Penile fracture: role of ultrasound

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 fracture: a case series of 18 patients

Introduction

Penile fractures are a rare urological emergency. It is defined as 'rupture of the tunica albuginea of one or both corpora cavernosa. The corpus spongiosum and the urethra may also be involved in this process.' The tunica albuginea is stiff and significantly thinner during erection than in the flaccid state, which is when injury generally happens.

Method

This case series was completed between January 2018 and January 2023 at the Department of General Surgery. Eighteen patients suspected of having penile fractures participated in were included this study. All patients were thoroughly evaluated upon hospital admission to identify the diagnosis, length of time since the accident, the site of the fracture, the extent of the penile hematoma, occurrence of blood at the external meatus, presence of urine retention, and intraoperative outcomes.

Results

The patients were between the ages of 24 and 70, with a mean age of 37. The duration before the presentation ranged from 7 h to 1 month (the median was 22 h). Sexual intercourse was the cause in 12 (66%) cases, rolling in the bed in three cases (16%), and blunt trauma in three cases (kicking and the edge of the bed) (16%). Pain and swelling were present in all of the patients. In 15 patients (or 83%), there was evidence of penile deviation. At presentation, 15 (72%) patients reported experiencing rapid detumescence, discomfort, and penile swelling after hearing a cracking (popping) sound. None of these individuals experienced urine retention or urethral hemorrhage, and all were emptied on their own following the episode. Physical examination showed penile ecchymosis, swelling, and substantial discomfort when the penile shaft was examined. All but three patients had an evident penile deformity. Surgery was performed under spinal anesthesia in 14 (77.7%) patients. Four patients with a delayed presentation (more than 1 week) were managed conservatively.

Conclusion

As a true urologic emergency, penile fractures should be treated immediately to reduce pain and swelling and ensure better functional and esthetic outcomes. Despite taking more time, a subcoronal circumcising degloving incision is the ideal method because it is exploratory and esthetically pleasing.

Imaging for the Initial Staging and Post-Treatment Surveillance of Penile Squamous Cell Carcinoma

Although relatively rare in the United States, penile squamous cell carcinoma is encountered worldwide at a higher rate. Initial diagnosis is often made on clinical exam, as almost all of these lesions are externally visible and amenable to biopsy. In distinction to other types of malignancies, penile cancer relies heavily on clinical nodal staging of the inguinal lymph node chains. As with all cancers, imaging plays a role in the initial staging, restaging, and surveillance of these patients. The aim of this manuscript is to highlight the applications, advantages, and limitations of different imaging modalities in the evaluation of penile cancer, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography.

A Self-Inserted Foreign Body in the Urinary Bladder and Urethra

Foreign objects in the lower genitourinary system are a rare urological emergency often associated with self-eroticism, drug intoxication, or psychiatric illness. In addition to clinical examination, multiple imaging modalities such as X-ray, ultrasound, computed tomography, and magnetic resonance imaging have been used for the diagnosis of foreign bodies. Surgical exploration and endoscopic extraction are the main approaches to the treatment. Here, we present the case of a 37-year-old male who presented to the emergency department with penile and urethral pain caused by an electrical wire inserted into the urethra. The electrical wire was protruding 15 cm from the urethral meatus. A 50 cm long cable was extracted from the urethra and urinary bladder under regional anesthesia. This case is remarkable for the length of the foreign body and the depth to which it was inserted reaching into the urinary bladder. Emergencies related to sexuality or unconventional sexual preferences can lead to avoidance or delay of medical treatment, which, in turn, can result in a higher risk of complications. The examining doctor should be sensitive to secretive and insecure behavior and should be considerate of the patient’s privacy to facilitate a thorough physical examination.

