grade 1: Oedema of distal penis. No evidence of skin ulceration or urethral injury.

  • Grade 2: Injury to skin and constriction of corpus spongiosum but no evidence of urethral injury. Distal penile oedema with decreased penile sensation.

  • Grade 3: Injury to skin and urethra but no urethral fistula. Loss of distal penile sensation.

  • Grade 4: Complete division of corpus spongiosum leading to urethral fistula and constriction of corpus cavernosum with loss of distal penile sensation.

  • Grade 5: Gangrene, necrosis, or complete amputation of distal penis.

It should be noted that strangulation injury may also lead to acute retention of urine [22].

The diagnosis of this condition is of course visual, but a complete assessment of damage extent may require further investigation—such as a urethral methylene blue test or voiding urography—after immediate removal of the offending object [23].

10.3.2 Management

Every attempt to remove the constricting object must be made promptly and with an appropriate method in order to preserve the integrity of the involved anatomical structures. Since the object to be removed may be of differing size and material, and equipment available at the time of the emergency may vary, there is no standard technique for removal and every treatment choice must be made on a case-by-case basis [24].

Depending on the severity of the injury and the grade of constriction, local anaesthesia may be necessary. This can be achieved with a standard penile block. In the case of acute urinary retention, emptying the bladder may be required by transurethral (when possible) or suprapubic catheterization [25].

As a first approach, manual removal with traction can be attempted by previously lubricating the area [26]. If the object is non-metallic or somewhat thin, it can be susceptible to being severed with relatively simple tools such as a cutter. Larger and sturdier object may require cutting with instruments commonly used in orthopaedic or orthodontic surgery, and even industrial tools such as saws and drills. Special precautions must be taken in order to avoid further damage to the penis, for example, by applying bandages, laryngoscopes, or tongue depressors for protection [27].

Of course, the immediate availability of heavy-duty cutting instruments is not to be taken for granted in a general hospital setting. On the other hand, a severely swollen penile shaft may not permit sufficient access for a large tool. Several authors describe a fairly atraumatic removal method known as the “thread” or “string” technique. A silk or similarly composed thread is passed under the constricting object with one of its ends. The other end is tightly wound around the length of the penile shaft, starting from the position of the object and proceeding distally. This causes the girth of the swollen penis to gradually decrease as the coils wound. Then, the string is unwound, starting from the proximal end and so the object is made to slip off [28]. Modifications to this technique account for excessive swelling of the glans by incision or positioning of a Medicut needle in the glans to continuously draw blood and reduce engorgement during the procedure [27]. Other authors advocate for the aspiration of corporal blood from the glans or the lateral aspects of the penile shaft to manage oedema and congestion [29].

When all possible attempts at removing the object fail, surgery is the only remaining option. Degloving of the penile shaft is followed by penile reconstruction techniques ranging from skin grafting to total phallic reconstruction, depending on the extent of the injury [25].

Long-term consequences of a penile strangulation injury mostly depend on the timing of resolution. Rates of lasting sequelae range from 13% to 30% in the literature, mainly involving penile amputation and the developing of urethrocutaneous fistulae, so it is safe to say that more than two-thirds of patients usually achieve a full recovery when treated [30, 31].

10.4 Penile Blunt Trauma

Fabrizio Palumbo, Francesco Sebastiani

10.4.1 Clinical Presentation

Penile trauma deriving from an external force is a fairly uncommon occurrence: rates of incidence in emergency departments approximate one every 175,000 patients. The anatomical disposition of male genitalia makes injury relatively unlikely, but sexual activity, traffic, work, and sports accidents can nevertheless pose a risk of blunt trauma. From the diagnostic and pathophysiologic point of view, it is important to distinguish between a trauma occurring in an erect penis and one occurring in a flaccid penis, since the resulting injuries usually vary [32].

Blunt penile trauma in a flaccid penis is usually a consequence of perineal or general lower-body trauma, such as those occurring in traffic accidents. This usually results in the crushing of the cavernosal crura against the pelvic bones with consequential extratunical or cavernosal haematoma without rupturing of the tunica albuginea. Infrequently, there can be rupture of the cavernosal artery with formation of an arterial-lacunar fistula which can manifest as high-flow priapism [33]. If pelvic bone fracture is present, there is a 5–10% chance of posterior urethral lesions: in fact, the posterior urethra is linked to the pelvis bone by means of the puboprostatic ligaments as well as the perineal membrane [34].

When it comes to trauma involving an erect penis, penile fracture deriving from tunica albuginea rupturing is the most likely consequence. The tunica albuginea presents a two-part structure composed of collagen and elastin: the inner layer is circularly arranged, while the outer layer is longitudinally arranged. The tensile resistance of the tunica depends on the outer layer, which has a typically variable thickness and it is thinnest in its ventrolateral aspect, especially during erection. In this situation, the tunica albuginea thins from 2 mm to 0.5–0.25 mm [35]. Even though the tunica albuginea can support fairly high intracavernosal pressures without rupturing, the sudden increase caused by abnormal bending of the erect penis can exceed the resistance of the albuginea, causing it to tear. This is defined as a penile fracture. Urethral injury may also be present in 10–20% of cases [36]. Of note, the albuginea ruptures are usually unilateral, and when bilateral, they tend to be more frequently associated with urethral injury. The tears in the albuginea are usually transverse and located on the ventral and proximal aspect of the shaft [37].

Aside from the previously cited traffic, work, and sports accidents, the vast majority of penile traumata occurs to an erect penis in the act of sexual intercourse (80% of patients) according to a recent metanalysis [37]. This usually is attributable to a buckling injury sustained while accidentally striking the perineum or pubic bone during vigorous sexual activity or, according to some authors, because some sexual positions pose a greater risk than others (“woman on top” or “doggy-style”) [38]. Aetiology of the trauma may also vary according to geographical region of origin and ethnicity: in Africa and Middle East, nearly 50% of penile fracture events are attributable to a manoeuvre known as “Taghaandan,” which is the act of abruptly bending the erect penile shaft to facilitate immediate detumescence and is derived from local habits [39]. Other known causes are excessive force during masturbation, rolling over in bed with an erect penis, and micturition attempts with an erect penis [37]. In terms of age group, this seems to be an injury that mostly occurs in sexually active young adults and adults, with an average age of 36 years [37].

