- Email: [email protected]
Rupture of the Corpus Cavernosum: Surgical Management
0022-5347 /83/1305-0917$02.00/0 Vol. 130, November
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
RUPTURE OF THE CORPUS CAVERNOSUM: SURGICAL MANAGEMENT GARY S. NICOLAISEN,* AITAN MELAMUD, RICHARD D. WILLIAMS AND JACK W. McANINCH From the Department of Urology, University of California School of Medicine, San Francisco General Hospital and Veterans Administration Medical Center, San Francisco, California
ABSTRACT
Rupture of the corpus cavernosum is an uncommon injury resulting from a direct blow to the erect penis. The injury is easy to recognize but treatment remains controversial. Our uniform operative plan, consisting of immediate exploration, identification, sharp debridement and primary repair of the tear in the tunica albuginea with absorbable sutures, resulted in preservation of normal penile erection in 7 patients. The hospital stay was brief (mean 3.8 days) and there were no complications. These results compare favorably to operative management as reported in the literature. Conservative management is associated·with a 29 per cent complication rate and a mean hospital stay of 14 days. Therefore, early surgical repair of the rupture is advocated. Traumatic rupture of the corpus cavernosum is uncommon. Although its etiology, pathological findings and clinical presentation have been described in the literature the treatment of choice remains uncertain. Treatment options that have been reported previously are immediate surgical exploration with primary closure of the tunica albuginea and nonoperative management, consisting generally of a pressure dressing of iced compresses with or without an indwelling catheter to provide counterpressure. 1-5 Enzyme debridement, anti-inflammatory agents and antibiotics, as well as diethylstilbestrol, amyl nitrate or diazepam to suppress erections temporarily have been advocated.3·6-11 Early reports stressed nonoperative management. Thompson stated that "conservatism is the watchword concerning care of these patients". 2 Recent studies have proposed early surgical exploration with primary repair, citing universally excellent results and decreased hospital stay as indications.3·5· 11-13 However, several investigators continue to advocate conservative management. 10• 14 Owing to the data supporting early surgical intervention we have elected to treat this injury operatively with a uniform preoperative and postoperative plan. We herein compare our results to those reported previously. MATERIALS AND METHODS
Recently, we have evaluated and treated 7 men with rupture of the corpus cavernosum. Patient age at presentation ranged from 22 to 31 years, with a mean age of 26 years. Of these patients 5 had been injured during sexual intercourse, 1 during masturbation and 1 while attempting to place the erect penis into his pants. All patients heard a cracking sound followed immediately by detumescence, pain, swelling, angulation and local skin discoloration (fig. 1). All patients voided spontaneously, although 1 had difficulty initiating a stream. Only 1 patient had gross hematuria, while 6 had no significant hematuria on urinalysis (<5 red blood cells per high power field). A retrograde urethrogram was obtained in 5 patients, including the patient with gross hematuria. There was no evidence of urethral injury. All 7 patients were treated by immediate surgical exploration via a distal circumferential incision, followed by evacuation of the hematoma, identification of the tear and sharp debridement of the edges as necessary. The tear (1.5 to 2.0 cm. long) was closed primarily with interrupted absorbable Accepted for publication April 15, 1983. Read at annual meeting of American Urological Association, Las Vegas, Nevada, April 17-21, 1983. * Requests for reprints: Urology, U-518, University of California, San Francisco, California 94143.
