The role of ultrasound (US) and magnetic resonance imaging (MRI) in penile fracture mapping for modified surgical repair

A review of the literature and proposed algorithm for penile fracture management

INTRODUCTION

In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury.

OBJECTIVES

To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation.

METHODS

A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature).

RESULTS

The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature.

CONCLUSION

Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

Penile Ultrasound: An Essential Tool in an Emergency Setting (Traumatic and Non-Traumatic Diseases)

Penile conditions requiring urgent care are uncommon and result from trauma and a variety of non-traumatic causes. Some cases could rapidly evolve into an emergency situation and require prompt treatment to prevent severe complications. Therefore, correct and rapid diagnosis is fundamental. Although clinical history and physical examination are essential, diagnostic imaging is usually required to confirm the clinical diagnosis. In this setting, the sonologist in the emergency department has to be familiar with the basic US penile anatomy and with the most common US findings in urgent penile care. US is the key imaging method because it is readily available, safe, cost-effective, and well-tolerated by the patient. US can differentiate intracavernosal from extracavernosal hematomas and detect rupture of the tunica albuginea, consistent with penile fracture, that requires early surgical exploration. Color Doppler evaluation and spectral analysis are necessary to depict vascular abnormalities.

Penile Fractures: Evaluation and Management

Penile fracture is a urologic injury with an etiology that varies based on the cultural milieu. Diagnosis can be made based on history and physical examination alone. Patients should be evaluated with RUG or cystoscopy when urethral injury is suspected. Ultrasound or MRI is a helpful adjunct when the diagnosis is unclear, and can assist in identifying the location of the rupture. Surgical management is favored over conservative measures to improve outcomes. Delayed surgical repair may not be inferior to immediate intervention.

Fractures of the penis

A penile fracture is a traumatic rupture of the tunica albuginea of the corpora cavernosa in an erect penis, usually as a result of blunt trauma during sexual activity. The aetiology varies with geographical region, with the USA and Europe having a higher incidence of sexual trauma and the Middle East having a higher rate of self-manipulation. Diagnosis is usually clinical, but numerous imaging modalities have been used to confirm the fracture site and to help plan appropriate surgical management. Clinical examination will find a detumescent penis with a diffuse penile swelling and ecchymosis: the classic eggplant sign. The penis will often deviate away from the side of the injury. A history of the patient's inability to pass urine after the injury or of blood at the urethral meatus suggests an associated urethral injury. Immediate surgical management is the mainstay of treatment, with many surgeons favouring a degloving approach. Penile fractures also carry a risk of urethral tears and urethral repair may be necessary. This article describes the aetiology, presentation and management of penile fractures to enable identification and treatment in daily clinical practice.

The Management of Penile Fracture: a Review of the Literature with Special Consideration for Patients Undergoing Collagenase Clostridium Histolyticum Injection Therapy

PURPOSE OF REVIEW

To review the current literature on acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie's disease.

RECENT FINDINGS

The immediate repair of traumatic penile fracture injury is associated with significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury. Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.

MRI of the penis

This article reviews the anatomy and magnetic resonance imaging (MRI) appearance of the penis. The recommended technique for MRI of the penis is outlined, with discussion of the benefits and drawbacks to imaging the penis after artificial erection. Common penile pathologies are reviewed, with a summary of their clinical features, MRI appearance, and treatment. The ability to demonstrate the erectile bodies and vasculature helps to evaluate vascular pathologies such as priapism, Mondor disease, and cavernosal thrombosis. MRI is also a useful tool to assess for traumatic abnormalities of the penis, with the depiction of soft tissue anatomy and fascial layers allowing for evaluation of penile fracture and penile contusion. Malignant disease of the penis is also reviewed, including squamous cell carcinoma, urethral carcinoma, metastases, and rare neoplasms. Staging of these neoplasms is addressed, with discussion of how MRI can be used to assess the extent of tumor involvement. MRI also clearly demonstrates the tunica albuginea, which allows for evaluation of Peyronie's disease.

Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes

INTRODUCTION

The epidemiology of penile fractures in the emergency setting is not well described.

AIM

Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States.

METHODS

ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample.

MAIN OUTCOME MEASURE

Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated.

RESULTS

8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair.

CLINICAL IMPLICATIONS

A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity.

STRENGTHS & LIMITATIONS

This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community.

CONCLUSION

This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities. Rodriguez D, Li K, Apoj M, et al. Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes. J Sex Med 2019;16:248-256.