Penile blunt trauma without fracture usually presents with pain and local haematoma, with high-flow priapism possibly following [32]. Penile fracture has a more peculiar clinical presentation. It is typical that the patient recalls being engaged in sexual intercourse when suddenly hearing a “snapping” or “popping” noise, followed by sudden detumescence [40]. The patient then presents with haematoma and penile swelling, rarely penile deviation. Haematoma is the most common finding, and its distribution and extension depends on the integrity of the Buck’s fascia: in the case of breaching, it can extend beyond the penile shaft and reach the perineum (with the peculiar “butterfly” disposition) or the abdomen [41]. Urethral injury is suspected in the case of haematuria, acute urinary retention, or other voiding symptoms [42].

Diagnosis is frequently apparent just from patient history and clinical signs [43]. Ultrasound examination, although operator-dependent, is frequently used in this context to detect the presence and location of cavernosal rupturing, which usually appears as an irregular hypoechoic or hyperechoic defect in the albuginea. Colour-Doppler US may also be used as an adjunct procedure in the suspect of concomitant vascular abnormalities [32]. Magnetic Resonance Imaging (MRI) has shown a 100% sensitivity and 77.8% specificity in detecting tunical rupture, and fairly lower but acceptable results for detection of urethral injury. It could theoretically help avoid unnecessary surgery in border-line cases, but it is not a substitute of clinical assessment and may not be readily available in emergency situations so it is not considered part of routine assessment [44]. The suspected presence of urethral injury may require further diagnostic procedures such as cystourethrography or cystoscopy [45].

10.4.2 Management

Conservative management with compression bandages, cooling, anti-inflammatory, antibiotic, and analgesic therapy is usually only viable for contusions without fracture or cases with documented minimal damage to the albuginea and corpora [46]. In all other cases involving penile fracture, immediate or minimally delayed surgical exploration is considered to be the best approach to minimize long-term sequelae [47].

Since timing affects later outcomes, most surgeons perform surgery within a few hours after the trauma, especially in the presence of detectable urethral injury. However, if the latter can be excluded based on diagnostics, surgical intervention can safely be delayed to a maximum of 48 h [48].

Surgical treatment of penile fracture involves the evacuations of blood clots and the repair of the tunica albuginea defect. The usual incision is sub-coronal with consequent full degloving of the penile shaft, but since most tunical tears are located in the proximal segment of the shaft, alternative accesses such as penoscrotal have been adopted to avoid the possible complications associated with degloving (haematoma, skin necrosis, infections, and oedema). Of course, fairly accurate pre-operative detection of tunical defects is required in order to correctly plan the surgical approach [48].

The tunical tears are usually repaired with slow absorbable sutures to avoid the formation of palpable knots which usually follow the utilization of non-absorbable sutures [49]. Identification of urethral injury requires immediate intra-operative repair, preferably in two layers and using small sutures, with a Foley catheter positioned afterwards [47].

Regarding long-term consequences, conservative management of penile fracture has proven to be more associated with negative sequelae than immediate surgical repair. Corporeal fibrosis, plaque formation, and secondary penile curvature occur in roughly 50% of non-surgically treated penile fractures and require subsequent surgical correction in up to 16% of cases. Erectile dysfunction is also more frequent than with surgical treatment [50].

After repair, long-term complications are less frequent and include indurated scars at the site of repair, penile deformity, erectile dysfunction, and urethral stricture [37].

10.5 Penile Open Trauma

Fabrizio Palumbo, Francesco Sebastiani

10.5.1 Clinical Presentation

As with penile blunt trauma, occurrence of penetrating injuries to the male genitalia is fairly uncommon due to its anatomical location. Most of the reported cases of open trauma to the penis are derived from wartime reports, traffic accidents, crime, and industrial machinery. Therefore, oftentimes and depending on the cause, an open wound which involves the penis is part of a complex condition which may involve several other organs and anatomical regions [51].

Stabbing and bullet wounds to male genitalia involve the penile shaft in 80–90% of cases, followed in frequency by the scrotum and the urethra: the latter sustains injury in up to 22% of cases [52]. Aside from visually apparent damage to the shaft, it is therefore important to immediately assess eventual damage done to the urethra, which can be signalled by the presence of blood in the urethral meatus, haematuria, and voiding symptoms [53]. Diagnostic evaluation of urethral injury is strongly recommended and can be performed with urine analysis, retrograde urography, cystoscopy, or intraoperative application of methylene blue [54].

Biting injury to the male genitalia have been described, deriving both from humans and animals. This occurrence is rare even if bites in general make for about 1% of all emergency department consultations [55]. Aside from the obvious damage to the skin, soft tissues and possible urethral involvement, the main danger in biting wounds is infection, which occurs in about 10–20% of cases. Animal bites more often pose the risk of transmitting rabies, tetanus, Staphylococcus, Streptococcus, E. coli, and anaerobes infection, while human bites bear the additional risk of potential sexually transmitted diseases such as syphilis, hepatitis, HIV, and herpes [56].

Burning wounds to male external genitalia are extremely rare in isolation and, for the most part, are a component of larger body burns. About 5–13% of burn victims report burns of the penis and perineum, mainly in the context of daily life, traffic and industrial accidents by flame, scalding, and chemical burns [57]. Clinical assessment of burn depth is paramount to choosing the correct managing options, but can be challenging and may require a specialist consultation [58].