sutures. An indwelling catheter and a Koban pressure dressing were applied, both of which were removed 1 or 2 days postoperatively. No patient subsequently experienced penile swelling or urinary retention and all 7 were discharged from the hospital 3 or 4 days postoperatively. RESULTS
None of our patients sustained a urethral injury. Our operative and postoperative plan resulted in a brief hospital stay of 3 to 4 days (mean 3.8 days) and preservation of normal erectile function in every case. There were no complications. Normal erections occurred before 3 patients were discharged from the hospital and before the followup visit (1 to 3 months) in 4. DISCUSSION
Presently, there are 110 cases (including our 7) of rupture of the corpus cavernosum in the literature. 1-26 Of the 60 patients reported on in the English literature 50 were treated from the time of injury and 10 presented with late complications. 6·12· 16· 18 Pathophysiology. The pathological lesion is a tear of the tunica albuginea of 1 corpus or, rarely, both corpora resulting ip hematoma formation, swelling and skin discoloration (fig. 2). 1-3, 7 Rupture occurs only when the erect penis is subjected to a direct external force. 1-3 During erection the tunica albuginea thins and becomes more susceptible to injury, especially if it has lost some of its elasticity, for example from fibrosis after periurethral infection. 1-3, 7 In 58 per cent of the cases rupture occurred during sexual intercourse. Usually, the penis slips out of the vagina and then is thrust against the perineum or symphysis pubis, which results in a tear of the tunica albuginea.1-26 Of the cases 26 per cent were caused by abnormal bending of the penis by the patient, usually during masturbation or when trying to place the erect penis into the pants, and 16 per cent were caused by other trauma, including rolling over in bed, being kicked by a horse or hitting a bed post. 1-26 Clinical presentation. Characteristically, the patient hears a sharp, cracking sound followed by immediate detumescence, rapid swelling, discoloration and deformity of the penis, often with angulation away from the injured corpus. 3 Pain generally is severe but several cases have occurred with only minimal discomfort. Urination usually is unimpeded unless there is an associated urethral injury. However, hematoma formation and swelling may cause external urethral compression leading to obstructive symptoms or urinary retention. 3• 13· 19 Urethral injury. Of 50 patients seen at the time of injury 11 (22 per cent) sustained a urethral injury, which was partial in
917
918
NICOLAISEN AND ASSOCIATES
FIG. 1. Typical findings at initial presentation
FIG. 2. Intraoperative photograph shows tear of corpus cavernosum
10. 7 •8• 12• 14• 15• 18• 20 When urinalysis was reported none of 18 patients with normal results had sustained a documented urethral injury. 1•3 • 6 •9 • 13• 21 • 24 Microhematuria was documented in only 1 patient. 21 Of 11 patients presenting with gross hematuria or blood at the meatus 10 (91 per cent) sustained a documented urethral injury (the patient without urethral injury experienced gross hematuria as noted previously). 7 •8 • 12• 14• 15• 18• 20 The patient with a urethral injury without blood at the meatus was unable to void and the injury was documented at surgical exploration. 7 Treatment. Presently, no long-term prospective randomized studies are available to establish whether operative or nonoperative management is the optimal treatment. However, careful review of the literature sheds light on the problem. Including our 7 cases 50 were managed from the time of injury: 26 operatively (immediate exploration, evacuation of the hematoma and repair of the tunica albuginea) 3- 5 , 11- 13• 15• 20 • 22- 24 and 24 nonoperatively. 1• 2 • 4- 10• 14• 17- 19• 21 • 24- 26 In no case managed initially by primary repair has there been a complication such as expanding hematoma, persistent pain or angulation, or development of a fibrotic plaque precluding intercourse. Circumcision was necessary in 1 patient (4 per cent) for a superficial wound infection of the foreskin. 20 Of 24 patients managed nonoperatively 17 (73.9 per cent) have had satisfactory erections and 7 (29.2 per cent) have experienced complications. 1• 2• 7• 17• 18• 24 Two patients underwent delayed primary repair because of persistent clot and angulation, 1 and angulation with a pulsatile mass, respectively. 17 Both patients eventually had satisfactory erections. One patient underwent exploration and delayed primary repair because of penile abscess, 26 and 1 required incision and drainage of a penile abscess owing to an infected hematoma.17 Both patients later experienced normal erections. In 1 patient persistent extravasation of urine through a tear in the urethra and adjacent tunica albuginea, and then into the subcutaneous