Risk factors for penile fracture compared with a surgical control cohort in the United States: the role of substance abuse

Penile fracture (PF) is a surgical emergency. Given its rarity, we queried a national cohort over an 11-year period to study the temporal and demographic variations in presentation, evaluation, and management of patients with PF compared with a cohort of control patients. The National Inpatient Sample was queried between the years 2005 and 2016 for patients with a diagnosis of PF. Appendectomy patients were selected as a control cohort, given the non-discriminatory nature of this disease. Clinical and demographic data of the patients were compared with that of controls. Presenting symptoms, rates of surgical repair, and rates of associated surgical procedures were evaluated in the PF cohort. During the study period, 5802 patients were hospitalized for PF. The annual incidence of PF remained unchanged at 1.0-1.8 cases per 100 000 hospitalizations over the study period. Compared with the control cohort, PF patients were more likely to be younger (38.7 years vs 41.2 years, P ≤ 0.001), have lower rates of comorbidities except erectile dysfunction (1.4% vs 0.1%, P ≤ 0.001), and were more likely of Black race (25.4% vs 6.2%, P ≤ 0.001). Notably, PF patients had significantly higher rates of substance abuse (26.4% vs 18.1%, P ≤ 0.001), despite no difference in the diagnosed psychiatric disorders. PF rarely presented with hematuria (3.5%); however, urethral evaluation was performed in 23.1%, most commonly with cystoscopy (19.2%). PF occurs more commonly in a younger, healthier male population, and among minorities. Importantly, rates of substance abuse appear to be higher in the PF cohort compared with those of controls.

Findings regarding non-sexual penile fracture in a referral emergency hospital

Purpose:

To describe penile fracture (PF) findings with non-sexual etiology in a referral emergency hospital, with emphasis on demographic data, clinical and intraoperative findings and long-term outcomes.

Materials and Methods:

Patients with PF of non-sexual cause operated at our institution from January 2014 to January 2019 were submitted to surgical treatment and monitored for at least three months after surgery. Etiology of trauma, epidemiological and clinical presentation data, time to intervention and operative findings were reviewed retrospectively. The evaluation of postoperative erectile function was carried out by filling out the International Index of Erection Function - 5 (IIEF-5). The tool used to assess urinary function was the International Prostate Symptom Score (IPSS) questionnaire.

Results:

Of a total of 149 patients submitted to surgical treatment for PF, 18 (12%) reported non-sexual etiology. Twelve (66.6%) cases were due to penile manipulation through the act of bending the penis during morning erection, three (16.6%) when rolling over in bed with erect penis, one (5.5%) when embracing the wife during erection, one (5.5%) to laying on the partner with erect penis and the other (5.5%) when sitting on the toilet with an erection. Operative findings were unilateral corpus cavernosum injury in all cases. Only one (5.5%) patient had a partial urethral lesion. Follow-up time varied from 3 to 18 months (mean, 10.1 months). Three (16.6%) patients developed erectile dysfunction six months after surgery. However, all of them responded to treatment with IPDE-5 and reported improvement of erection, with no need for medication, on reevaluation after 18 months. One (5.5%) patient developed penile curvature < 30 degrees. Thirteen (72.2%) patients developed penile nodules. No patient presented voiding complaints during follow-up.

Conclusions:

PF is a rare urologic emergency, especially with the non-sexual etiology. However, PF should always be considered when the clinical presentation is suggestive, regardless of the etiology. Penile manipulation and roll over in bed were the most common non-sexual causes. These cases are related to low-energy traumas, usually leading to unilateral rupture of corpus cavernosum. Urethral involvement is uncommon but may be present. Early treatment has good long-term clinical outcome, especially when performed in specialized centers with extensive experience in FP.

Penile fracture in a Peyronie’s disease patient: a case report

Background

Penile curvature in men with Peyronie’s disease (PD)—caused by tunica anchoring plaques with loss of focal fiber elasticity—theoretically increases the risk of penile fracture during sexual activity. Penile fracture is the result of tearing of the tunica albuginea of one or both corpora cavernosa, usually during sexual intercourse, and is among the most serious urological emergencies. Generally, a patient presented to a surgical emergency within 48 h of injury can be handled successfully with minimum complications. Immediate surgical treatment is the current standard of care and has a relatively low risk of late complications.