Surgical reconstruction for penile fracture: a systematic review

Penile fracture is a rare condition that describes the rupture of the corpus cavernosum following direct, high-pressure trauma to the erect penis. There is no standardized management algorithm for these patients. We performed a systematic review of the past 10 years regarding management of penile fractures. A complete PRISMA-P 2015 checklist was performed where we reviewed English articles published over the past 10 years to identify 105 articles, where 63 articles were of relevance and subsequently narrowed to a total of 28 articles into the final review for this study. We determined that immediate penile exploration and tunica repair is considered the most common and current management of penile fractures with experts demonstrating that it leads to the fastest in recovery in erectile function and positive cosmetic outcomes. However, we also determined that the specific algorithm can be variable-down to the suture material, use of catheterization, urethroplasty when involved, and length of recovery/follow-up. In the last several decades, men with penile fracture have been treated, in most cases, with immediate surgical intervention. This review highlights the varying practices regarding surgical exploration, injury repair, and postoperative management in men with a penile fracture. Immediate penile exploration and tunica repair have been the mainstay approach of management.

Multimodality imaging of the male urethra: trauma, infection, neoplasm, and common surgical repairs

OBJECTIVE

The aim of this article is to describe the indications and proper technique for RUG and MRI, their respective image findings in various disease states, and the common surgical techniques and imaging strategies employed for stricture correction.

RESULTS

Because of its length and passage through numerous anatomic structures, the adult male urethra can undergo a wide array of acquired maladies, including traumatic injury, infection, and neoplasm. For the urologist, imaging plays a crucial role in the diagnosis of these conditions, as well as complications such as stricture and fistula formation. While retrograde urethrography (RUG) and voiding cystourethrography (VCUG) have traditionally been the cornerstone of urethral imaging, MRI has become a useful adjunct particularly for the staging of suspected urethral neoplasm, visualization of complex posterior urethral fistulas, and problem solving for indeterminate findings at RUG.

CONCLUSIONS

Familiarity with common urethral pathology, as well as its appearance on conventional urethrography and MRI, is crucial for the radiologist in order to guide the treating urologist in patient management.

Acute penile trauma: imaging features in the emergency setting

In an emergency department, penile traumas are uncommon and a prompt diagnosis is necessary. Penile injury may result from penetrating and non-penetrating trauma. Non-penetrating injuries can produce cavernosal hematomas or fractures: if not treated promptly, these lesions can result in fibrosis or erectile dysfunction. Penile traumatic lesions need a clinical approach first, but a radiological study is often required: ultrasonography with color and spectral Doppler study is usually the first approach. In some cases, magnetic resonance imaging may be performed to better recognize even small discontinuity of the tunica albuginea. Radiologists have to be aware of the various radiological patterns of penile traumatic lesions, in order to establish a prompt and correct diagnosis.

MRI of the Penis: Indications, Anatomy, and Pathology

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

Efficacy of diffusion-weighted imaging in symptomatic and asymptomatic multiple sclerotic plaques

Introduction:

Magnetic resonance imaging (MRI) currently accompanies clinical findings in disease diagnosis, patients’ follow-up, assessment of drugs complications, and evaluation of treatment response. Although contrast-enhanced MRI (CE-MRI) is considered as the imaging modality of choice for multiple sclerosis (MS), due to disease chronicity, applying multiple doses of gadolinium-based contrast agents (GBCAs) increases the risk of nephrogenic syndrome in patients with acute (ARF) and chronic renal syndromes (CRF). Moreover, the effect of gadolinium on the fetus is not well-known in pregnant patients. Therefore, this study evaluates the possibility of replacing postcontrast images with physiologically based MRI sequences such as diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC).

Method:

We prospectively evaluated 26 patients with known multiple sclerosis. The patients with MS attacks and the asymptomatic patients who were referred for follow-up were enrolled. Conventional MRI including postcontrast T1W, DWI, and ADC were performed for all patients. The signal intensity (SI) of all enhancing and nonenhancing plaques of more than 10 × 10 mm size were investigated in all sequences and analyzed.

Results:

A total of 83 plaques were detected in T2-FLAIR sequences of which 51 plaques were enhanced (68%) after gadolinium administration. While 42 MS plaques had hypersignal intensity in DWI (56%), 32 plaques had iso- or hyposignal intensities in DWI (44%). No statistically significant values were obtained.

Conclusion:

Although DWI could not replace CE-MRI, using these two modalities together could increase detection of active MS plaques and alter patients’ therapy and prognosis.