tissue of the penis through a second tear in the tunica, necessitated delayed primary repair of the urethra and corpus cavernosum, resulting in normal erections and urination. 7 One patient who underwent delayed evacuation of a hematoma and placement of a drain subsequently complained of painful, markedly deformed erections. 2 The remaining patient had a fibrotic plaque and angulation, and was awaiting further treatment at the time of the report. 18 The duration of hospitalization was reported in 14 of 24 patients managed conservatively1•6 • 7• 14• 1618·20·22·26 and in 23 of 26 treated by early surgical repair. 35·8·11·14·15·19·22·24·26 Over-all, average hospital stay was 14 days, with a range of O to 72 days, in patients treated nonoperatively (31 days, with a range of 8 to 72 days, if a complication ensued) and 6.6 days, with a range of 3 to 21 days, in patients managed with an operation (3.8 days, with a range of 3 to 4 days in our 7 patients). In addition, 10 patients with a history of untreated rupture of the corpus cavernosum presented late with fibrosis and angulation of the penis. 6 • 12• 16- 18 Of these patients 6 await definitive therapy, while 4 underwent exploration with excision of the fibrotic area (repair of the tunica albuginea in 36 • 16• 18 and interposition of a dermal graft in 1 because of the size of the defect17 ). Satisfactory erections were reported in all 4 cases. It is difficult to ascertain the significance of these cases since the number of untreated patients who have acceptable erections is unknown. Finally, of 50 patients presenting at the time of injury 11 also had a urethral injury, 10 of which occurred as a result of sexual intercourse. 2 •7 •8 • 12• 15• 18• 20 The tear was partial in all but 1 case. 15 Of 7 patients managed with an indwelling catheter or a suprapubic tube 7 •8 • 1214• 18 2 suffered strictures that responded to dilation, 12•14 and 1 had persistent extravasation requiring exploration and repair.7 Three patients underwent immediate exploration and repair of the urethra, 15• 20 and 1 required dilation for a mild stricture without further difficulty. 15 Followup is unavailable for 1 patient. 18 Because the urethral injury generally is a small, partial tear we favor temporary urinary diversion via percutaneous suprapubic cystostomy, which has been effective in treating partial urethral lacerations. 27 One patient sustained a complete urethral transection. However, attempted passage of a urethral catheter may have converted a partial tear into a complete transection. Therefore, we believe that urethral catheterization is contraindicated in patients with suspected urethral injuries. We favor primary repair over an indwelling catheter if a complete transection is documented. In agreement with Sant,20 we can find no rationale for administration of systemic antibiotics and do not use them routinely. Furthermore, enzyme debridement and anti-inflammatory agents should not be required to inhibit hematoma formation and edema if early repair is done. We do not use drugs routinely to inhibit erections. However, we have had success with administration of amyl nitrate and diethylstilbestrol if erections become a problem. CONCLUSIONS
Treatment of rupture of the corpus cavernosum is directed toward evacuation of the hematoma, and identification and primary repair of the tear, since our data indicate that this approach is successful uniformly in preserving normal erections without complications. Furthermore, this treatment plan is associated with a brief hospital stay and rapid return of function. Our data agree with those for surgical management reported in the literature. Because nonoperative management is associated with a 29 per cent complication rate and a longer hospital stay, especially if a complication occurs, we believe early intervention is indicated in all cases of rupture of the corpus cavernosum. An associated urethral injury is present in 22 per cent of the
RUPTURE OF CORPUS CAVERNOSUM
cases, usually with blood at the meatus or inability to void. Retrograde urethrography is indicated unless a voided urinalysis is unremarkable. Although it appears that the outcome of a urethral injury is excellent, regardless of treatment, we favor simple urinary diversion by percutaneous cystostomy. REFERENCES 1. Fetter, T. R. and Gartman, E.: Traumatic rupture of penis. Amer.
J. Surg., 32: 371, 1936. 2. Thompson, R. F.: Rupture (fracture) of the penis. J. Urol., 71: 226, 1954. 3. Meares, E. M., Jr.: Traumatic rupture of the corpus cavernosum. J. Urol., 105: 407, 1971. 4. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 5. Gross, M., Arnold, T. L. and Waterhouse, K.: Fracture of the penis: rationale of surgical management. J. Urol., 106: 708, 1971. 6. Zenteno, S.: Fracture of the penis. Case report. Plast. Reconstr. Surg., 52: 669, 1973. 7. Creecy, A. A. and Beazlie, F. S., Jr.: Fracture of the penis: traumatic rupture of corpora cavernosa. J. Urol., 78: 620, 1957. 8. Saxe, T. L.: Fracture of the penis. J. Med. Soc. New Jersey, 56: 614, 1959. 9. Antony, J.: Fracture of the penis. Int. Surg., 62: 561, 1977. 10. Jallu, A., Wani, N. A. and Rashid, P.A.: Fracture of the penis. J. Urol., 123: 285, 1980. 11. Hudson, M. J. K.: Rupture of the corpus cavernosum of the penis. Brit. J. Clin. Pract., 29: 191, 1975. 12. Goh, H. S. and Trapnell, J.E.: Fracture of the penis. Brit. J. Surg., 67: 680, 1980. 13. Giederman, J. M. and Paris, P. M.: Fracture of the penis. Ann.
