Reconstructing manhood: a unique case report of a penile gunshot wound and its surgical management

Abstract

Introduction:

Penile injuries are a common finding in many traumatic presentations, but a penetrating gunshot wound (GSW) to the male external genitalia is a rare finding in the US. Traumatic penile injuries commonly present with pain, erythema, blood at the urethral meatus, and difficulty voiding. A proper diagnostic workup still makes it difficult to locate the site of injury. Appropriate and time-efficient management of penile injuries is important to minimize future complications such as erectile dysfunction, abnormal curvature, and difficulty voiding.

Presentation of Case:

In this case report, we present a rare, traumatic GSW to the penis in a 25-year-old male patient without significant medical history, along with the relevant diagnostic and operative management. CT angiography, Doppler ultrasound, and cystoscopy all played a crucial role in accurate diagnosis. This case represents the complex management of a patient with penetrating injuries to the penis, including penile exploration and repair of the corpora cavernosa.

Clinical Discussion:

GSWs to the penis are a rare but devastating traumatic injury. Accurate identification and assessment of injury extent are critical to preventing long-term genitourinary complications. The anatomical structures involved, including the urethra and corpora cavernosa, make these injuries particularly challenging to manage due to the potential for complications like infection, erectile dysfunction, and urethral strictures.

Conclusion:

Penile GSWs present a unique challenge due to the functional and anatomical complexity of the organ. A multidisciplinary approach and individualized management plans are key in managing such injuries.

Introduction

Penile gunshot wounds (GSWs) are rare, comprising 1.7%–10% of all GSWs^[1^]. Even small penetrating GSWs to the penis can cause devastating injuries to the structures of the penis and scrotum, along with other internal structures^[2^]. Penile injuries risk erectile and voiding dysfunction due to urethral or cavernosal damage^[2,3^]. In the management of patients with GSWs to the penis, it’s crucial to accurately identify the location and extent of the injuries to determine the appropriate treatment aimed at preserving genital form and function^[4^]. In this case report, we present a rare case of a penile GSW with injury to the corpora cavernosa in a young male patient. This case report has been reported in line with the SCARE checklist^[5^].

HIGHLIGHTS

• Rare presentation: Penile gunshot wounds comprise a small fraction of urogenital trauma but carry a high risk of erectile and voiding dysfunction.

• Diagnostic accuracy: CT angiography, Doppler ultrasound, and intraoperative cystoscopy allowed precise injury characterization and exclusion of urethral damage.

• Novel technique: An angiocatheter with saline injection was used intraoperatively to localize a corpora cavernosa laceration, a rarely reported approach.

• Effective management: Prompt penile exploration, degloving, and primary repair of the corpora cavernosa resulted in successful recovery without postoperative complications.

• Clinical significance: This case highlights the value of multimodal imaging, intraoperative adjuncts, and early repair in preserving penile function.

Case report

A 25-year-old male with no significant medical history presented after sustaining multiple GSWs, including to the left back, penis, groin, and right buttock. He complained of pain in the right lower extremity (RLE) and penis, along with numbness and difficulty moving the right leg due to pain. Physical exam revealed an uncircumcised penis with an entry and exit wound involving the scrotum and extending into the thigh, with active bleeding.

CT angiography (CTA) showed probable disruption of the corpora cavernosa and urethra. Scrotal Doppler ultrasound confirmed the injury was limited to the penis. A retrograde urethrogram was performed at bedside that showed no signs of extravasation or involvement of the anterior urethra. However, it is notable to mention that the contrast did not reach all the way to the bladder. Urology was consulted, and the patient underwent penile exploration, cystoscopy, repair of the corpora cavernosa, and circumcision approximately 9 hours post-admission. Early exploration of the penile injury was not feasible due to the extended time required to stabilize the patient from multiple GSWs.

Intraoperative findings included a bullet tract extending from the left to the right side of the penis (Fig. 1). Cystoscopy revealed no urethral injuries, and a Foley catheter was placed. Circumcision and degloving of the penis to the base revealed dorsal and lateral hematomas. An angiocatheter was placed, and saline injection initially showed fluid leakage from the lateral side of the right corpora, indicating a distal injury. A 2–2.5 cm laceration in the right corpora cavernosa was identified using an angiocatheter and closed with 2-0 Vicryl sutures (Figs 2 and 3). No leakage was observed after saline-induced erection. The fasciae and scrotal laceration were also closed. The patient recovered well postoperatively, voided successfully, and was discharged in stable condition.

Figure 1.

Entry and exit wound from the left to right side of penis.

Figure 2.

Laceration in the right corpora cavernosa.

Figure 3.

Suture repair of laceration in right copora cavernosa.

Discussion

GSWs to the penis are a rare but devastating traumatic injury^[3^]. Accurate identification and assessment of injury extent are critical to preventing long-term genitourinary complications^[2^]. The anatomical structures involved, including the urethra and corpora cavernosa, make these injuries particularly challenging to manage due to the potential for complications like infection, erectile dysfunction, and urethral strictures^[3^]. This case represents complex management of a patient with multiple GSW, including penetrating injury to the penis, along with the use of advanced imaging, such as CTA and Doppler. This highlights the challenges to accurately assess the extent of penile injury, especially urethral damage, by using intraoperative cystoscopy to evaluate urethral involvement^[6^]. Notably, an angiocatheter was used to identify defects in the corpora, a technique rarely reported in similar cases. The patient’s stable postoperative course underscores the importance of a multidisciplinary approach in managing severe genitourinary trauma.