Trouser zips-related injury has been described to account for a significant portion of penile injuries, especially in the paediatric population. This is thought to be due to the location of trouser zippers, which is close to the male genitalia [59]. However, it seems to be not entirely uncommon an injury also in the male adult population: an epidemiological research carried out in the United States found that 29.8% of all penile injuries presenting in an emergency department occurred while using a trouser zip, making it the most common aetiology of adult penile injury in the emergency departments [60]. Most commonly, the penile skin is the part that becomes entrapped between the locked teeth or within the buckle of the fastener, while involvement of the scrotum is much rarer [60].

Traumatic amputation of the penis can be partial or complete, depending on the severity of the cause. Main causes are self-infliction by patients with psychiatric disorders, bizarre autoerotic acts, daily life, traffic or industrial accidents, wartime wounds, or uncontrolled surgical practices such as clandestine ritual circumcisions [61, 62]. Clinical assessment should include a close evaluation of the extent of the amputation to define which anatomical structures have been damaged, prior to attempting surgical treatment.

10.5.2 Management

Treatment of penile open trauma may be multi-faceted and complex. Aside from primary wound treatment, there are multiple other factors to be considered. Functional recovery entails the possibility for the patient to restore erection and sexual activity, fertility, and regular micturition. Cosmetic results may also be of importance. Since aetiologies and causative factors can be diverse, as well as the extent of damage sustained, no single strategy can be considered effective and treatment must be planned on a case-by-case basis [51].

Stabbing and bullet wounds require immediate surgical exploration. Objectives are wound cleaning, control of bleeding, eventual removal of foreign bodies and debridement of necrotic tissue, with scrupulous antibiotics and tetanus prophylaxis. In the case of urethral injury, urinary diversion by means of a suprapubic catheter guarantees micturition without further damage to the urethra [51]. Reconstruction of affected anatomical structures is necessary. In the case of urethral injury, repair procedures can be performed immediately in the first approach if the damage is minimal. Authors have reported approaches ranging from open surgery primary repair to endoscopic realignment over a stenting urethral catheter. In the case of extensive damage, it is preferrable to defer to a staged uretroplasty. Long-term sequelae depend on the original injury and include penile curvature, urethral stricture, and erectile dysfunction though outcomes are usually acceptable [63].

Biting wounds treatment revolves mainly around antibiotic, rabies, and tetanus prophylaxis with the surgical approach consisting primarily of wound irrigation, tissue debridement, and closure or repair of defects. Depending on the extent of damage, reconstructive techniques such as skin flaps, immediate or staged urethroplasty, or even phalloplasty may be required. Complications stem mainly from the contaminated nature of the wound and include infection and necrosis [64].

In the case of burns affecting the genitalia, treatment depends strictly on the extent of damage. In most cases, the approach is conservative, with local irrigation, topical antibiotics, and covering medication. Debridement of non-viable tissue may be performed immediately or during the process of secondary healing, if needed. Skin graft and plastic reconstructive surgery are kept as a last resort for severe conditions or to deal with late-stage disfiguring scarring [57].

Trouser zip-related entrapment of penile skin requires removal of the zip lock, which can be achieved in various ways. Lubrication and careful unzipping can be attempted. Further methods involve the incision of the fabric component of the zip lock between each tooth, the cutting of the slider buckle with a suitable severing tool, or the excision of the trapped portion of skin, which involves circumcision if the prepuce is affected [60].

Amputation management, as in other traumata of the genitalia, depends on the timing of medical attention-seeking on behalf of the patient and on the extent of the injury. In the literature, penile reimplantation has been shown to be successful if performed within a maximum of 7–15 h after the event. Other factors which can be beneficial to a penile reattachment attempt are the availability of a surgical microscope to locate and utilize viable veins, arteries and nerves, team expertise, severity of the injury, and the condition of the severed distal segment of the shaft. Even in the case of immediate apparent technical success of the operation, sequelae such as infection, loss of penile sensation, erectile dysfunction, urethral stricture, skin necrosis, and penile implant failure are well documented, although less common with microvascular repair [65].

10.6 Testicular Trauma

Fabrizio Palumbo, Francesco Sebastiani

10.6.1 Clinical Presentation

Scrotal trauma includes blunt and penetrating injuries along with burns, bites, and skin avulsions as already seen above regarding penile trauma. The anatomical location and morphology of the scrotum apparently makes it vulnerable to traumatic injury, though the incidence of scrotal trauma is actually quite low due to the presence of somewhat protective elements such as the tunica albuginea surrounding the testicles and the mobility of the scrotal sac [51]. Blunt trauma to the testicles is the most frequent and may result in testicular contusion, scrotal haematoma, testicular dislocation, haematocele, and testicular rupture. The latter two are respectively represented by the accumulation of blood in the tunica vaginalis and the disruption of the tunica albuginea [66]. Testicular dislocation or migration is quite rare, with the testis migrating along the length of the inguinal canal, towards the abdomen and suprapubic region, or in a subcutaneous aberrant position [67]. The testis has a higher risk of damage when the dynamics of the trauma force it to be pressed against hard structures such as the inferior pubic ramus or the pubic symphysis. It has been demonstrated that the structure of the testis can withstand a maximum force of 50 kg, beyond which testicular rupture ensues [68]. Of all possible kinds of testicular trauma, penetrating trauma and testicular rupture are the most severe forms which constitute true scrotal emergencies and require immediate surgical treatment, while low-grade traumas are often reported days later by patients showing signs of self-limiting traumatic epididymitis [69].

Regarding possible aetiologies, sports-associated trauma seems by far the most common occurrence at over 50% of cases, while traffic accidents (especially concerning motorbikes), falls, and violent injury make for the rest [70].

