Optimal timing of surgical intervention for penile fracture: a narrative review of the modern literature

INTRODUCTION

Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts.

OBJECTIVES

This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes.

METHODS

We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles.

RESULTS

We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention.

CONCLUSION

Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

Isolated Penile Fracture and Complete Urethral Injury After a Motorcycle Accident: A Case Report and Literature Review

Tri-tubular penile fracture (PF) is a rare urological subdivision of PFs commonly caused by a blow to the erect penis during sexual intercourse or aggressive manipulation. PF associated with complete urethral injury and bleeding is an extremely rare presentation. This is a case report of a healthy 20-year-old male who presented to the emergency room after a motorcycle accident, experiencing rapid penile swelling and urethral bleeding. The accident happened while he was riding his motorcycle with a full erection. The patient reported a tearing sensation, immediate detumescence, and excruciating penile pain. A clinical diagnosis of PF was made, and the patient was immediately taken to the operating room for surgical intervention. At the three-month follow-up, the patient reported satisfactory erections and good voiding function. This case highlights the importance of immediate surgical intervention and urethral evaluation to avoid PF complications.

The Role of Magnetic Resonance in Evaluating Abdominopelvic Trauma - Part 2: Trauma in Pregnancy, Vascular, and Genitourinary Injuries

Trauma is an important cause of mortality, particularly in the young. While computed tomography (CT) is the mainstay of body imaging in the setting of trauma, magnetic resonance (MR) imaging can be useful in stable patients. Although more commonly used in spinal and musculoskeletal trauma, MR also has a role in abdominopelvic trauma. Broadly, its uses include clarification of equivocal cases, monitoring complications of trauma, particularly with solid organ injury, or as a primary imaging modality for patients with low suspicion for injury for whom avoiding ionizing radiation is a priority-namely, in pediatric and pregnant patients. In this two-part review article, we will review clinical scenarios where this may be encountered, utilizing case examples. Our second installment will focus on the use of MR in pregnant patients and in the characterization of vascular and genitourinary trauma. Body MR can be useful in pregnant patients in characterizing injuries both specific for and not specific for pregnancy. Placental injuries and hematomas in particular may be better seen on MR relative to CT, owing to its superior contrast resolution. MR angiography can be performed either without or with contrast and can be useful to monitor low-grade traumatic aortic injuries. Renal and ureteral injuries can be followed with MR to help identify urine leaks, either in a delayed presentation or in patients who have an iodinated contrast allergy. Lastly, penile injuries are often imaged with ultrasound, but may benefit from additional imaging with MR when the tunica albuginea cannot be completely seen due to overlying hematoma.

Catastrophic Complications of Circumcision by Traditional Circumcisers

Circumcision is one of the important public surgeries performed globally. It is a popular non-therapeutic procedure that can be performed by people of various abilities and skills, ranging from trained medical practitioners to non-specialists, depending on their cultural and social backgrounds. Consequently, this surgery may cause varying types and frequencies of complications. Glans amputation and death due to severe bleeding, as a complication of this procedure, are rare, and the patients are left with morbidity and life-long complications. Here, we describe two cases of catastrophic complications due to ritual circumcision (one penile glans amputation and one death).

Retained Bullet in the Penis

Gunshot injuries to the genitourinary system are extremely rare among trauma cases and represent a complex clinical scenario to physicians. This rare case involves a 20-year-old male with a retained bullet in his penis following a close-range, low-velocity gunshot wound to the right lateral thigh. Our case report examines this unique clinical scenario and the diagnostic approach that should be taken to decrease the chances of negative cosmetic and functional outcomes.

Isolated Injury to Prepuce After Motor Vehicle Collision

A four-year-old male restrained passenger in the rear seat was in a motor vehicle collision. He had pain and swelling in the tip of the penis with the inability to micturate. The patient on evaluation had an isolated injury of the prepuce. The patient underwent an evaluation to rule out underlying penile/urethra and associated injury of kidney and bladder. The patient had an isolated injury to prepuce, causing urinary retention for which he underwent circumcision.

Influences of Immunocastration on Endocrine Parameters, Growth Performance and Carcass Quality, as Well as on Boar Taint and Penile Injuries

Simple Summary

Surgical castration of male pigs is associated with pain. Improvac^®, a GnRH vaccine induces an endogenous immune reaction that leads transiently to a decrease in testicular steroid synthesis after second vaccination. Investigating consequences of different vaccination schemes revealed that GnRH vaccination reliably prevents boar taint, if the manufacturers’ recommendations are applied. It had beneficial effects on animal welfare as it reduced penile injuries. Animals showed improved feed efficiency, leaner carcasses, and lower PUFA (polyunsaturated fatty acids) percentages than surgically castrated animals. Thus, immunocastration offers a reliable and animal friendly alternative to surgical castration.

