Surgical our experience in patients with penile fracture – part 2

Surgical our experience in patients with penile fracture – part 2

FINDINGS

The mean age of the patients who were admitted to the emergency with sound of a sudden fracture in the penis was 39.22 ± 14.47 (19-67). (Table 1). The time elapsed from the occurrence of the case to the admission to hospital was found to be 4.33 ± 1.97 hours (2-8 hours). In the history of the patients, penile fracture occurred due to the forceful manipulation of the penis in 5 patients (27.8%), during turning in the bed during sleep in 5 patients (27.8%) , during sexual intercourse in 6 patients (33.3%) and during masturbation in 2 patients (11.1%).  (Table 2). Bruise, hematoma and swelling of the penis revealed in the physical examination. In addition to these findings, butterfly-shaped bruise extending through the pubis was observed in 2 patients. While twelve of the patients were operated under spinal anesthesia, 6 patients underwent general anesthesia. Determined during operation mean tear size in tunica albuginia was 12.66 ± 3.06 mm (8-20mm) and consistent with ultrasonography. While 11 (61.1%) of the defects were detected in the right corpus spongiosum, 7 (38.9%) were detected in the left corpus spongiosum.   The tunica albuginea defect was located in the distal penile in 14 patients (77,8%), in the midpenil in 3 patients (16,7%) and in the proximal penile in 1 patient (5,5%). The mean hospital stay was 3 ± 0.90 days (2-5 days). As the preoperative IIEF-5 scores of the patients could not be reached, no calculations can be made, while in late postoperative period the IIEF-5 score was 26.05 ± 1.55 (23-29). (Table 1).

RADIOLOGICAL EVALUATION penis

DISCUSSION

The penile fractures, majority of which is caused by blunt trauma, is an urological emergency. Anamnesis and physical examination are typical. The incidence is not known clearly, but most cases are reported from Mediterranean and Far East countries (2,13,14).  Thickness of the tunica albugine, which is 2 mm thick in flask, decreases up to 0.25 mm in erection and penile fracture occurs mostly due to intracavernosal pressure increase due to trauma (6,15). The laseration is generally in the transverse direction. Tunical rupture is mostly unilateral, occurs in the distal penile region and does not exceed the diameter of the corpus cavernosum (16). A fracture of the penis can affect further potency and the likelihood of erectile dysfunction. To avoid erectile dysfunction, you can start treatment with Generic Viagra. But before any treatment you should consult your doctor.

In more than half of the penile fracture cases, a change in position during sexual intercourse is reported in the etiology. Manual manipulations during masturbation and sudden movements during sleep can cause it less frequently. In the studies reported from the Middle East and Arab countries, it is seen that it was formed by manual twisting of the penis to stop hardening in ¾ of the patients (17). The fact that patients do not give correct anamnesis because of embarrassment prevents their etiological causes from being fully revealed. In our study, penile fracture was observed due to the forceful manipulation of the penis in 5 patients (27.8%), turning in bed during sleep in 5 patients (27.8%), during sexual intercourse in 6 patients (33.3%) and masturbation in 2 patients (11.1%). Our findings were consistent with the literature.

Given the literature, the age range determined for penile fracture is between 16-82 (18). The mean age of our patients was 39.22 ± 14.47 years (19-67 years) and was consistent with the literature. The typical history of the patients is the sudden refraction sound, followed by loss of erection, swelling, bruising, and penile deviation on the opposite side of the fracture. The hematoma, which is the cause of swelling and bruising, is mostly limited to Buck’s fascia. Occasionally, the hematoma may cross the Buck fascia and be confined to the Colles fascia; which leads to a butterfly-like appearance extending to pubis and perineum (19). Only 1 of our cases had bruises extending to the pubis and perineum.

Anamnesis and physical examination are usually adequate but radiological imaging may be required in unclear cases. In the radiological imaging, superficial penile ultrasonography, penile color doppler ultrasonography, MRI, cavernosography are the modalities used commonly. Ultrasonographic examination of the presence of hematoma, integrity of the tunica, defect size can be determined (20). Superficial penile ultrasonography was performed in all patients.

Penile fracture cases may be accompanied by urethral injury. This ratio varies between 10% and 30% in series (21).  Urethrageia and/or urinary failure may occur in these patients. Retrograde urethrography is helpful in these patients. None of our patients had urethrorage.

