Ulwaluko: medical guideline
Dr. Dingeman J. Rijken
Initial assessment
Clean the penis and remove all debris, such as traditional medicine, slough and superficialgangrene. Consider the use of a penile block if the shaft is intact. HIV testing should beoffered to all patients; full blood count and renal function should be taken if indicated.
Common complications are dehydration, acute renal failure, septic shock, trauma (includingcrush syndrome), reactive arthritis, and endocarditis. Document penile complications usingthe classification system. Wet gangrene has the potential to spread quickly and should betreated immediately. Fournier’s gangrene is relatively uncommon but needs urgent referralto a tertiary centre for surgical debridement.
Penile complications
Antibiotics should be prescribed according to the degree of local sepsis. For mild sepsis (s1) antibiotics are not indicated and only antiseptic dressings should be applied (such as povidone-­‐iodine). Oral amoxicillin with clavulanic acid (Augmentin) is indicated in moderate sepsis (s2). Intravenous antibiotics (cefalosporines and metronidazole) are indicated in severe sepsis (s3) and gangrene (sx). Paraffin dressings (Jelonet) may be used once the local sepsis has resolved.
Moderate wound defects (w1) usually heal without intervention but this may take severalweeks. Large wound defects (w2) should be observed for healing tendencies and might needskin grafting. Patients with total loss of the penile skin (w3) should be referred for skingrafting once the local sepsis has resolved.
Partial loss of the epithelium of the penile glans (g1) usually heals quickly once local sepsis iscontrolled. Patients with total epithelium loss (g2) and tissue loss (g3) should be observedinitially. The glans is covered with stratified epithelium that regenerates in case of a partialthickness wound. Besides, epithelium has a remarkable potential to regenerate from theexternal meatus and proximal edge of the defect. Poorly healing wounds are best referredfor skin grafting.
Insert urinary catheters in case of tissue loss of the glans (g3) or gangrene. A catheter mayalso be needed in case of severe local sepsis (s3) to facilitate dressings. Remove them assoon as possible to avoid urethral strictures.
Gangrene of the skin or superficial gangrene of the glans should be removed during theinitial assessment or soon afterwards. More extensive gangrene requires a reservedapproach and patients will need to be counselled extensively.
Dry gangrene will spontaneously detach, a process that may take several weeks to complete.
Wet gangrene may become dry if adequately treated, or will otherwise slough off. Theprocess of detachment can be accelerated using a blunt dissection technique: gentleseparation of the tissues by fingers during dressing changes. The aim should be to achievedetachment over a number of days, which will reduce the duration of antibiotics use andhospital stay.
Before applying this technique, one needs to ascertain that the patient has a fullunderstanding of his situation to prevent further psychological trauma (and litigation). Becautious to use it during the first few days after admission, when the focus should be ongeneral recovery and counselling. Adequate communication and note keeping are ofparamount importance.
Sexual function
The degree of sexual function is proportional to the amount of tissue that is preserved.
Tissue loss of the glans (g3) might lead to a mildly decreased sensation but carries a goodprognosis.
Most patients with an amputation of the glans (with or without a small part of the shaft) willbe able to achieve erections, allowing for sexual intercourse. Orgasm and ejaculation ispossible, but might be delayed due to decreased genital sensitivity.
Patients with amputations of a larger part of the shaft or total amputations will have asignificantly impaired sexual function. Normal sexual intercourse is not possible; orgasm andejaculation can sometimes be reached when other erogenous zones are stimulated.
Surgical reconstruction of the penis is possible in some cases. However, the main purpose ofthis is to improve the cosmetic appearance and to restore previous urinary habits (beingable to pass urine standing up in public washrooms). Sexual function cannot be restored.

Source: http://www.ulwaluko.co.za/Downloads_files/Medical%20guideline.pdf

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