Abstract

Castration of male pigs without anesthesia is a significant welfare issue. Improvac^®, a GnRH vaccine induces an endogenous immune response leading to a decrease in testicular steroids. Consequences of different vaccination schemes on testicular function and carcass quality were evaluated in immunocastrated boars (IC), surgical castrates (SC), and entire males (EM). Therefore, 128 male piglets were assigned to five treatment-groups and a long term follow-up group. IC groups received two vaccinations (V1, V2) with Improvac^® at 8 and 12, 12 and 16, or 12 and 18 weeks. Testosterone-concentrations decreased significantly two weeks after V2 in feces and dropped in serum from V2 to slaughter (S) except IC-8/12 without differing significantly. GnRH-binding results indicated the highest values for IC-12/18 animals. While IC-12/16 and IC-12/18 animals showed boar taint compounds below the threshold levels, two IC-8/12 animals had concentrations above the threshold level. Feed-efficiency was higher in EM than in SC with IC in between. In IC compared to EM, a decreasing amount of polyunsaturated-fatty-acids was obvious and GnRH-vaccination reduced penile injuries. The examined vaccination protocols reduce penile injuries, improve feed efficiency and carcass quality, and reliably prevents boar taint, if manufacturer’s recommendations concerning vaccination schedules are applied. Therefore immunocastration offers a reliable, animal friendly alternative to surgical castration.

Stepwise approach in the management of penile strangulation and penile preservation: 15-year experience in a tertiary care hospital

Objective: To present our stepwise approach to the management of penile strangulation and penile preservation with 15 years’ experience in a tertiary care hospital, as penile strangulation is a rare urological emergency that requires immediate attention.

Patients and methods: A prospective observational study was performed from March 2003 to December 2018 of patients presenting with penile strangulation to our hospital.

Results: Nine patients with penile strangulation presented to us between March 2003 and December 2018. The most common motive for the application of a foreign body was sexual gratification (four patients). Three of the nine patients had a mental disorder. Objects used for strangulation included: metallic nut (three), metallic ring (two), plastic bottle (two), wooden hole (one), hammer head (one), and horse hair to control bleeding during circumcision (one). Most of the foreign bodies were located in the proximal penile region. The mean operative time was 38 min and three of the nine patients had complications.

Conclusions: Penile strangulation is one of the rare urological emergencies experienced by a urologist. Removal of the foreign body can be difficult and there is no universal method of removal, as each case differs. So, following our stepwise approach can aid in removal of foreign body quickly and preserve the penis from fatal outcomes. Urologist should be aware of all the available armamentarium used for the removal of such foreign bodies.

Abbreviation: SPC: suprapubic cystostomy

British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - penile amputation

Male genital emergencies relating to the penis and scrotum are rare and require prompt investigation and surgical intervention. Clinicians are often unfamiliar with the management of these conditions and may not work in a specialist centre with on-site expertise in genitourethral surgery. A series of consensus statements have been developed by an expert consensus committee comprising members of the British Association of Urological Surgeons (BAUS) Section of Andrology and Genitourethral Surgery together with experts from urology units throughout the UK. Penile amputation is a rare genital emergency, which requires prompt intervention and microsurgical reconstruction. The consensus statements will outline the management of these cases for non-specialist units, as well as recommendations for reconstruction for specialists.

Ultrasound-guided dorsal penile nerve block performed in a case of zipper entrapment injury

Injury to the penis resulting from zipper entrapment is a painful condition that presents a unique anesthetic challenge to the emergency physician and may even require procedural sedation for removal. In this case report, we describe successful removal of zipper entrapment from the penis of a 34-year-old patient after the application of an ultrasound-guided dorsal penile nerve block. We discuss the anatomy, sonographic features, and steps required for the nerve block procedure. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45:589-591, 2017.

Penile fracture epidemiology, diagnosis and management in Iran: a narrative review

Penile fracture (PF) is considered an emergency in urology. In the literature there are some case series reporting considerable incidence of PF in some parts of Iran. There are no accurate data about the incidence of PF all around Iran. Although it may be uncommon in other parts of the country and in the other countries, it can also be underreported. There are some challenges in diagnosis, management, and also reporting of these cases. In this review of Iranian medical literature, we searched for penile fracture and penile injury keywords in Medline, Scopus, SID, Google and Persian medical journals. We reviewed the status of epidemiology, etiology, diagnosis, management and complications of PF in different parts of Iran in the published literature. To collect more accurate data, we also performed a questionnaire-based study with sending questionnaires by emails to 700 urologists throughout the country with 14% response rate. Incidence of PF varies significantly in different parts of Iran. Western province of Kermanshah has a significantly higher rate of PF. Adding data from different regions of Iran, we calculated that incidence of PF in Iran can be estimated between 1.14 to 10.48 per 100,000 of male populations, most probably closer to lower end. Although the incidence of PF varies significantly in different geographical areas, urologists practicing in Iran on average may encounter a PF patient every 3.5 months. To diagnose PF, majority of reviewed studies relied on history and clinical examination and did not recommend imaging except in patients with possible urethral injuries. Immediate surgical intervention can make good functional results with low morbidity and short hospital stay. Delayed surgical intervention and observational management approaches need large population studies with long term follow up.

Penile self-harm: a case report and concise clinical review

Male genital self-mutilation is extremely rare and may be associated with severe psychopathology. This study reports the case of a 26-year-old man who presented after incising his prepuce with a knife and placing a rubber band around his foreskin. A plastic ring was also found underneath the prepuce. Clinical examination revealed a lateral preputial laceration with gross preputial oedema and dark red discoloration with a clear demarcation where the elastic band had been placed. A pelvic X-ray revealed no other foreign bodies. Following 72 h of observation he developed signs of preputial necrosis, which prompted urgent circumcision; this revealed a healthy underlying glans. In conclusion, male genital self-harm requires urgent urological and psychiatric assessments to prevent surgical and psychiatric sequelae including necrotizing fasciitis and suicide.