Clinical and instrumental examination should be aimed at investigating the eventual presence of major testicular injury such as rupture and penetrating wounds. Anamnestic history of recent trauma and clinical examination are the first steps to a correct diagnosis. The patient usually presents with scrotal pain and a swelling which can be tender or firm at palpatory evaluation and can be indicative of the internal accumulation of blood: transillumination is negative in the case of haematocele. Scrotal skin may show signs of aberrant discoloration referrable to haematoma. Conversely, if the affected hemiscrotum appears to be empty at palpation, a testicular dislocation may be suspected [69]. General symptoms of testicular trauma range from nausea, vomit, and giddiness to syncope or fainting.

It is important to note that no matter how accurate the physical examinations, findings may be discordant with the extent of the internal injury. Ultrasonography is the first-line imaging method to evaluate scrotal trauma, especially when adjunct colour Doppler is performed. Findings coherent with testicular rupture are heterogeneous parenchymal echostructure and irregular margins of the tunica albuginea. US colour-Doppler imaging can also contribute to the evaluation of the presence of parenchymal blood flow, scrotal wall thickening due to haematoma, and the presence of haematocele within the tunica vaginalis. Despite being operator-dependent and open to the possibility of false-negative descriptions, sensitivity, and specificity in ruling out testicular rupture has consistently been reported to be over 90% in various case series, making US the most useful diagnostic tool in scrotal trauma [71]. Magnetic Resonance Imaging has proved to be even more reliable in diagnosing testicular rupture, especially in uncertain cases, but the costs and possible lack of ready availability in the emergency settings are to be considered important drawbacks to its first-line employment [72]. When it comes to traumatic testicular dislocation, although rare, the diagnosis may be fairly challenging and require accurate US or even Computed Tomography scans to locate the testis [73].

10.6.2 Management

The objective of a correct treatment of testicular injury is the protection of testicular function and the prevention of long-term sequelae such as impaired fertility, hypogonadism, and chronic pain, which are fortunately infrequent if timely treatment is administered [74].

Minor trauma can be conservatively managed as long as the diagnostic workup has ruled out all serious conditions. A testicular contusion or scrotal haematoma limited to the skin wall can be safely managed without surgical intervention, as well as haematoma or haematocele which is less than three times larger than the contralateral testis [75]. Conservative management consists in cooling therapy, anti-inflammatory drugs, and scrotal elevation support [69]. Even so, large haematoceles initially treated with conservative intent may demand delayed surgical treatment due to the developing of infection or persistent pain: in these cases, outcomes are often poorer and the operation results more frequently in orchiectomy [76].

Major trauma, such as testicular rupture, large haematoma, and haematocele, as well as penetrating injuries, require prompt surgical intervention. Exploration allows for evacuation of blood clots, haemostasis, removal of necrotic tissue, and repair of the tunica albuginea, usually with an absorbable suture. In the case of extensive and irreparable damage, orchiectomy can be necessary [77]. Penetrating trauma requires removal of non-viable tissue and reconstruction of damaged structures. This can involve the spermatic cord with consequent vasovasostomy, the tunica albuginea, and scrotal skin with reconstruction techniques which can also be multi-staged when damage is extensive [78]. Testicular dislocation may rarely be approached under anaesthesia with US-guided reduction, but most of the times, it requires surgical intervention. It has been observed that adherence phenomena readily ensue in the victim, so careful dissection, relocation, and fixation of the testis in the scrotal sac is the correct approach [73].

Overall, timely and on-point treatment of testicular trauma yields favourable outcomes: if surgical treatment is performed within 48–72 h from the injury, up to 80% of patients manage to avoid orchiectomy [51].

10.7 Testicular Torsion

Fabrizio Palumbo, Francesco Sebastiani

10.7.1 Clinical Presentation

Testicular torsion is a true urologic emergency which demands immediate intervention from the specialist in order to prevent testicular loss. It occurs because of a twisting of the spermatic cord which causes venous congestion, impairment of arterial blood flow, and eventual ischemia of the testis [69].

There are two pathophysiologic categories of testicular torsion. Intravaginal torsion occurs because the tunica vaginalis of the testicle is not perfectly adherent to the posterolateral side of the testicle, as it physiologically should be, but it is instead attached in a higher position surrounding the epididymis and the spermatic cord. This causes the testicle to hang more freely than normal in the tunica vaginalis, which enables torsion. This anatomical situation is known as the clapper-bell deformity [79]. Extravaginal torsion is more typical of the perinatal stages of life, when the tunica vaginalis has not yet adhered to the gubernaculum testis, enabling the whole testicle along with the spermatic cord and the tunica vaginalis to become twisted [80].

The twisting of the spermatic cord leads to impairment of venous outflow and arterial inflow, which consequently causes ischemia. If the torsion is complete, the viability of the testis deteriorates rapidly; therefore, it has been documented that salvage is frequently possible if detorsion is performed in less than 8 h, but it is rare after 24 h from the event [81]. Ischemia onset is reported to be generally happening at 4–8 h after torsion [82].

Testicular torsion is not a rare occurrence: about 0.5% of emergency department visits involve some kind of scrotal complaint, of which roughly a quarter end up being attributable to this condition [83]. It can happen at any age, but the most common age groups are infants in the perinatal stage and adolescents aged between 12 and 18 years [84]. A familial link and predisposition have been recently suggested among risk factors [85]. Other predisposing factors cited in the literature are hyperactive cremasteric reflex in cold weather [86], as well as the presence of the clapper-bell deformity described above [79]. The onset may be spontaneous, consequent to physical activity, or associated with trauma to the scrotum [80].

Patient history and examination are important in guiding the diagnosis, which is sometimes challenging due to multiple possible differential diagnoses. Testicular torsion may be suspected especially in the presence of susceptible age and abrupt appearance of single-sided testicular pain with less than 24-h duration—even if pain lasting more than 24 h does not put testicular torsion out of question. The patient may present with nausea, vomiting, scrotal enlargement, testicular pain on palpation, redness and retraction of scrotal skin, proximal dislocation of the testicle with or without aberrant positioning. Alterations of cremasteric reflex and the Prehn’s sign—with a lack of pain relief when elevating the testicle—may be present but are not to be considered fully reliable [87].