Case presentation

We present a case of penile fracture in a male with a history of PD referred to the emergency department with severe pain. Clinical history assessment and physical examination revealed a penile fracture with underlying PD. He underwent emergency surgical exploration via subcoronal incision. Penile plication was not necessary for our case because the angulation of the penis was less than 15° after examination of artificial erection.

Conclusion

Penile fracture in a patient with underlying PD is a rare urological emergency that should be treated surgically with fracture repair as early as possible. Penile plication might be necessary in severe cases (angulation > 60°).

Diagnostic utility of penile ultrasound in Peyronie's disease

PURPOSE

To review the literature regarding the use of penile ultrasound in the evaluation and management of Peyronie's disease.

METHODS

A literature review was performed using PubMed from 1980 to 2018 using the keywords: Peyronie's disease, ultrasound, sonography, calcification, penile fracture, and penile hematoma. Articles were reviewed for study size, image protocols, and findings. In addition, we reviewed images from 227 penile ultrasounds performed on Peyronie's disease patients at the Walter Reed National Military Medical Center between 2014 and 2018.

RESULTS

Through extensive urological and radiographic literature review over the last four decades, common patterns and characteristic of Peyronie's plaques were identified. These characteristics are not always delineated by physical examination alone. The ultrasound images often added objective information including etiology of erectile dysfunction and location or plaques, and presence of calcifications which aid in patient counseling and treatment protocols.

CONCLUSIONS

The use of B-mode ultrasound with color Doppler in the evaluation and management of Peyronie's disease is a quick, cost-effective process that provides objective information that can assist the urologist in the treatment of patients with Peyronie's disease.

Penile fracture and investigation of early surgical repair effects on erectile dysfunction

OBJECTIVES

Penile fracture is one of the urological emergencies caused by direct trauma to an erect penis during sexual intercourse, which results in a tear in the tunica albuginea within the corpus cavernosum. Serious complications such as penile curvature and erectile dysfunction may develop due to inappropriate and/or late surgical repair. This study aims to evaluate patients with penile fracture and to describe their demographics, surgical repairs, and long-term outcomes.

MATERIALS AND METHODS

A total of 56 patients who were diagnosed with penile fracture between January 2012 and June 2017 were reviewed. Clinical features, pre-operative assessment, time from injury to surgery, tunica defect properties, and presence of urethral injury were assessed. Early surgical management was performed. Outcomes, including International Index of Erectile Function 5 pre-operation and after 6 months, were evaluated.

RESULTS

The mean age was 30.2 (18-57) years. In etiological questionnaires, 32 (57.2%) patients reported direct trauma to an erect penis during intercourse. The mean size of tunica defects was 1.61 ± 0.42 (0.3-3.6) cm of the nine (16%) patients, and penile fracture was associated with urethral injury. There was no significant difference in International Index of Erectile Function 5 scores before the surgery and 6 months after surgery. Penile skin necrosis developed in one patient 10 days post-operation.

CONCLUSION

Early surgical repair could be an effective method of achieving post-operative erection success in patients with penile fracture due to direct trauma during intercourse.

Nail Scissor as a Rare Foreign Body in the Urethra: Case Report

Foreign bodies in the urethra are rare in the literature. A majority of the foreign bodies administered in the urethra are because of a psychiatric disorder, senility, intoxication, and self-erotic stimulation. Clinical examination and imaging tests, such as X-ray, ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) have been used for the diagnosis of foreign bodies. Surgical exploration or endoscopic extraction are the main approaches to the treatment. This case report deals with a 45-year-old male patient who was admitted with urethral pain to the emergency service. A nail scissor was diagnosed in the urethra and endoscopic extraction was performed under regional anesthesia.