Andrological emergencies are often a poorly taught aspect of urology. This article outlines the key emergencies and provides a simple approach to their immediate management.
Contents
Anatomy of the penis
Overview
The penis is both a reproductive and urinary organ, located anterior to the perineum, inferior to the pubic symphysis, and above the scrotum.
Structural components
- Corpora cavernosa (x2.
- Corpus spongiosum (x1).
Arterial inflow
Branches of the internal pudendal artery (from the internal iliac artery):
- Cavernosal arteries > supply corpora cavernosa, responsible for erection.
- Bulbourethral artery > supplies corpus spongiosum.
- Dorsal penile artery > supplies glans and penile skin.
Venous outflow
Subtunical venules drain blood from the corpora into the deep dorsal vein.
Innervation
- Parasympathetic (S2–S4, pelvic splanchnic nerves) – responsible for erection.
- Sympathetic (T11–L2, hypogastric nerves) – Responsible for ejaculation.
- Somatic (pudendal nerve) – Provides sensation to the penis (dorsal nerve of penis). [1]
Anatomy of the penis. Image from: https://www.magonlinelibrary.com/doi/full/10.12968/bjon.2020.29.9.S6
Phimosis and Paraphimosis
Definitions
- Phimosis: non-retractile (‘tight) foreskin; physiological (<5y) or pathological.
- Paraphimosis: retracted foreskin trapped behind glans > urological emergency.
Presentation
- Phimosis: asymptomatic or ballooning on micturition, weak stream, painful erections, recurrent balanitis.
- Paraphimosis: acute pain, swelling, constricting ring, proximal oedema.
Management
- Phimosis: observation (children), topical steroids + stretching, surgery (preputioplasty, frenuloplasty or circumcision for definitive management).
- Paraphimosis: analgesia, reduce oedema (cold/compression/osmotic agents), manual reduction ± local anaesthetic. If unsuccessful, then dorsal slit. Definitive = circumcision. [2]
Priapism
Definition
Prolonged, unwanted erection, in the absence of sexual desire or stimulus, lasting >4h.
Greek God of fertility – Priapus. Image from https://en.wikipedia.org/wiki/Temple_of_Priapus
Types
- Ischaemic (low flow): painful, rigid, emergency; hypoxia/acidosis.
- Non-ischaemic (high flow): post-trauma, less painful, semi-rigid, non-emergency.
- Stuttering: recurrent ischaemic episodes, often sickle cell related.
Investigations
- History (duration, trauma, haematology, medications).
- Exam: rigidity, pain, sings of trauma.
- DO A BLOOD GAS! Cavernosal blood gas: hypoxic, acidotic = ischaemic.
- Doppler/US if unclear.
Cavernosal blood gas technique. Image from https://coreem.net/core/priapism/
Management
- Ischaemic: emergency aspiration +- intracavernosal phenylephrine (ideally <6h). If failed then surgical shunt. >24h → high risk permanent erectile dysfunction (ED).
- Non-ischaemic: observation; persistent cases > selective embolisation.[3]
Emergency aspiration – Ischaemic priapism. Image from https://www.jaypeedigital.com/book/9789351526261/chapter/ch7
Surgical shunt techniques – Ischaemic Priapism. Image from https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Priapism.pdf
Penile fracture
Defintion
Rupture of tunica albuginea of corpora cavernosa, usually during intercourse.
Penile fracture – Ruptured tunica albuginea with cavernosal haematoma. Image from https://epos.myesr.org/posterimage/esr/ecr2023/161857/mediagallery/931036?deliveroriginal=1
Presentation
- “Popping” sound, immediate detumescence, pain.
- Exam: swollen, bruised “aubergine” deformity; deviation.
- Urethral involvement: blood at meatus, urinary retention.
Penile fracture- classic ‘aubergine’ presentation. Image from https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Penile%20injury.pdf
Investigations
- Clinical diagnosis.
- Adjuncts: US, MRI.
MRI showing penile fracture. Image from https://radiopaedia.org/articles/penile-fracture
Management
Prompt surgical repair (<24hours). Delay increases risk of ED, curvature, deformity. [4]
Summary
- Phimosis = tight foreskin (normal in kids, abnormal in adults).
- Phimosis treatment = observe, steroid cream, or circumcision.
- Paraphimosis = foreskin stuck behind glans > emergency.
- Paraphimosis treatment = reduce swelling, manual reduction, or dorsal slit/circumcision.
- Priapism = unwanted erection >4h.
- Ischaemic priapism = emergency, painful, rigid, acidotic > Aspirate +/- phenylephrine+/-shunt.
- Penile fracture = “pop,” pain, swelling, aubergine > urgent surgery to prevent risk of ED
References
[1] Adams, B. (2025) The Penis – Structure – Muscles – Innervation – TeachMeAnatomy, Teachmeanatomy.info. Available at: https://teachmeanatomy.info/pelvis/the-male-reproductive-system/penis/.
[2] Reynard, J., Brewster, S. and Biers, S. (2016) Oxford handbook of urology. Oxford University Press.
[3] BAUS: Shunting procedures for periapsis (persistent, painful erections). Available at: https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Priapism.pdf
[4] Rees, R.W. et al. (2018) ‘British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies – penile fracture’, BJU International, 122(1), pp. 26–28. Available at: https://doi.org/10.1111/bju.14167.
Written by Dion Davies (FY2)
Edited by Joseph Latham (CT3)