Certain clinical presentations may be challenging because of vagueness of the symptoms or overlap with other differential diagnoses. The pain may not always be referred to the affected testicle, but rather to the inguinal or lower abdominal area. The pain can also be intermittent, or rather the symptoms can be mimicked by a number of other conditions. Such is the case with torsion of cryptorchid testicles, torsion of testicular appendages, epididymo-orchitis, hernia, neoplasms, and many others [88].

In the face of these challenges, various clinical decision tools and nomograms have been designed to aid the clinician. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) [89] defines five criteria to grade a suspect of testicular torsion. Each criterion gets a score:

  • Testicular swelling: 2 points.

  • Hard testicle: 2 points.

  • Absence of cremasteric reflex: 1 point.

  • Nausea or vomiting: 1 point.

  • High-riding testicle: 1 point.

A total score of 0–2 is considered low risk with 100% negative predictive value for torsion. No further diagnostics is needed. A score of 3–4 is considered intermediate and requires Ultrasonography for further investigation. A score of 5 or more is considered high risk with 100% positive predictive value for torsion: immediate surgical exploration is suggested.

The diagnostic workup of suspect testicular torsion can strongly benefit from Ultrasonography with colour Doppler evaluation. Although operator-dependent, the ready availability, low costs, and lack of ionizing radiation far outweigh its drawbacks. Standard US can help in diagnosis by visualizing pathognomonic findings such as the scrotal whirlpool sign of the spermatic cord or the redundant spermatic cord sign. The testicle may also be found in an abnormal horizontal lie [90]. On the other hand, colour Doppler evaluation helps in establishing the presence of macrovascular blood flow: in complete testicular torsion, vascularization is typically absent [91]. However, when testicular torsion is incomplete or the patient is young with small volume testicles, false negatives can occur [92]. High-resolution colour Doppler US should be used if available, and some authors advocate for advanced US techniques such as Contrast-Enhanced US which, however, may not always be readily available [93].

Other imaging techniques with high detection rates of testicular torsion are Computed Tomography, Magnetic Resonance Imaging, and Nuclear Imaging, but all are severely limited by availability in the emergency setting, costs, and exposure to ionizing radiation. They can be useful in dubious situations, but delay surgical exploration which, in and of itself, is the gold standard in the diagnosis of testicular torsion and also allows treatment [94].

10.7.2 Management

As stated before, testicular salvage in the case of torsion is strictly time-dependent. In particular, salvage rate approximate 100% if detorsion is achieved within 4 h of the event, and decreases to 90% if delayed by 4–8 h [95].

Manual detorsion can be attempted; however, it should not be intended as a means to avoid surgical exploration rather than a way to limit the consequences of prolonged ischemia while preparations for intervention are underway. For the left testicle, manual rotation should be performed in a clockwise fashion from the point of view of the practitioner; while for the right testicle, it should be performed counterclockwise. The manoeuvre can be repeated to account for the usual range of testicular torsion which may vary from 180 to 1080 degrees. Generally speaking, resolution of pain and restoration of blood flow on US are to be considered indicative of a successfully performed manoeuvre, which are nevertheless to be followed by surgical exploration and testicular fixation since residual torsion may still be present. Manual detorsion can be difficult or impossible to carry out in the presence of encumbering scrotal wall thickening, hydrocele, or intense local inflammation [96].

Surgical exploration under anaesthesia is the gold standard to confirm or rule out a diagnosis of testicular torsion and constitutes the treatment of choice. The incision is usually transverse hemiscrotal or performed in the midline. After gaining access to the scrotal sac, the number of cord rotation can be identified and detorsion can be carried out. Testicular viability is then intraoperatively assessed: depending on the age of the patient and duration of ischemia, clinical signs of re-establishment of blood flow can appear in the form of improvement in colour. Furthermore, intraoperative Colour Doppler US or fluorescent dye may be of help in making the decision. Fixation of a salvaged testis is mandatory, as is fixation of the contralateral testis to prevent recurrence of torsion and metachronous torsion on the other side. On the other hand, it is important to perform orchiectomy in the case of a non-salvageable testis to prevent the formation of anti-sperm antibodies that could potentially hamper functionality of the contralateral testis [97].

The main long-term concerns in patients who suffered from testicular torsion are subfertility and infertility. Unilateral torsion has been shown to importantly affect spermiogenesis in 50% of cases and to produce borderline impairment in 20% [98]. Though research in the field has not yet fully clarified, if there are precise correlations, it has been noted that high levels of anti-sperm antibodies are usually found in testicular torsion patients, regardless of whether an orchiectomy or orchidopexy with testicular salvage have been performed. Sperm motility has been shown to be usually higher after orchiectomy than after orchidopexy. The hypothesis is that maintenance of a compromised, ischemic testis may impair testicular function [99]. Other sequelae include infection and delayed atrophy of the salvaged testis. Case series have been reported in which the rate of atrophy in the salvaged testis can reach 41%, so the topic of prolonged follow-up, its relevancy and significance after testicular torsion is a matter of debate [100]. Cosmetic concerns regarding an empty hemiscrotum after orchiectomy are sometimes expressed by the patient; however, it should be noted that the actual acceptance rate of testicular prosthesis placement is relatively low and amounts to about one-third of the patients who are offered this possibility by the surgeon. It has to be said that modern testicular prostheses exhibit low complication rates and high patient satisfaction [101].

10.8 Penile Abscess

Fabrizio Palumbo, Francesco Sebastiani

10.8.1 Clinical Presentation

Corpus cavernosum abscess is a very rare, urgent condition which poses the risk of sepsis, loss of function of the penis and eventual penectomy if left untreated [102]. The most frequently detected causative agents are Neisseria gonorrhoeae, coagulase-negative Staphylococcus aureus, Trichomonas vaginalis, along with polymicrobial infection occurrences [103].