Early surgical repair is important for penile fracture treatment. There are also publications defending the conservative treatment approach. Strict bandage, cold application, foley catheter insertion, antibiotherapy, fibrinolytic therapy and antiinflammatory treatment are applied in the conservative treatment. In the surgical treatment, hematoma is evacuated, followed by bleeding control and ruptured primary is repaired. As a result of conservative treatment, painful erection, penile deviations and arteriovenous fistulas and related erectile dysfunction can be seen (22,23). The success rates of these two studies comparing these two treatments were 92% in the surgical treatment group and 59% in the conservative treatment group (24). We applied early surgical treatment to all of our patients.

It was seen that morbidity rates of the patient who underwent surgical treatment were lower and they were hospitalized for a shorter period of time. As a result, erectile dysfunction is less common compared to conservative treatment (25). Preoperative IIEF-5 scores of the patients are not known, and when their postoperative IIEF-5 scores are evaluated, it is seen that erectile functions are not disrupted. None of our patients had late complications such as penile curvature, pain  during erection and sexual intercourse and erectile dysfunction.

For the repair of tunica albuginea defects in penile fracture, different incisions such as direct incision, dorsal longitudinal, penoscrotal, lateral or subcoronal circumferential incision can be used. With both subcoronal and circumferential induction, both corpus cavernosum and corpus spongiyozum are clearly visible and do not pose a cosmetic problem after the operation. In cases of excessive hematoma and edema, it is difficult to reach proximal with subcoronal circumferential incision (26). Inguinal scrotal incision is recommended for excessive edema (27). We performed surgical treatment with a subcoronal circular incision because we thought that it provided good field of vision in all of our cases.

RESULTS

Penile fracture is a rare urologic emergency that can be diagnosed clinically. Radiological imaging may be required in suspected cases. Early surgical treatment provides successful results in terms of functional, cosmetic and erectile functions.

REFERENCES

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  3. Beilan JA, Wallen JJ, Baumgarten AS, Morgan KN, Parker JL, Carrion RE. Intralesional Injection of Collagenase Clostridium histolyticum May Increase the Risk of Late-Onset Penile Fracture. Sex Med Rev. 2018;6(2):272-8.
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  14. Penson DF, Seftel AD, Krane RJ, Frohrib D, Goldstein I. The hemodynamic pathophysiology of impotence following blunt trauma to the erect penis. J Urol 1992;148(4):1171-80.
  15. Raheem AA, El-Tatawy H, Eissa A, Elbahnasy AH, Elbendary M. Urinary and sexual functions after surgical treatment of penile fracture concomitant with complete urethral disruption. Arch Ital Urol Androl. 2014;86(1):15-9.
  16. García Gómez B, Romero J, Villacampa F, Tejido A, Díaz R. Early treatment of penile fractures: our experience. Arch Esp Urol. 2012;65(7):684-8.
  17. Al-Shaiji TF, Amann J, Brock GB. Fractured penis: diagnosis and management. J Sex Med. 2009;6(12):3231-40.
  18. Singh G, Capolicchio JP. Adolescent with penile fracture and complete urethral transection. J Pediatr Urol. 2005;1(5):373-6.
  19. Sawh SL, O’Leary MP, Ferreira MD, Berry AM, Maharaj D. Fractured penis: a review. Int J Impot Res. 2008;20(4):366-9.
  20. Agarwal MM, Singh SK, Sharma DK, Ranjan P, Kumar S, Chandramohan V, Gupta N, Acharya NC, Bhalla V, Mavuduru R, Mandal AK. Fracture of the penis: a radiological or clinical diagnosis? A case series and literature review. Can J Urol. 2009;16(2):4568-75.
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Table 1. Clinical data of patients

Age (years) 39.22 ± 14.47 (19-67)
The time to contact the emergency department (hours) 4.33 ± 1.97 (2-8)
Localization
           Right (%) 11 (61.1)
           Left (%) 7 (38.9)
Localization of Rupture
           Distal (%) 14 (77.8)
          Midpenyl (%) 3 (16.7)
          Proximal (%) 1 (5,5)
Defect Length (mm) 12.66 ± 3.06 (8-20)
Average Hospitalization time (day) 3 ± 0.90 (2-5)
Postoperative IIEF-5 score 26.05 ± 1.55 (23-29)

IIEF-5: International Erectile Function Scale

Table 2. Etiology of penile fracture

Etiology Number of Patients %
Forceful manipulation of the penis 5 27.8
Turning in bed during sleep 5 27.8
During sexual intercourse 6 33.3
Masturbation 2 11.1

 


By Dr. Ravi Mootha, M.D. On: May 07, 2019 at 20:06:17