The case of the month

November 2006 case of the month

A young man admitted in ER complains with penile pain and swelling, after a coital trauma. He reports that a sharp bending of the shaft occurred a few hours before during a penetrative intercourse, while he was in supine position and the partner on the top. He had heard a “pop” noise simultaneous with the pain, followed by immediate detumescence. Since then he had urinated once, whit urethral burning, but no haematuria or urethral bleeding. (Case provided by Dr Ferninando Fusco, Urologist, Department of Urology, University Federico II Naples, Italy, ferdinando-fusco@libero.it)

Question 1
Which diagnostic evaluation is required?

No further evaluation. This is a straightforward clinical diagnosis of penile fracture.
Ultrasounds scan of the penis.
Cavernosography
Penile MRI

Comment
In such cases, identifying the site and the extension of the fracture adds much safety and accuracy to the treatment. If available, an ultrasounds scan (US) is the first choice. MRI should be used only in case of in conclusive results from the ultrasounds (e.g. severe swelling of superficial layers of the penis). Cavernosography would be very useful in selected cases, but in the vast majority of cases it is not available in an emergency setting, even in referral centers.

In the present case, the US showed a proximal, bilateral ventral fracture. This finding, even in absence of urinary retention or urethral bleeding, warrants a retrograde urethrography to exclude a urethral lesion.
As a matter of fact, in this patient the urethrography showed a silent urethral rupture, that had not been suspected at the clinical presentation and would have been probably overlooked if US had not been performed.

Question 2
Which treatment is advisable?

The absence of urethral bleeding and haematuria exclude urethral rupture. A conservative management with ice, compressive sponges, analgesic and antibiotics is advisable.
A surgical repair of the fracture is advisable. A longitudinal incision upon the haematoma would consent a minimally invasive access to the site of the fracture.
A surgical repair of the fracture is advisable. A penile degloving consent a better access to the site of the fracture.
A surgical repair is advisable. The surgical access should be chosen after having precisely localized the tunical rupture by ultrasound.

Comment
In this case, the US findings absolutely excluded a conservative approach and patients underwent an immediate surgical procedure.
However, data is available in the literature showing how the interventional approach should be preferred in all cases of penile fracture.
After a conservative management, indeed, the short and log term complication rate (haematoma, infection, abscess, penile deformity, diverticula, fistula, ED) ranges from 10% to 53% [Fergany et al, Urology 1999; Mydlo et al, Urology 1998]. An immediate (<36h) surgical approach gives better short and long term results with a very lower complication rate, [Zargooshi, J Urol, 2000; Esterlit et al., Urol Int, 1996; Asgari et al., J Urol, 1996], and also a shorter hospitalization time (average 3.8 days) [Nicolaisen et al., J Urol, 1993].
At the light of these data, a conservative approach should be offered only if the patients refuse the surgical procedure, therefore answer 1 is wrong.
Answer 2 and 3 are wrong as well, as the site of the haematoma does not always correspond to the site of fracture and there is no surgical access that consent an optimal control for all possible sites of fracture. Therefore, the best surgical access should be considered only after visualizing the site and the extension of the fracture with imaging techniques (answer 4).
In the present case, the proximal, ventral, bilateral fracture was comfortably managed through a penoscrotal access, which also consented a easy repair of the urethral rupture.
Patient was dismissed after 72h and had no complications.