The literature on the subject is mainly derived from case reports and very small case series. Triggering events reported as-of yet include penile trauma, cavernosography, intracavernosal injections, Winter procedures for priapism and undetermined causes [103,104,105,106,107,107].

The entity and severity of presentation presents wide variation. Local symptoms include penile swelling and discoloration, abnormal consistency of the corpora, pain, voiding symptoms, cutaneous or urethral discharge in the case of rupturing or fistula. Systemic signs include fever, elevated white cells count and sepsis, although they are not always present [102].

Though there is no standardized approach to instrumental diagnosis, imaging techniques may be required to fully assess the extent of tissue damage before planning a treatment strategy. Standard US may show subcutaneous tissue swelling, inhomogeneous hypoechoic areas in the corpora cavernosa, and interruptions in the tunica albuginea. Contrast-enhanced US, when available, may document avascular areas wrapped in hyperperfused rims and may help define a suspicion of fistula [108]. CT scan may be required for a correct staging of abscess extent and for assessing the eventual involvement of other organs [109].

10.8.2 Management

Treatment should be early and aggressive in order to avoid potential sepsis and loss of the organ. Antibiotic prophylaxis is of course necessary and should take account of culture-isolated pathogens when possible [103].

Although puncture drainages of the corpora are often described as an early approach with the aim of pus excretion and microbiological sample collection, they have rarely shown to be a definitive and effective treatment. Most of the cases reported in the literature ultimately required some kind of surgical exploration of the corpora cavernosa with cavernotomy and debridement of non-viable tissue. This has a high chance of resulting in fibrosis and erectile dysfunction, although these sequelae can be treated with penile vacuum pump therapy and eventual penile prosthesis implantation provided the infection is fully resolved [102].

Penectomy is considered the last-resort treatment when conservative approaches fail due to untimely management or uncontrollable infection [104].

10.9 Fournier’s Gangrene

Fabrizio Palumbo, Francesco Sebastiani

10.9.1 Clinical Presentation

First described by French physician Jean Alfred Fournier in 1883, Fournier’s gangrene is a form of necrotizing fasciitis of the genital and perineal region with concomitant thrombosis of local arteries. It results in gangrene of the skin and subcutaneous tissue, sepsis, and multiple organ failure [110]. Its prognosis is poor and time-dependent as untimely treatment can be fatal in over 90% of cases [111].

Fournier’s gangrene is rare: 1.6 cases per 100,000 men per year are reported in the literature. Men are notably far more at risk than women, and the average reported age is 50.9 years [112]. Most cases arise from localized infectious processes of the genitals, perineal, or anorectal area—which on their part can derive from poor hygiene, trauma, iatrogenic instrumentation or surgery, intestinal afflictions, etc.—in the presence of predisposing conditions. The latter are thought to include immunodepression, alcoholism, obesity, and cancer [113].

The pathogenetic origin of Fournier’s gangrene is due to the necrosis of fascial structures prompted by bacteriemia. Infections lead to a cytokine-induced process of endothelial damage and abnormal activation of the coagulation cascade leading to thrombosis of the vessels which provide vascularization to the fascia. Concomitant endothelium extravasation, swelling, and white blood cells recruitment contribute to furthering the ischemia and necrosis process [113].

Patient history can help in suspecting this diagnosis when predisposing factors are noted. It is not unusual that medical attention-seeking on behalf of the patient is not immediate, especially if the patient presents concomitant situations that prevent him from noticing early symptoms, e.g., morbid obesity, poor hygiene, impairments in self-care ability, and low socio-economic status. When observed, local signs and symptoms range from discoloration and ulceration of genital and perianal skin to full-on tissue necrosis with palpable crepitus, purulent discharge, and swelling, usually appearing and worsening during the course of 3–5 days. There can be voiding symptoms and micturition impairment. General signs and symptoms correlate with the degree of sepsis: fever, white blood cells alterations such as leucocytosis or leukopenia, alterations in platelet count, elevated C-reactive protein, dysproteinaemia, alterations in indexes of renal or hepatic function indicative of multi-organ failure [114].

Beside clinical assessment, it is important to obtain imaging documentation in order to correctly define the extent of the infection, its source and possible spreading pathways [115]. US easily detects the presence of fluid and gas in subcutaneous tissues and may be useful for better orienting the clinical diagnosis; however, its major drawback is the impossibility to precisely stage the extent of the disease. In fact—aside for evaluation of the scrotum—deep assessment of the perineum or the ischioanal fossa is often impractical or impossible to perform with an US probe, depending on the anatomy of the patient and the severity of the condition. CT scan is the imaging modality of choice in Fournier’s gangrene, especially when contrast-enhanced, because of its complete assessment of the abdominal and pelvic area in which it detects affected areas showing gas and fluid collection. Precise research of possible sources of infection in the abdomen increases the chance of planning optimal surgical treatment [116]. Technically speaking, MRI should yield a superior degree of precision in the assessment of soft tissues, but its reports in the literature are limited by the lower availability in emergency clinical settings [117].

10.9.2 Management

Fournier’s gangrene requires immediate emergency treatment upon presentation and detection in order to avoid a fatal outcome. Broad-spectrum antibiotics accounting for Gram-positive, Gram-negative, and anaerobic bacteria are suggested as a means to reduce systemic toxicity and limit the circulation of the causative microorganism. In the case of subsequent successful microbic isolation via cultures, the choice of drugs can be adjusted accordingly. Patient resuscitation may be in order in the case of severe sepsis [118].