919
Emerg. Med., 9: 435, 1980. 14. Walton, J. K.: Fracture of the penis with laceration of the urethra. Brit. J. Urol., 51: 308, 1979. 15. Gross, M., Arnold, T. L. and Peters, P.: Fracture of the penis with associated laceration of the urethra. J. Urol., 117: 725, 1977. 16. Abrahamy, R. and Leiter, E.: Post-traumatic segmental corpus cavernosum fibrosis: the diagnostic value of cavernosography and the surgical correction by cavernosum-cavernosum shunt. J. Urol., 123: 289, 1980. 17. Farah, R. N., Stiles, R., Jr. and Cerny, J.C.: Surgical treatment of deformity and coital difficulty in healed traumatic rupture of the corpora cavernosa. J. Urol., 120: 118, 1978. 18. Pryor, J. P., Hill, J. T., Packham, D. A. and Yates-Bell, A. J.: Penile injuries with particular reference to injury to the erectile tissue. Brit. J. Urol., 53: 42, 1981. 19. Davies, D. M. and Mitchell, I.: Fracture of the penis. Brit. J. Urol., 50: 426, 1978. 20. Sant, G. R.: Rupture of the corpus cavernosum of the penis. Arch. Surg., 116: 1176, 1981. 21. Baretz, L. H.: Fracture of the penis. Urol. Cutan. Rev., 36: 515, 1932. 22. Palomar, J.M., Halikiopoulos, H. and Polanco, E.: Primary surgical repair of the fractured penis. Ann. Emerg. Med., 9: 260, 1980. 23. Parrillo, S. J., Kelley, S., Finkelstein, L. and Weiner, I.: Fracture of the penis. Ann. Emerg. Med., 10: 376, 1981. 24. Sinkoe, S. J.: Traumatic rupture of the corpora cavernosa. Report of a case. Amer. J. Surg., 12: 446, 1931. 25. McKay, H. W. and Hawes, G. A.: Traumatic fracture of the penis. J.A.M.A., 105: 1031, 1935. 26. Bergner, D. M., Wilcow, M. E. and Frentz, G.D.: Fracture of penis. Urology, 20: 278, 1982. 27. McAninch, J. W.: Traumatic injuries to the urethra. J. Trauma, 21: 291, 1981.
THE JOURNAL OF UROLOGY
Copyright © 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
RUPTURE OF THE CORPUS CAVERNOSUM: SURGICAL MANAGEMENT GARY S. NICOLAISEN,* AITAN MELAMUD, RICHARD D. WILLIAMS AND JACK W. McANINCH From the Department of Urology, University of California School of Medicine, San Francisco General Hospital and Veterans Administration Medical Center, San Francisco, California
ABSTRACT
Rupture of the corpus cavernosum is an uncommon injury resulting from a direct blow to the erect penis. The injury is easy to recognize but treatment remains controversial. Our uniform operative plan, consisting of immediate exploration, identification, sharp debridement and primary repair of the tear in the tunica albuginea with absorbable sutures, resulted in preservation of normal penile erection in 7 patients. The hospital stay was brief (mean 3.8 days) and there were no complications. These results compare favorably to operative management as reported in the literature. Conservative management is associated·with a 29 per cent complication rate and a mean hospital stay of 14 days. Therefore, early surgical repair of the rupture is advocated. Traumatic rupture of the corpus cavernosum is uncommon. Although its etiology, pathological findings and clinical presentation have been described in the literature the treatment of choice remains uncertain. Treatment options that have been reported previously are immediate surgical exploration with primary closure of the tunica albuginea and nonoperative management, consisting generally of a pressure dressing of iced compresses with or without an indwelling catheter to provide counterpressure. 1-5 Enzyme debridement, anti-inflammatory agents and antibiotics, as well as diethylstilbestrol, amyl nitrate or diazepam to suppress erections temporarily have been advocated.3·6-11 Early reports stressed nonoperative management. Thompson stated that "conservatism is the watchword concerning care of these patients". 2 Recent studies have proposed early surgical exploration with primary repair, citing universally excellent results and decreased hospital stay as indications.3·5· 11-13 However, several investigators continue to advocate conservative management. 10• 14 Owing to the data supporting early surgical intervention we have elected to treat this injury operatively with a uniform preoperative and postoperative plan. We herein compare our results to those reported previously. MATERIALS AND METHODS
Recently, we have evaluated and treated 7 men with rupture of the corpus cavernosum. Patient age at presentation ranged from 22 to 31 years, with a mean age of 26 years. Of these patients 5 had been injured during sexual intercourse, 1 during masturbation and 1 while attempting to place the erect penis into his pants. All patients heard a cracking sound followed immediately by detumescence, pain, swelling, angulation and local skin discoloration (fig. 1). All patients voided spontaneously, although 1 had difficulty initiating a stream. Only 1 patient had gross hematuria, while 6 had no significant hematuria on urinalysis (<5 red blood cells per high power field). A retrograde urethrogram was obtained in 5 patients, including the patient with gross hematuria. There was no evidence of urethral injury. All 7 patients were treated by immediate surgical exploration via a distal circumferential incision, followed by evacuation of the hematoma, identification of the tear and sharp debridement of the edges as necessary. The tear (1.5 to 2.0 cm. long) was closed primarily with interrupted absorbable Accepted for publication April 15, 1983. Read at annual meeting of American Urological Association, Las Vegas, Nevada, April 17-21, 1983. * Requests for reprints: Urology, U-518, University of California, San Francisco, California 94143.
