ABSTRACT
This case
report highlights various aspects of penile fracture, which is a rare
urological emergency . The incidence of
penile fracture is slightly increasing these days, may be due to performance
enhancing medicines. It being a medical
emergency patient must seek immediate medical support. A swift diagnosis and management is essential
to avoid undesirable after effects as discussed. This presentation delineates on how
sonography helps to make a complete diagnosis of this condition.
Key words :
Penile fracture , sonography , penile trauma, tunica albuginea
INTRODUCTION
Penile
fracture is due to rupture of the tunica albuginea sheath covering the erectile
corpora cavernosa. It may involve one or
both corpora cavernosa. The condition is
usually under reported due to ethical and phychological reasons observed by the
patients . The diagnosis of fracture
penis is usually clinical . The
sonography is asked when the observations are
atypical , and to confirm the
diagnosis , and to evaluate site, size, orientation and extend of tunical injury along with
penile soft tissue status and hematoma.
CASE
REPORT
A 36 years
old man presented with development of sudden painful swelling and deformity of the
penis following sexual intercourse.
After having strong clinical suspicion of penile fracture, the urologist
referred the case for sonographic evaluation .
Sonography of penis was done with
high resolution linear probe in
longitudinal , transverse, oblique and horizontal planes with the region of
interest in detail. USG showed diffuse
skin and soft tissue thickening of penis with a small defect in the continuity
of tunica albuginea [an echogenic line encircling hypoechoic cavernosa] of Left
lateral corpora cavernosa of penile mid shaft [fig 1-3 ]. The defect was about 15 mm in size & transversely
oriented with a large inhomogenic
hematoma noted overlying it. The
hematoma was seen as inhomogenic
echopoor & avascular mass adjacent to defect [ fig 1-3] . Rest of the corpora and spongiosa appeared
normal. Both cavernosal arteries showed normal
to little low resistance blood flow pattern [fig 4]. No evidence of corpora spongiosa or urethral
injury was seen . So, based on these
ultrasound findings [ that is - cavernosal tunical sheath tear with associated
hematoma ] a diagnosis of penile fracture was made and a detailed report was furnished . The case was then urgently operated by the
urologist [ tunical repair and hematoma drainage ] and the findings were
confirmed[fig 5-8 ]. Post operative recovery
was uneventful , & the patient behaved normally for erectile function in subsequent follow-up visits.
Fig 1 –
Transverse US penile scan shows defect
in tunical sheath of left corpora cavernosa on lateral aspect [ arrow] with
adjacent hematoma
Fig 2-
Horizontally oriented longitudinal penile scan showing tunical sheath defect [ arrow] &
overlying penile shaft hematoma.
Fig 3- Both
TS & LS color Doppler penile scans showing sheath defect , avascular
hematoma & average vascularity in
rest of penile shaft.
Fig 4 –
Spectral Doppler display left cavernosal
artery
Fig 5 – Per
op. photograph showing subcut. Penile shaft hematoma
Fig 6 – Per
op. photograph depicting sheath defect
Fig 7 –
Photograph after tunical sheath repair
Fig
8 – Photograph after complete penile
surgery
[ Operative
photographs courtesy – Dr. Manish Bhansali ,M.S. , D.N.B.{Urology},
Bhilwara]
DISCUSSION
Penile shaft
consist of two elongated columns of erectile tissue called corpora cavernosa
placed dorsolaterally , and a corpus spongiosum ventrally containing erectile tissue and urethra. Each column is enclosed in tunica albuginea
sheath which is extension of Buck’s fascia over these cylindrical structures [
1, 2] . During erection these corporas
enlarges due to blood pooling in vascular sinusoids and the tunica albuginea is
thinned . Any extrinsic bending force to erected penis causes rupture of
tunica due to rapid rise of inside pressure in corporas. Activities like masturbation , self manipulation,
sexual intercourse , and rolling over bed, can cause penile trauma and result
in fractures. Vaginal intercourse being
the most common cause [ 3 ] . Increased
use of drugs which enhance the duration of erection [ 4 ], pre-existing penile
disease or periurethral infections [ 5 ] increase the chance of penile
fractures. The affected person usually
complain [ 1 -2 , 5 ] hearing of , or feeling , a sudden crack or snap in the penis with sudden loss of erection and resultant swollen, deviated, painful
penis . In most of the cases usually one
side of distal two third of penile shaft is fractured with less than half of
cavernosal circumference affected.
Associated hematoma may be intra- cavernosal , intra and or extra
cavernosal or may extend to scrotum, suprabubic area, perineum, and in some
cases , even upto thighs . Associated
urethral injury may present as hematuria and dysuria.
The
diagnosis of penile fracture is usually clinical, however not possible make or may be inconclusive sometimes
, needs further imaging . The modalities
available are cavernosography, sonography [ USG ] and MRI to confirm and
identify penile fractures. MRI being
multiplanar and with good soft tissue
resolution scores over other modalities , however , for practical purposes,
sonography preferred over MRI as it is easily available , cost effective ,
portable radiation free , less time consuming and allows dynamic evaluation of
the region of interest [ 6 ]. High
resolution sonography clearly depicts penile soft tissue anatomy , outline of
corporas including status of tunica albuginea sheath and associated hematoma .
Loss of continuity or defect in tunica albuginea with associated hematoma
signifies fracture of penile shaft [ as seen in this case] .
These
patients requires early surgical treatment in form of hematoma removal and tunical repair , which
has been stated better than conservative measures [ 3, 5 ] , as this reduces
the chance of scarring , angulation deformity and painful erection syndrome
consequences.
This patient
was immediately subjected to surgery, which was uneventful, & showed normal
postoperative recovery. The patient gave history of satisfactory penile erection in his follow up
visits .
So, it is
worth to know about this urogenital emergency by the Doctors , so as to make a
swift diagnosis of “ fracture penis “ and to refer such a case for appropriate
mamagement to avoid devastating physical, functional and psychological consequences.
CONCLUSION
A case of penile
fracture needs to be diagnosed and treated promptly to avoid complications
. Ultrasound is considered to be an
imaging modality of choice in emergency
as it is noninvasive, cost effective , radiation free , easily and widely
available and can be repeated even at bed side . All Doctors must be aware of this entity in all aspects including
clinical perspective , knowing about imaging findings and realising urgent need
for treatment to avoid complications.
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textbook of anatomy. 5th
ed. Philadelphia, Pa: Lippincott-Raven; 1997. pp. 639–700.
3. Ruckle HC, Hadley HR, Lui PD. Fracture
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