Surgical debridement with removal of necrotic and infected tissue is the crucial step to halt progression of the disease. Even a few hours delay has been shown to significantly increase the risk of death [119]. Extensive removal of all non-viable tissue, including a slim window of healthy adjacent tissue, is recommended. It is important to note that patients require daily wound care and possibly repeated surgical operations during the course of the hospital stay in order to fully excise all affected tissue. An average of 3.5 surgical operations per patient has been reported in the literature [120]. Depending on the extent of tissue necrosis, it could be necessary to consider a faecal and/or urinary diversion, respectively, via colostomy and cystostomy [121].

In regards to reconstructive procedures after successful and complete removal of necrotic tissues, various options are described. Vacuum-assisted closure (VAC) is a method which exposes the open wound to negative pressure, with the intent to reducing oedema and promoting blood flow to enhance second-intention healing. When available and suitable to the extent and location of tissue defects, it has proved advantageous over conventional wound management [122]. In the case of larger defects, various plastic reconstruction techniques such as scrotal advancement flaps, split thickness skin grafts, fascio-cutaneous, and myo-cutaneous flaps have been considered. They are reported to have satisfactory results, but as complex surgical procedures, there exists the possibility of further complications [117].

10.10 Penile Prosthesis Complications

Nicola Mondaini, Luca Crocerossa

10.10.1 Clinical Presentation

Penile prosthesis implantation is the gold standard in treatment of ED when medical therapy either fails or is contraindicated or unwanted by the patient. Despite improvements in surgical technique and implanted materials, IPP surgery retains a substantial complication rate. Complications of IPP implantation, while infrequent, can become serious and may be accompanied by severe morbidity and decreased satisfaction. These complications can be intraoperative or postoperative. Intraoperative complications include perforation of the tunica albuginea during dilatation of the corpora or perforation of the septum, with or without urethral injury [123]. The most frequent and severe postoperative complication is infection. Other major postoperative complications include mechanical failure: erosion and protrusion of cylinders; “S-shaped” deformity of the penis; and glans deflection; reservoir dislocation or acute abdomen due to bowel injury. The scrotum is the most common location for haematoma formation and this is due to an absence of compressive forces to abate any local bleeding. Haematomas can present in the immediate postoperative period or in a delayed fashion [124].

The recognition of urethral perforation can be difficult, so it is recommended that clinicians take extra caution to look for potential signs such as urethral bleeding, a visible dilator on the urethral meatus or prosthesis cylinder, or leakage of irrigation solution out of the urethra after instilling the corpora through the corporotomy [125, 126].

Penile prosthesis infections can be divided into clinically apparent and subclinical penile prosthesis infections. Clinically apparent penile prostheses can be diagnosed from symptoms such as new onset of penile pain, erythema, and induration overlying a prosthesis part, fever, drainage, and ultimately device extrusion. While most of these infections occur in the early perioperative period, late device infections have been documented. Subclinical prosthetic infections occur more frequently. These infections, which most often manifest by chronic prosthesis-associated pain, are difficult to diagnose and even more challenging to treat [127]. The complications of surgery can have economic ramifications (hospital admissions and revision surgery) and also negatively impact patient satisfaction and quality of life as there is a risk of penile length loss [124].

Cylinder erosion typically presents with the prosthesis protruding through the glans, urethral meatus, or distal penile shaft. Urethral erosion is characterized by dysuria, urethral discharge, early prosthetic infection, and glans necrosis [125].

10.10.2 Management

Almost all of these, postoperative complications require surgical repair. In case of urethral injury, depending on the size and location of perforation, the surgeon must determine whether continuation or cessation of the operation is appropriate. If there is a proximal perforation, immediate urethral repair accompanied by primary implantation and urinary diversion with a suprapubic catheter is suggested and abandoning the procedure should be considered if the injury is closer to the urethral meatus. However, when a urethral injury occurs and one or both corpora are dilated, abandoning the procedure may end in irreversible corporal fibrosis and penile shortening. Consequently, some clinicians have advocated for the insertion of a temporary malleable prosthesis after salvage washout and later a definitive inflatable prosthesis [125, 126].

Infection requires removal of the prosthesis and antibiotic administration. Alternatively, removal of the infected device with immediate replacement with a new prosthesis has been described using a washout protocol with successful salvages achieved in >80% of cases [128]. In case of reservoir dislocation, surgical reposition is mandatory. In case of acute abdomen due to bowel injury, removal of the reservoir and colostomy are necessary. The management of haematomas is usually conservative, and scrotal exploration is seldom required.

10.11 Priapism

Nicola Mondaini, Luca Crocerossa

10.11.1 Clinical Presentation

Priapism is defined as a penile erection lasting longer than 4 h in absence of sexual stimulation [129]. Incidence of priapism ranges between 0.3 and 5.4 per 1,00,000 males per year. Based on patient history and pathophysiology, two variants of priapism can be defined: ischaemic or low-flow priapism (IP) and non-ischaemic or high-flow priapism (NIP). IP is the most common type of priapism, accounting for 95% of cases; it is characterized by a minimal or no arterial inflow associated to complete occlusion of venous outflow of the corpora cavernosa; the resulting state of acidosis, glucose deficiency and hypoxia induces oedema, inflammation, and progressive necrotic degeneration of smooth muscle cells. Stuttering or intermittent priapism is a subtype of IP characterized by an history of recurrent self-resolving painful erections lasting less than 4 h and usually occurring in patients with sickle cell disease (SCD) or other hematologic diseases. The most frequent causes of IP are the recreational use of erectile agents (intracavernous injection of alprostadil, papaverine, phentolamine or, rarely, oral PDE-5 inhibitors) and the use of antipsychotics or trazodone. Hereditary hematologic pathologies or blood cancers can cause IP by altering blood viscosity. Rarer aetiologies include amyloidosis, pelvic tumours, spinal cord, or peripheral nerve injuries. NIP is caused by the disruption of cavernous tissues almost invariably due to pelvic or genital trauma (straddle injury) resulting in an arteriolar-sinusoidal fistula leading to excessive corpora blood flow.