Comparison of uterine and ovarian stromal blood flow in patients with polycystic ovarian syndrome

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders. The aim of this study was to find the correlation between color Doppler ultrasound and serum tests as auxiliary diagnostic criteria in areas where there is no possibility of some tests. A total of 108 patients were enrolled. They were divided into three groups including patients with PCOS, patients with PCOA ultrasound, patients with ovaries and normal hormone tests. Transvaginal sonography was performed from three groups and the results were evaluated in gray scale. The volume of the ovary, the number of follicles and the placement of follicles were recorded using using Doppler spectrum of uterine artery and ovarian stroma. Their arterial resistance index was also calculated. In the next step, serum samples were evaluated to determine the level of LH, FSH, free testosterone, DHEAS and 17-OHP hormones in the early follicular phase. Gray scale ultrasonographic findings (volume and number of ovarian follicles) as well as LH values were higher in patients with PCOS than those in the other two groups. These results proved the reliability of using these factors in the prediction of PCOS. In this study, Doppler indexes did not correlate with the size of the ovaries, the number of ovarian follicles and the measured hormone levels. The findings of transvaginal ultrasound and investigating the relationship with clinical and laboratory outcomes, a more suitable pattern could be chosen for more accurate patient selection and, leading to timely treatment and reducing the complications of the disease.

Color Doppler sonography of the aortic isthmus in intrauterine growth-restricted fetuses and normal fetuses

Intrauterine growth restriction is associated with a significant increase in morbidity and perinatal mortality, and increases the likelihood of fetal death, asphyxia, meconium aspiration, hypoglycemia, and neonatal hypothermia. The aim of this study was to determine aortic isthmus flow difference by using color doppler sonography in Intrauterine growth restriction and normal fetuses. The data presented were obtained from 30 mothers, who referred to the radiology department of Akbarabadi Hospital of Tehran with a diagnosis of intrauterine growth restriction. An ultrasound was performed to determine the status of placenta, fetus, and amniotic fluid. The umbilical arterial doppler assessment was used to confirm diagnosis of intrauterine growth restriction. Thirteen (43.3%) were nulliparous mothers and 17 (56.7%) were multiparous mothers. 30 pregnant women with healthy fetuses were enrolled as control group. According to the ultrasound findings, Dactus Venus wave type was recorded in intrauterine growth restriction fetuses, which was reported as normal (26 subjects; 86.7%) and abnormal (4 subjects; 13.3%). All together, this study provides appropriate guidance to use doppler for delivery timing and to control risk factors.

Marshall and Rotterdam Computed Tomography scores in predicting early deaths after brain trauma

Trauma is one of the most important issues of most healthcare systems accompanying with head trauma in the most cases. We sought to determine the scoring system and initial Computed Tomography (CT) findings predicting the death at hospital discharge (early death) in patients with traumatic brain injury based on Marshall and Rotterdam CT scores. This is a cross sectional study on traumatic neurosurgical patients with mild-to-severe traumatic brain injury admitted to the emergency department of Emam Reza Hospital, Birjand University of Medical Sciences. Patients≥18 years old with TBI during last 24 hours with GCS≤13 were included and exclusion criteria were multiple trauma, penetrating injuries, previous history of anticoagulant therapy, pregnancy, not willingness for participation. Their initial CT and status at hospital discharge, one and three months (dead or alive) were reviewed, and both CT scores were calculated. We examined whether each score is related to death using SPSS11 by The Mann-Whitney U at the level of p≤0.05. Overall, 98 patients were included. Mean age was 43.52±21.29. Most patients were male (63.3%). Mean Marshall and Rotterdam CT scores were 3.2±1.3 and 2.5±1. The mortality at two weeks, one moth and three months were 19.4%, 20.4%, and 20.4%. Rotterdam CT score was significantly different based on type of hematoma. Median GCS score in alive and dead patients on 2 weeks were 10 and 4 (p=0.0001), at one month were 10 and 4 (p=0.0001), and at three months were 10 and 4 (p=0.0001). The median Marshall CT score on 2 weeks were 2 and 4 (p=0.0001), at one month were 2 and 4 (p=0.0001), and at three months were 2 and 4 (p=0.0001). The median Rotterdam CT score on 2 weeks were 2 and 4 (p=0.0001), at one month were 2 and 3 (p=0.001), and at three months were 2 and 3 (p=0.001). The Rotterdam CT score was significantly correlated with mortality at two weeks, one month and three months (p=0.004, p=0.001, and p=0.001, respectively). The Marshall CT score was not significantly correlated with mortality at any time. The Rotterdam CT score was more accurate for prediction of mortality on 2 weeks (ROC80.9), at one month (ROC80.7), and at three months were (ROC80.7) than The Rotterdam CT score (ROC 76, 74.1, and 74.1, respectively). This study concluded that The Marshall CT score was more accurate for prediction of mortality on 2 weeks, at one month, and at three months were than The Marshall CT score with higher ROC. The correlation of the Rotterdam CT score with mortality was significant.