| ORIGINAL REPORTS |
S. De Stefani*, R. Stubinski, F. Ferneti, A. Simonato,G. Carmignani
*Department of Urology University of Trieste (Italy)
Department of Urology University of Genoa (Italy)
Fracture of the penis is an uncommon pathology1.It consists in a rupture of the tunica albuginea of one or both corporacavernosa following injury to an erect penis. The most common causes areblunt trauma during sexual intercourse, masturbation, unconscious nocturnalpenile manipulation or a fall onto the erect penis7. The reasonwhy rupture of the albuginea occurs only during erection lies in the factthat in the normal flaccid condition the penis occupies a position whichis well protected against blows or blunt traumas. In the erect penis thetunica albuginea thins from 2 mm to 0.5 - 0.25 mm and thus it is more susceptibleto traumatic tearing. Penile fracture associated with urethral injury iseven more uncommon and accounts for 10 to 20% of reported cases. Promptdiagnosis and immediate surgical repair allows for earlier resumption ofsexual activity and gives a lower incidence of penile chordee secondaryto blood clot absorption and fibrous tissue formation2. Surgeryis mandatory for the prevention of late sequelae following injury especiallyin cases associated with urethral rupture. At times the corporeal tearis very large and in patients with concomitant lesions involving the urethrasurgical repair can become difficult and require particular technical shrewdness.
We report the surgical repair of 8 cases of penile fracture,two of which were complex involving both corpora cavernosa and an associatedpartial rupture of the urethra.
MATERIAL AND METHODS
Between 1986 and 1997, 8 cases of blunt penile traumawere referred to our institution. Patients were admitted to emergency roombetween 2 and 48 hours following the accident. History revealed that sexualintercourse was the commonest ethiology (5 cases), followed by masturbation(2 cases) and a fall onto the erect penis as a consequence of heavy alcoholintake in one patient.
All patients refer to have heard a characteristic "crackingsound" during intercourse followed by immediate loss of erection, onsetof severe pain and swelling of the penis. The subsequent penile hematomawhich formed, brought about penile deformityand discoloration, which differed in severity from patient to patient.In one patient blood loss from the external urethral meatus was present(Fig.1) and another patient complained of the inability to urinate fromthe moment of the accident onwards (which occurred 12 h beforehand). In4 cases the hematoma and shaft deformity wereso severe that the patients immediately underwent explorative surgery withoutany further investigation (Fig.2). In the remaining 4 patients, presenting a more circumscribedhematoma, the site of injury was evidenced by means of contrast enhancedcavernosography. We were not able to identify the site of injury by simplypalpating the penis, as has been reported in the literature by others authors,in any of our patients. In two cases the lesion of albuginea was clearlyvisible during an ultrasound examination.(Fig.8) Two patients, one with a severe hematoma and one with a more limitedlesion, also had a urethral rupture. In both flexible cistoscopy was performedimmediately before surgery, and the urethral lesion was evidenced.
Operation was performed via a circumferentialsubcoronal incision. After evacuation of the hematoma (Fig.3) the corporeal tear was identified(Fig.4) and closed with a 4/0 PDS interrupted suture. In one case the lesionwas very large and reconstruction of the corpora was carried out by meansof a split thickness dermal graft harvested from the left thigh (Fig.5).
In two cases the corpus spongiosum and urethra were partiallysevered(Fig.6). Reconstruction was performed using a 6/0 polyglactin sutureafter debridment of the wound edges. In one case the urethral lesion wasalmost complete and located at the level of the corpora cavernosa tear.After urethral repair, a subdartoic vascularised blanket flap was wrappedaround the urethra to improve its healing and separate the urethra fromthe albuginea at the site of the lesion.
A 14 Fr. urethral Foley catheter was placed during surgeryin order to prevent inadvertent urethral damage (except in cases in whicha urethral injury was suspected) and removed 24 hours after the operation.In those patients in which the urethra was reconstructed, the catheterwas removed after 7 days. Perioperative antibiotic prophylaxis was institutedin all cases, our preference was a third generation cephalosporin.
