SONOGRAPHIC EVALUATION OF FRACTURE PENIS

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.

REFERENCES

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2. Rosse C, Gaddum-Rosse P. Pelvis and perineum. In: Rosse C, Gaddum-Rosse P, editors. Hollinhead’s textbook of anatomy. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997. pp. 639–700.

3. Ruckle HC, Hadley HR, Lui PD. Fracture of penis: diagnosis and management. Urology.1992;40(1):33–35. [PubMed]

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7. S. G. Kachewar et al , Ultrasound Evaluation Of Penile Fracture , Biomed Imaging & Interventional Journal  2011 oct-dec ; 7[4]: e27.