Flexible cystoscopy allowed rapid assessment of the urethra and facilitated Foley catheter placement, minimizing the risk of urethral trauma or infection. This case illustrates the benefit of combining cystoscopy with surgical exploration, especially when urethral injury is suspected.

Urethral injuries occur in 11%–29% of penetrating penile injuries^[6^]. AUA guidelines recommend retrograde urethrogram or cystoscopy for suspected urethral damage^[7^]. Retrograde urethrogram remains the gold standard, with 92% sensitivity and 100% specificity, though flexible cystoscopy is a practical alternative in certain operative settings^[8^].

Ultrasound is a valuable, noninvasive tool for assessing penile trauma^[9^]. However, its accuracy is highly operator dependent and often hindered by hematomas or edema, limiting its utility in deep or complex injuries^[10^]. Despite its limits, ultrasound effectively detects testicular injuries and should be used to exclude scrotal involvement, as in our case.

MRI offers better tissue resolution but is costly, slow, and often unavailable in emergencies. For this reason, immediate surgical exploration remains the standard in high-risk penetrating penile injuries^[11^].

There is no universal guideline for managing penile GSWs, though early surgical repair is increasingly favored over conservative management due to a lower complication rate^[12,13^]. Conservative management carries risks such as erectile dysfunction, pain, priapism, and penile curvature, with complication rates ranging from 25% to 53%^[12,13^]. Early intervention was found to reduce the length of hospital stay (3.8 vs 14 days on average)^[13^].

Nevertheless, certain patients – especially those who are unstable or require other urgent interventions – may benefit from urinary diversion and delayed repair. This allows for tissue demarcation and may lead to better outcomes in select cases^[2^]. Contused tissue, particularly the corpus spongiosum, may recover over time due to robust vascularity.

In cases involving tunica albuginea tears and cavernosal injuries, immediate exploration and primary repair using absorbable sutures is the preferred approach and preserves erectile function^[13^]. Degloving via sub-coronal incision allows optimal exposure but carries risks such as infection and skin necrosis^[14^]. Foreign bodies should be removed under fluoroscopic guidance^[15^]. In military settings, staged repairs and negative pressure wound therapy followed by grafting have been used for severe injuries^[16^].

Glanular injuries, though uncommon, may require reshaping or grafting depending on injury extent. Split-thickness skin or buccal mucosa grafts can be employed for significant tissue loss^[16^].

In our case, the use of an intraoperative angiocatheter helped localize the corpora cavernosa laceration – a rarely described technique. Combined with flexible cystoscopy, degloving, and direct repair, this led to a successful resolution of the injury without complications. The patient was discharged on postoperative day four, consistent with the literature on median hospital stay following surgical repair. Unfortunately, long-term follow-up was not possible due to loss to follow-up.

This case is noteworthy because it was managed in a non-war-zone civilian trauma center, yet it demonstrates a streamlined, resource-efficient operative strategy – specifically the angiocatheter-guided artificial erection method – to localize and repair a cavernosal injury. This technique has the potential to be readily transferred to austere or war-zone settings, where rapid bedside localization and definitive repair may be critical and complex imaging modalities as well as resources may be limited.

Limitations

The patient was discharged in stable condition and reported normal voiding prior to discharge; however, no subsequent follow-up was available. Complications following a degloving incision of the corporal body for penile GSW repair include infection, wound dehiscence, skin necrosis, urethral stricture or fistula, erectile dysfunction, and penile curvature. The expected time frame for initial wound healing is typically 2–4 weeks, with long-term complications (such as urethral stricture or erectile dysfunction) potentially manifesting over months to years^[17,18^]. Although we cannot comment on this patient’s long term functional outcome due to loss to follow-up, this is not uncommon in trauma cohorts, with reported attrition rates of upward of 50%^[19,20^]. The patient demonstrated normal voiding and satisfactory wound healing during hospitalization, indicating a favorable early postoperative course; nonetheless, we acknowledge this as a limitation and emphasize the importance of structured long-term follow-up with objective assessment of erectile function, voiding parameters, and cosmetic outcomes in future cases.

Conclusion

Penile GSWs present a unique challenge due to the functional and anatomical complexity of the organ. Prompt imaging, endoscopic evaluation, and surgical intervention are essential to optimize outcomes. A multidisciplinary approach and individualized management plans are key in managing such injuries. While our patient had a favorable short-term outcome, standardized protocols and further case documentation are necessary to improve long-term care and functional recovery in similar cases.

Ethical approval

This study was exempt from ethical approval.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

No sponsor to declare.

Author contributions

M.W.A.H.: Writing the paper and Revision. N.R.: Writing the paper, Revision, and Submission. P.S.: Study concept, Writing case, and Revision. L.B.: Editing paper. B.R.: Trauma surgeon. D.E.R.: Senior author; Surgeon of the case.

Conflicts of interest disclosure

No conflict of interest.

Research registration unique identifying number (UIN)

Not applicable.

Guarantor

Jideofor Aniukwu.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.