The value of magnetic resonance imaging in the diagnosis of penile fracture

Long term complications of penile fracture repair: Erectile dysfunction and penile curvature

OBJECTIVE

To determine the factors that cause erectile dysfunction and penile curvature after repair of penile fracture (PF).

METHODS

Data from 25 patients who underwent PF repair was retrospectively analyzed. PF was diagnosed by examining patients' medical histories and performing physical examinations. All patients underwent immediate PF repair. All patients filled out the International Index of Erectile Function (IIEF-5) form and penile curvature was examined.

RESULTS

The median age of patients at the time of surgery and the median follow-up duration were 46 years (22-60 years) and 95 months (12-156 months), respectively. Two of the patients had concomitant urethral injury. At the final follow up, erectile dysfunction (ED) was present in 13 patients (52%). Among these patients, 9 patients (36%) had mild ED and 4 patients (16%) had moderate ED. With a univariate analysis, age and penile curvature were significantly associated with ED (p=0.008 and p=0.039, respectively). With a multivariate analysis, age was independently associated with ED (p=0.048, odds ratio=1.104, 95% confidence interval 1.000-1.218). The IIEF-5 scores correlated with age (p=0.009, r=0.510). Seven patients (28%) had penile curvature and one patient underwent penile plication surgery.

CONCLUSION

After PF repair, age is the only risk factor for ED and penile curvature rarely requires surgical treatment.

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.

Design of a RF-resonant set improving locally the B1+ efficiency. Applications for clinical MRI in andrology and urology

Modern diagnostic imaging methods for andrology and urology fall behind other well-developed applications such as cardiology or neurology. Particularly, MRI despite its superior soft tissue contrast is hardly used for MR-imaging of the penis, primarily due to the lack of the corresponding receive or transmit coils. In order to fix this, a new radio frequency resonator, based on the birdcage operating principles has been designed, simulated, fabricated, tested and compared experimentally to existing RF coils. In order to provide high transmit efficiency and high sensitivity, while maintaining the coil safety, the resonator spatially separates alternating magnetic and electric fields. The transmitted magnetic field (B1+) is concentrated in the centre of the imaging volume, while the electric field remains on its edge and does not lead to tissue heating. The resonator design was optimised for human MRI in 1.5 T scanners. Both simulations and experiment showed the resonator to provide around 100-fold specific absorption rate reduction, around 10-fold improvement of the transmit efficiency and more than 10-fold enhancement of the signal to noise ratio (SNR) in a phantom compared to the body coil, around 2-fold SNR enhancement in a phantom compared to the commercial flexible 4-element coil, and up to 1.5-fold enhancement compared to the same coil in-vivo.

The value of pre-operative MRI in management of penile fractures

Penile fracture is a urological emergency which requires urgent assessment and surgical intervention to avoid long term complications. In this report, we describe a case in which penile MRI was used for initial assessment and surgical planning. This allowed exact localisation of the tunical tear and allowed direct incision over the tear for repair. In this case, the man avoided circumcision, which would be often required with the conventional degloving approach.

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.

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.

Fracture With Urethral Injury: Evaluation by Retrograde Urethrogram

Penile fracture is a rare condition. It primarily involves the rupture of the corpus cavernosum during erection, which may also affect the corpus spongiosum and urethra. We describe the case of a 35-year-old man who presented with acute penile pain, penile swelling, and a hematuria after a blunt trauma during sexual intercourse. The emergency retrograde urethrogram revealed a rare condition, extravasation of the opaque material from the penile urethra into the cavernous structure. The partial rupture of the corpus cavernosum with urethral disruption was repaired surgically. At the 3-month postoperative follow-up control, no complications were reported by the patient who has had both normal erectile and voiding functions. In cases of penile fracture with suspected urethral injury, retrograde urethrogram can be used for definitive diagnosis.

Current Management of Penile Fracture: An Up-to-Date Systematic Review

INTRODUCTION

Because of the low incidence of penile fracture, many aspects of the diagnostic process and of the surgical and functional outcomes are rarely reported.

AIM

To systematically review the current literature on the surgical management of penile fracture, focusing on etiology, diagnosis, functional outcomes, and postoperative complications.

METHODS

The present review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration standards for systematic reviews. A systematic search for the terms penile fracture, fracture of penis, trauma of penis, rupture of corpora cavernosa, and immediate management of penile fracture was been carried out in the PubMed, EMBASE, Cochrane, SCOPUS, and Science Citation Index databases.

MAIN OUTCOME MEASURES

Etiology of penile fracture, clinical presentation, types of radiologic investigations and their accuracy, surgical approach, suture material used for tunica repair, timing of surgical exploration, intraoperative findings, surgical complications, and functional outcomes.