sutures. An indwelling catheter and a Koban pressure dressing were applied, both of which were removed 1 or 2 days postoperatively. No patient subsequently experienced penile swelling or urinary retention and all 7 were discharged from the hospital 3 or 4 days postoperatively. RESULTS
None of our patients sustained a urethral injury. Our operative and postoperative plan resulted in a brief hospital stay of 3 to 4 days (mean 3.8 days) and preservation of normal erectile function in every case. There were no complications. Normal erections occurred before 3 patients were discharged from the hospital and before the followup visit (1 to 3 months) in 4. DISCUSSION
Presently, there are 110 cases (including our 7) of rupture of the corpus cavernosum in the literature. 1-26 Of the 60 patients reported on in the English literature 50 were treated from the time of injury and 10 presented with late complications. 6·12· 16· 18 Pathophysiology. The pathological lesion is a tear of the tunica albuginea of 1 corpus or, rarely, both corpora resulting ip hematoma formation, swelling and skin discoloration (fig. 2). 1-3, 7 Rupture occurs only when the erect penis is subjected to a direct external force. 1-3 During erection the tunica albuginea thins and becomes more susceptible to injury, especially if it has lost some of its elasticity, for example from fibrosis after periurethral infection. 1-3, 7 In 58 per cent of the cases rupture occurred during sexual intercourse. Usually, the penis slips out of the vagina and then is thrust against the perineum or symphysis pubis, which results in a tear of the tunica albuginea.1-26 Of the cases 26 per cent were caused by abnormal bending of the penis by the patient, usually during masturbation or when trying to place the erect penis into the pants, and 16 per cent were caused by other trauma, including rolling over in bed, being kicked by a horse or hitting a bed post. 1-26 Clinical presentation. Characteristically, the patient hears a sharp, cracking sound followed by immediate detumescence, rapid swelling, discoloration and deformity of the penis, often with angulation away from the injured corpus. 3 Pain generally is severe but several cases have occurred with only minimal discomfort. Urination usually is unimpeded unless there is an associated urethral injury. However, hematoma formation and swelling may cause external urethral compression leading to obstructive symptoms or urinary retention. 3• 13· 19 Urethral injury. Of 50 patients seen at the time of injury 11 (22 per cent) sustained a urethral injury, which was partial in
917
918
NICOLAISEN AND ASSOCIATES
FIG. 1. Typical findings at initial presentation
FIG. 2. Intraoperative photograph shows tear of corpus cavernosum
10. 7 •8• 12• 14• 15• 18• 20 When urinalysis was reported none of 18 patients with normal results had sustained a documented urethral injury. 1•3 • 6 •9 • 13• 21 • 24 Microhematuria was documented in only 1 patient. 21 Of 11 patients presenting with gross hematuria or blood at the meatus 10 (91 per cent) sustained a documented urethral injury (the patient without urethral injury experienced gross hematuria as noted previously). 7 •8 • 12• 14• 15• 18• 20 The patient with a urethral injury without blood at the meatus was unable to void and the injury was documented at surgical exploration. 7 Treatment. Presently, no long-term prospective randomized studies are available to establish whether operative or nonoperative management is the optimal treatment. However, careful review of the literature sheds light on the problem. Including our 7 cases 50 were managed from the time of injury: 26 operatively (immediate exploration, evacuation of the hematoma and repair of the tunica albuginea) 3- 5 , 11- 13• 15• 20 • 22- 24 and 24 nonoperatively. 1• 2 • 4- 10• 14• 17- 19• 21 • 24- 26 In no case managed initially by primary repair has there been a complication such as expanding hematoma, persistent pain or angulation, or development of a fibrotic plaque precluding intercourse. Circumcision was necessary in 1 patient (4 per cent) for a superficial wound infection of the foreskin. 20 Of 24 patients managed nonoperatively 17 (73.9 per cent) have had satisfactory erections and 7 (29.2 per cent) have experienced complications. 1• 2• 7• 17• 18• 24 Two patients underwent delayed primary repair because of persistent clot and angulation, 1 and angulation with a pulsatile mass, respectively. 17 Both patients eventually had satisfactory erections. One patient underwent exploration and delayed primary repair because of penile abscess, 26 and 1 required incision and drainage of a penile abscess owing to an infected hematoma.17 Both patients later experienced normal erections. In 1 patient persistent extravasation of urine through a tear in the urethra and adjacent tunica albuginea, and then into the subcutaneous