Clinical presentation of IP is characterized by a fully rigid erection often associated to penile pain. Glans and corpus spongiosum of the urethra are often flaccid. Contrarywise, NIP typically manifests as a painless, incomplete erection that occurs after days to weeks from a pelvic trauma. A natural erection during sexual stimulation or for nocturnal penile tumescence can be the trigger for both.

10.11.2 Management

The goal of emergency management of priapism is the resolution of the acute episode in order to preserve the long-term erectile function. Management should include at least patient’s medical history, physical examination, corporal aspiration, and penile blood gas analysis [123]. History should focus on the onset and duration of the erection, presence of concomitant diseases and medications, use of recreational drugs, history of traumas and previous episodes of priapism. Physical examination must also include the evaluation of the abdomen and perineum.

Penile blood aspiration is performed by inserting a large bore (19-gauge or higher) butterfly needle in one or both of corpora cavernosa; regional anaesthesia before the procedure is achieved by infiltration at 2 and 10 o’clock at the base of the penis shaft which ensures sufficient block of the dorsal penile nerves to relieve pain and increase patient compliance. One drain puncture is enough for detumescence since corpora usually communicate through an incomplete midline septum; needle can be inserted either into corpora tip, through the glans, or into the middle of the shaft; in this case, 3 or 9 o’clock positions are preferred to not damage the urethra and the dorsal neurovascular bundle.

Initial aspirated blood will help differentiation between priapism types, being dark red in IP and bright red in NIP. Blood gas analysis is necessary for confirmation: in IP, blood gas values are typical of hypoxemic acidotic blood, with a PO2 lower than 30 mmHg, a PCO2 higher than 60 mmHg and a pH lower than 7.25. in NIP, blood gas analysis reveals systemic oxygenated blood, having a PO2 higher than 90 mmHg, a PCO2 lower than 40 mmHg and a pH around 7.4. Colour duplex Doppler ultrasonography of the penis can be used in conjunction with or as an alternative to penile blood gas analysis to differentiate between IP and NIP.

NIP must be promptly recognized and distinguished from IP owing its relative low risk in developing ED and the tendency to spontaneous resolution; moreover, NIP cannot be managed with any of the therapies for IP; NIP should be treated conservatively with ice and pelvic compression and/or angioembolization of the arterial-sinusoidal fistula after 1–2 months after onset. NIP is therefore not a medical emergency and will not be discussed further.

The treatment of stuttering priapism coincides with that of IP which is described below; however, a supportive therapy for the underlying haematological condition should be added, including hydration, oxygen administration, and blood transfusions as well as a long-term therapy for the prevention of future episodes.

In IP, corporal aspiration should be continued until arterial blood is seen through the syringe and complete detumescence is reached; restoration of oxygenated blood is required for preventing smooth muscle necrosis, fibrotic degeneration, and long-term ED. Cold saline irrigation with 0.9 NaCl is often associated to aspiration to promote evacuation of blood clots. Aspiration is resolutive in 30% of IP cases [130]. In case of failure, injection of sympathomimetic agents should be initiated. Phenylephrine is the most commonly used agent, given its high selectivity of α1-adrenoreceptors with low systemic cardiovascular effects. A dose of 100 to 200 μg of phenylephrine must be injected at intervals of 3–5 min until detumescence. A cumulative dose of 1000 μg is considered the maximum to avoid significant adverse events (hypertension or bradycardia) in adults [131]. Pulse and blood pressure sequential monitoring is required during administration and for at least 1 h afterwards. The efficacy of aspiration/irrigation and sympathomimetic injection is reported to be around 80% [132].

In case of failure of the above measures, surgical management of IP should be considered. Surgical procedures for IP are divided in shunting procedures and penile prothesis implantation (PPI). Shunting is the first-line treatment after aspiration/injection and are distinguished in proximal and distal shunting; goal of both is the drainage on hypoxic blood and restoration of venous outflow of the corpora cavernosa by the creation of an iatrogenic fistula with other structures.

Proximal shunts restore the venous outflow by creating communication between the corpus cavernosum and corpus spongiosum at the base of the penis or between the corpus cavernosum and the saphenous vein; proximal shunts have now fallen into disuse due to the risk of serious complications such as urethral damage, local thrombosis, and pulmonary embolism.

Distal shunting aims to create a fistula between the tip of corpora and the glans. Several percutaneous procedures have been described; however, there is insufficient evidence to draw definitive conclusions on which to choose for efficacy, safety, and prevention of relapse or long-term ED. The three most common techniques obtain this result by inserting a biopsy needle (Winter’s technique) or a No. 11 blade scalpel (Ebbehoj’s technique) or by inserting and rotating a No. 10 blade scalpel (T-shunt) through the glans into the corpora cavernosa. These procedures are usually performed unilaterally, but they can be repeated on the contralateral side if erection is not resolved. Corporoglanular dilation by an Hegar dilator can be added to increase the blood flow through the shunt (tunnelling).

Shunt procedures must be reserved to patients with IP lasting less than 24 h. Within this time limit, the changes in smooth muscle are still reversible and men who have achieved detumescence recover their potency in nearly all cases [133]. On the other side, patients with IP lasting longer than 48 h are bound to develop ED and must be treated with PPI. PPI is usually performed between 2 and 3 weeks after IP onset. This time window seems to balance the risks associated to an early implantation (including high rates of infections and penile prosthetic erosions, especially in patients treated with distal shunting) and the risks associated with a delayed PPI (including a high complication rate and poor patient satisfaction due to foreshortening and narrowing of the corpora cavernosa caused by penile fibrosis) [134]. In patients with IP lasting longer than 24 h but less than 48 h, the decision on the type of procedure to perform can be guided by a contrast-enhanced penile MRI, that has been shown to have an extremely high sensitivity in detecting necrosis/fibrosis of the smooth muscle.