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Ultrasound of Acute Penile Fracture
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Ultrasound of Acute Penile Fracture A 28-year-old man with a history of autism presented to the emergency department with acute penile swelling and severe pain after he heard a snap from striking an erect penis with a door earlier that day. He had no voiding difficulties, and beyond the autism, he had no other medical or surgical history. Examination revealed a purple edematous penile shaft. No blood was noted at the meatus and there was no palpable tunical defect. Microscopic analysis of the urine did not reveal red blood cells. A penile ultrasound showed a 3.7 cm hematoma along the proximal dorsal aspect of the penis in continuity with a focal disruption of the tunica albuginea of the right corpora cavernosa (see figure). Penile fracture is a relatively uncommon urological emergency which results from traumatic injury to the erect penis. In the western hemisphere it is typically associated with injury incurred during vaginal intercourse when the erect penis strikes the symphysis pubis. High incidences have been reported in Middle Eastern countries where it is associated with self-manipulation to achieve detumescence.1 Penile fracture has only rarely been associated with a direct blow to the erect penis as described in this case. Tear of the tunica albuginea of the corporal body in the erect state results in a “snap,” large penile hematoma and deformity. The
less common injury to the superficial dorsal vein or smaller vessels of the penis will have a similar presentation. The use of penile ultrasonography in the diagnosis and management of penile fracture is controversial. Ultrasound, the most commonly used imaging modality, demonstrates a focal discontinuity in the tunica albuginea with an associated hematoma beneath the deep fascia of the penis.2 Its use has been criticized because of added expense and false-negative results due to occlusion of the tunical rupture by the hematoma.3 In a series of 170 patients with suspected fracture after penile injury imaging was not performed and the diagnosis was confirmed at the time of surgical exploration.1 However, the mechanism of injury in all of these patients was self-manipulation to achieve detumescence. Koifman et al reported that ultrasound can be useful in patients with a low clinical suspicion of fracture.4 Ultrasound in 25 patients with a low suspicion of penile fracture revealed either soft tissue edema or was normal. These patients were treated conservatively with ultimately good results. Other imaging methods include magnetic resonance imaging and cavernosography, both of which are infrequently used. If there is blood at the urethral
Longitudinal (A) and transverse (B) ultrasound images of penile fracture shows tear (thick arrow) in tunica albuginea of right corpora cavernosa (arrowhead) with adjacent hematoma (thin arrow).
0022-5347/13/1906-002253/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2013.08.072 Vol. 190, 2253-2254, December 2013 Printed in U.S.A.
www.jurology.com
j
2253
2254
RADIOLOGY PAGE
meatus or an inability to urinate, either retrograde urethrography or flexible cystoscopy should be performed before or at the time of surgical repair as approximately 10% to 20% of penile fractures are associated with urethral injury.2 In our patient no palpable defect was noted on examination and ultrasound confirmed the diagnosis. After penile exploration a 1 cm mid shaft tear of the tunica in the right corporal body was repaired. Convalescence was uneventful and the patient was discharged home that day. At followup 4 weeks later the patient denied erectile dysfunction, painful erections and an abnormal curvature.
Raman Unnikrishnan, Rakhee Goel, Chakradhar Thupili and Raymond Rackley Cleveland Clinic Cleveland, Ohio 1. Zargooshi J: Penile fracture in Kermanshah, Iran: the long-term results of surgical treatment. BJU Int 2002; 89: 890. 2. Avery LL and Scheinfeld MH: Imaging of penile and scrotal emergencies. Radiographics 2013; 33: 721. 3. Fergany AF, Angermeier KW and Montague DK: Review of Cleveland Clinic experience with penile fracture. Urology 1999; 54: 352. 4. Koifman L, Barros R, Junior RAS et al: Penile fracture: diagnosis, treatment, and outcomes in 150 patients. Urology 2010; 76: 1488.
Ultrasound of Acute Penile Fracture A 28-year-old man with a history of autism presented to the emergency department with acute penile swelling and severe pain after he heard a snap from striking an erect penis with a door earlier that day. He had no voiding difficulties, and beyond the autism, he had no other medical or surgical history. Examination revealed a purple edematous penile shaft. No blood was noted at the meatus and there was no palpable tunical defect. Microscopic analysis of the urine did not reveal red blood cells. A penile ultrasound showed a 3.7 cm hematoma along the proximal dorsal aspect of the penis in continuity with a focal disruption of the tunica albuginea of the right corpora cavernosa (see figure). Penile fracture is a relatively uncommon urological emergency which results from traumatic injury to the erect penis. In the western hemisphere it is typically associated with injury incurred during vaginal intercourse when the erect penis strikes the symphysis pubis. High incidences have been reported in Middle Eastern countries where it is associated with self-manipulation to achieve detumescence.1 Penile fracture has only rarely been associated with a direct blow to the erect penis as described in this case. Tear of the tunica albuginea of the corporal body in the erect state results in a “snap,” large penile hematoma and deformity. The
less common injury to the superficial dorsal vein or smaller vessels of the penis will have a similar presentation. The use of penile ultrasonography in the diagnosis and management of penile fracture is controversial. Ultrasound, the most commonly used imaging modality, demonstrates a focal discontinuity in the tunica albuginea with an associated hematoma beneath the deep fascia of the penis.2 Its use has been criticized because of added expense and false-negative results due to occlusion of the tunical rupture by the hematoma.3 In a series of 170 patients with suspected fracture after penile injury imaging was not performed and the diagnosis was confirmed at the time of surgical exploration.1 However, the mechanism of injury in all of these patients was self-manipulation to achieve detumescence. Koifman et al reported that ultrasound can be useful in patients with a low clinical suspicion of fracture.4 Ultrasound in 25 patients with a low suspicion of penile fracture revealed either soft tissue edema or was normal. These patients were treated conservatively with ultimately good results. Other imaging methods include magnetic resonance imaging and cavernosography, both of which are infrequently used. If there is blood at the urethral
Longitudinal (A) and transverse (B) ultrasound images of penile fracture shows tear (thick arrow) in tunica albuginea of right corpora cavernosa (arrowhead) with adjacent hematoma (thin arrow).
0022-5347/13/1906-002253/0 THE JOURNAL OF UROLOGY® © 2013 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2013.08.072 Vol. 190, 2253-2254, December 2013 Printed in U.S.A.
www.jurology.com
j
2253
2254
RADIOLOGY PAGE
meatus or an inability to urinate, either retrograde urethrography or flexible cystoscopy should be performed before or at the time of surgical repair as approximately 10% to 20% of penile fractures are associated with urethral injury.2 In our patient no palpable defect was noted on examination and ultrasound confirmed the diagnosis. After penile exploration a 1 cm mid shaft tear of the tunica in the right corporal body was repaired. Convalescence was uneventful and the patient was discharged home that day. At followup 4 weeks later the patient denied erectile dysfunction, painful erections and an abnormal curvature.
Raman Unnikrishnan, Rakhee Goel, Chakradhar Thupili and Raymond Rackley Cleveland Clinic Cleveland, Ohio 1. Zargooshi J: Penile fracture in Kermanshah, Iran: the long-term results of surgical treatment. BJU Int 2002; 89: 890. 2. Avery LL and Scheinfeld MH: Imaging of penile and scrotal emergencies. Radiographics 2013; 33: 721. 3. Fergany AF, Angermeier KW and Montague DK: Review of Cleveland Clinic experience with penile fracture. Urology 1999; 54: 352. 4. Koifman L, Barros R, Junior RAS et al: Penile fracture: diagnosis, treatment, and outcomes in 150 patients. Urology 2010; 76: 1488.