tissue of the penis through a second tear in the tunica, necessitated delayed primary repair of the urethra and corpus cavernosum, resulting in normal erections and urination. 7 One patient who underwent delayed evacuation of a hematoma and placement of a drain subsequently complained of painful, markedly deformed erections. 2 The remaining patient had a fibrotic plaque and angulation, and was awaiting further treatment at the time of the report. 18 The duration of hospitalization was reported in 14 of 24 patients managed conservatively1•6 • 7• 14• 1618·20·22·26 and in 23 of 26 treated by early surgical repair. 35·8·11·14·15·19·22·24·26 Over-all, average hospital stay was 14 days, with a range of O to 72 days, in patients treated nonoperatively (31 days, with a range of 8 to 72 days, if a complication ensued) and 6.6 days, with a range of 3 to 21 days, in patients managed with an operation (3.8 days, with a range of 3 to 4 days in our 7 patients). In addition, 10 patients with a history of untreated rupture of the corpus cavernosum presented late with fibrosis and angulation of the penis. 6 • 12• 16- 18 Of these patients 6 await definitive therapy, while 4 underwent exploration with excision of the fibrotic area (repair of the tunica albuginea in 36 • 16• 18 and interposition of a dermal graft in 1 because of the size of the defect17 ). Satisfactory erections were reported in all 4 cases. It is difficult to ascertain the significance of these cases since the number of untreated patients who have acceptable erections is unknown. Finally, of 50 patients presenting at the time of injury 11 also had a urethral injury, 10 of which occurred as a result of sexual intercourse. 2 •7 •8 • 12• 15• 18• 20 The tear was partial in all but 1 case. 15 Of 7 patients managed with an indwelling catheter or a suprapubic tube 7 •8 • 1214• 18 2 suffered strictures that responded to dilation, 12•14 and 1 had persistent extravasation requiring exploration and repair.7 Three patients underwent immediate exploration and repair of the urethra, 15• 20 and 1 required dilation for a mild stricture without further difficulty. 15 Followup is unavailable for 1 patient. 18 Because the urethral injury generally is a small, partial tear we favor temporary urinary diversion via percutaneous suprapubic cystostomy, which has been effective in treating partial urethral lacerations. 27 One patient sustained a complete urethral transection. However, attempted passage of a urethral catheter may have converted a partial tear into a complete transection. Therefore, we believe that urethral catheterization is contraindicated in patients with suspected urethral injuries. We favor primary repair over an indwelling catheter if a complete transection is documented. In agreement with Sant,20 we can find no rationale for administration of systemic antibiotics and do not use them routinely. Furthermore, enzyme debridement and anti-inflammatory agents should not be required to inhibit hematoma formation and edema if early repair is done. We do not use drugs routinely to inhibit erections. However, we have had success with administration of amyl nitrate and diethylstilbestrol if erections become a problem. CONCLUSIONS
Treatment of rupture of the corpus cavernosum is directed toward evacuation of the hematoma, and identification and primary repair of the tear, since our data indicate that this approach is successful uniformly in preserving normal erections without complications. Furthermore, this treatment plan is associated with a brief hospital stay and rapid return of function. Our data agree with those for surgical management reported in the literature. Because nonoperative management is associated with a 29 per cent complication rate and a longer hospital stay, especially if a complication occurs, we believe early intervention is indicated in all cases of rupture of the corpus cavernosum. An associated urethral injury is present in 22 per cent of the
RUPTURE OF CORPUS CAVERNOSUM
cases, usually with blood at the meatus or inability to void. Retrograde urethrography is indicated unless a voided urinalysis is unremarkable. Although it appears that the outcome of a urethral injury is excellent, regardless of treatment, we favor simple urinary diversion by percutaneous cystostomy. REFERENCES 1. Fetter, T. R. and Gartman, E.: Traumatic rupture of penis. Amer.