RESULTS

The total number of patients analyzed was 438, and the patients' an average age was 36 years. The most frequent reported cause of penile fracture was sexual intercourse (80% of cases). The most common finding at examination was a penile hematoma (97.5%). Although operator dependent, in experienced hands, ultrasonography was found to be a useful tool in confirming the location of the albuginea tear and identifying the presence of any concomitant urethral injury, helping the surgeon to choose the best surgical approach. Early surgical repair of a penile fracture was found to be a safe procedure, although long-term complications are not uncommon. Tertiary referral centers that managed a larger number of cases seemed to obtain more satisfactory long-term results with a significantly smaller number of complications.

CONCLUSION

A low incidence of postoperative complications and full satisfactory functional outcomes are reported when early repair is performed in high-volume centers. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current Management of Penile Fracture: An Up-to-Date Systematic Review. Sex Med Rev 2018;6:253-260.

Isolated Spongy Urethral Rupture from Abrupt Coital Distractive Force

The classic presentation of penile fracture is a cracking or snap sound, with sharp pain, immediate detumescence, swelling, deformation and ecchymosis. A penile fracture involves rupture of the tunica albuginea of one or both corpora cavernosa. Concomitant urethral rupture is reported to occur in 10% to 20% of penile fracture cases. Isolated urethral injury without penile fracture is extremely rare. We report the first case of isolated pendulous urethral rupture from an abrupt coital distractive force. We include a literature review and discussion of isolated urethral trauma secondary to sexual intercourse. Retrograde urethrography rendered a stunning clinical image which was integral to the diagnosis and management of this patient's injury.

Efficacy of magnetic resonance imaging for diagnosis of penile fracture: A controlled study

Purpose

To evaluate the diagnostic value of magnetic resonance imaging (MRI) in patients with suspected penile fracture.

Materials and Methods

A total of 122 patients admitted to our inpatient clinic with a suspicion of penile fracture following a recent history of penile trauma and who underwent surgical exploration were included this study. A thorough physical examination, a detailed medical history, description of the trauma, and preoperative International Index of Erectile Function (IIEF) scores were obtained for each patient prior to surgery. Thirty-eight of these patients were evaluated with MRI before the surgical exploration. Intraoperative findings were also recorded. Physical findings and IIEF scores were also recorded at postoperative 6 months.

Results

The mean age of our patient group was 36.5±12.3 years. Penile fracture was detected in 105 of 122 patients in whom surgical exploration was performed owing to a suspected diagnosis. The mean time interval from penile trauma to hospital admittance was 9.9±15.1 hours. No cavernosal defect was detected in 9 of 84 patients (10.7%) who were not evaluated with MRI prior to surgery. Compared with surgical exploration, MRI findings showed 100% (30 of 30) sensitivity and 87.5% (7 of 8) specificity in the diagnosis of penile fracture. MRI had a high negative predictive value of 100% (7 of 7) and a positive predictive value of 96.7% (30 of 31) with just 1 misdiagnosed patient.

Conclusions

MRI is a reliable diagnostic tool in the diagnosis of penile fractures. Compared to history and physical findings taken all together, the high sensitivity and specificity of this imaging technique can decrease the number of unnecessary surgical explorations.

The role of ultrasonography in the diagnosis and management of penile trauma

PURPOSE

In this prospective study, we studied the role of ultrasonography (US) in the diagnosis and management of penile trauma.

METHODS

Between 2007 and 2014, 14 patients (mean age 39 years) with suspected penile fracture underwent US examinations. Almost all patients had a history of injury during sexual intercourse or manipulation of the penis. US examinations were performed in transversal and longitudinal planes starting at the level of the glans and moving down to the base of the penis. Color-Doppler was used to identify the vascular pattern or to see any abnormal vascularity.

RESULTS

The most common blunt injury to the penis that occurred in nine patients was penile fracture due to rupture of the corpus cavernosum. A tear occurred in only one of the corpora cavernosa. US showed an irregular hypoechoic or hyperechoic defect at the cavernosal rupture site. Four patients presented an injury to the subtunical venous plexus in the absence of complete tunical disruption. One patient had urethral rupture with inability to urinate and apparent urethrorrhagia. Ten patients underwent surgical operation, while four patients were observed and discharged after 2 days. Mean follow-up was 32 months (range 3-58). After 8 to 12 weeks, all of them were able to be sexually active as before. Angulations of penis persisted in one patient.

CONCLUSION

US may be the preferred imaging technique for evaluation of penile fracture before surgery. It is easy to perform, non-invasive, widely available, and inexpensive, although it requires an experienced team.