RESULTS
Follow-up ranged from 2 months to 8 years (average 3.7years). There were no significant postoperative complications and the patientswere discharged from the hospital 3 days following operation. Six patientshave a normally conformed penis on erectionwith optimal functional and aesthetic result whilst two presented a mildcurvature due to residual fibrosis (Fig.7). These two patients underwent surgery 24 and 48 hours afterthe trauma, one has a follow-up which is too short to be significant (2months). All patients were potent as evidenced by means of pharmacological(prostaglandin) induced erection and patient questioning. Urethrographyand flexible cistoscopy demonstrated an excellent urethral healing at 8months and 1 year follow-up after urethral reconstruction.(Table2)
DISCUSSION AND CONCLUSION
In a literature review approximately 200 cases of penilefracture have been reported and 10% of these had an associated urethralinjury. Diagnosis is generally made from the history and physical examination.However, at times it may be difficult especially if urethral injury isnot suspected or the penile hematoma is limited, because hematoma is notpathognomonic for corpora cavernosa rupture. Preoperative cavernosographymust be strongly recommended in cases with limited hematoma or penile skinecchymosis because the extent of the lesion in corpora cavernosa is notalways comparable to physical signs, as mentioned above. In fact we observedone case of urethral rupture and two cases of a large albuginea tear (morethan 2 cm.) with only a limited hematoma and slight penile swelling. Ultrasoundexamination can evidence the albuginea defect when the subcutaneous oedemaand the hematoma are limited. When a urethral rupture was suspected followingurethral bleeding or an inability to urinate, then a preoperative flexiblecistoscopy examination is mandatory and allows one to pose the correctdiagnosis in all cases with minimal invasivity. Unlike urethrography, thismanoeuvre can be performed during the operation with a sterile techniquethus avoiding surgical field contamination and a waste of time.
We recommend immediate explorative surgery in the presenceof evident physical signs of major haemorrhage and penile deformity becauseultrasound diagnosis is more difficult in these patients due to the pronouncedsubcutaneous blood embedding and oedema. In these conditions a corporealalbuginea tear is present in 100% of patients.(Table1).
Prompt surgery gives better aesthetic and functional results,as evidenced by the two patients in our series with post-operative curvaturewho were operated after 24 and 48 hours. Experience with penile and urethralsurgery is important when a lesion is severe or associated to urethralinjury. In fact, surgical skills avoid postoperative complications suchas shaft curvature, corporal narrowing or urethral strictures. When a corporallesion is associated with urethral injury great care must be taken to avoidcontact between the severed spongious tissue and corporal tissue in orderto obviate the risk of post-operative impotence as a consequence of a spongio-cavernousfistula. For these reasons we think that a penile fracture does not require"emergency room" surgery but should be carefully evaluated and treatedfollowing strategies and tactics which are well known to experienced urologists.
Fig. 1: Flow-chart for surgical treatment of penile trauma
REFERENCES
1) Benet AE; Melman A : ìThe epidemiology of erectiledysfunction.î Urol Clin North Am, 1995 Nov, 22:4, 699-709
2) Goldman HB; Dmochowski RR; Cox CE: ìPenetrating traumato the penis: functional resultsî.J Urol, 1996 Feb, 155:2, 551-3
3) Ilkay AK; Levine LA: ìConservative management of high-flowpriapism.îUrology, 1995 Sep, 46:3, 419-24
4) Lazinger M; Beckmann CF; Cossi A; Roth RA : ìSelectiveembolization of bilateral arterial cavernous fistulas for posttraumaticpenile arterial priapismî. Cardiovasc Intervent Radiol, 1996 Jul-Aug,19:4, 281-4
5) Lehmann K; Schöpke W; Hauri D: ì Subclinical traumato perineum: a possible etiology of erectile dysfunction in young men.Eur Urol, 1995, 27:4, 306-10
6) Licht MR; Lewis RW; Sershon PD: "Immediate impotence afterpenetrating perineal trauma: restoration of erections with penile arteryrevascularization, corpus cavernosum aneurysm repair, and deep penile venousligationî. Urology, 1995 Oct, 46:4, 577-80
7) Matthews LA; Herbener TE; Seftel AD :îImpotence associatedwith blunt pelvic and perineal trauma: penile revascularization as a treatmentoption ì. Semin Urol, 1995 Feb, 13:1, 66-72
8) Rahmouni A; Hoznek A; Duron A; Colombel M; Chopin DK; MathieuD; Vasile N : ì Magnetic resonance imaging of penile rupture:aid to diagnosisî. J Urol, 1995 Jun, 153:6, 1927-8