J. Surg., 32: 371, 1936. 2. Thompson, R. F.: Rupture (fracture) of the penis. J. Urol., 71: 226, 1954. 3. Meares, E. M., Jr.: Traumatic rupture of the corpus cavernosum. J. Urol., 105: 407, 1971. 4. Waterhouse, K. and Gross, M.: Trauma to the genitourinary tract: a 5-year experience with 251 cases. J. Urol., 101: 241, 1969. 5. Gross, M., Arnold, T. L. and Waterhouse, K.: Fracture of the penis: rationale of surgical management. J. Urol., 106: 708, 1971. 6. Zenteno, S.: Fracture of the penis. Case report. Plast. Reconstr. Surg., 52: 669, 1973. 7. Creecy, A. A. and Beazlie, F. S., Jr.: Fracture of the penis: traumatic rupture of corpora cavernosa. J. Urol., 78: 620, 1957. 8. Saxe, T. L.: Fracture of the penis. J. Med. Soc. New Jersey, 56: 614, 1959. 9. Antony, J.: Fracture of the penis. Int. Surg., 62: 561, 1977. 10. Jallu, A., Wani, N. A. and Rashid, P.A.: Fracture of the penis. J. Urol., 123: 285, 1980. 11. Hudson, M. J. K.: Rupture of the corpus cavernosum of the penis. Brit. J. Clin. Pract., 29: 191, 1975. 12. Goh, H. S. and Trapnell, J.E.: Fracture of the penis. Brit. J. Surg., 67: 680, 1980. 13. Giederman, J. M. and Paris, P. M.: Fracture of the penis. Ann.
919
Emerg. Med., 9: 435, 1980. 14. Walton, J. K.: Fracture of the penis with laceration of the urethra. Brit. J. Urol., 51: 308, 1979. 15. Gross, M., Arnold, T. L. and Peters, P.: Fracture of the penis with associated laceration of the urethra. J. Urol., 117: 725, 1977. 16. Abrahamy, R. and Leiter, E.: Post-traumatic segmental corpus cavernosum fibrosis: the diagnostic value of cavernosography and the surgical correction by cavernosum-cavernosum shunt. J. Urol., 123: 289, 1980. 17. Farah, R. N., Stiles, R., Jr. and Cerny, J.C.: Surgical treatment of deformity and coital difficulty in healed traumatic rupture of the corpora cavernosa. J. Urol., 120: 118, 1978. 18. Pryor, J. P., Hill, J. T., Packham, D. A. and Yates-Bell, A. J.: Penile injuries with particular reference to injury to the erectile tissue. Brit. J. Urol., 53: 42, 1981. 19. Davies, D. M. and Mitchell, I.: Fracture of the penis. Brit. J. Urol., 50: 426, 1978. 20. Sant, G. R.: Rupture of the corpus cavernosum of the penis. Arch. Surg., 116: 1176, 1981. 21. Baretz, L. H.: Fracture of the penis. Urol. Cutan. Rev., 36: 515, 1932. 22. Palomar, J.M., Halikiopoulos, H. and Polanco, E.: Primary surgical repair of the fractured penis. Ann. Emerg. Med., 9: 260, 1980. 23. Parrillo, S. J., Kelley, S., Finkelstein, L. and Weiner, I.: Fracture of the penis. Ann. Emerg. Med., 10: 376, 1981. 24. Sinkoe, S. J.: Traumatic rupture of the corpora cavernosa. Report of a case. Amer. J. Surg., 12: 446, 1931. 25. McKay, H. W. and Hawes, G. A.: Traumatic fracture of the penis. J.A.M.A., 105: 1031, 1935. 26. Bergner, D. M., Wilcow, M. E. and Frentz, G.D.: Fracture of penis. Urology, 20: 278, 1982. 27. McAninch, J. W.: Traumatic injuries to the urethra. J. Trauma, 21: 291, 1981.