Penile Fracture with Isolated Corpus Spongiosum Injury

CASE REPORT Penile fracture with isolated corpus spongiosum injury

JS Cerone, P Agarwal, S McAchran and A Seftel

Department of Urology, Case Western Reserve University, Cleveland, OH, USA

Penile fractures are classically described as presenting with rapid detumescence of an erection associated with blunt trauma. This clinical finding is due to a tear in the tunica albuginea surrounding the corpora cavernosum. We, however, present the case of a patient who presented with a ‘classical’ penile fracture but was found on surgical exploration to only have an isolated corpus spongiosum injury. International Journal of Impotence Research (2006) 18, 218–220. doi:10.1038/sj.ijir.3901389; published online 8 September 2005

Keywords: penile fracture; corpus spongiosum injury; tunica albuginea injury

Introduction penis on his partner’s pelvic bone. Physical exam- ination revealed a flaccid edematous penis. No Penile fractures are generally due to rupture of the ecchymosis was noted on exam and there was no corpora cavernosum/tunica albuginea secondary blood at the meatus. The patient was noted to have to blunt or sexual trauma to the erect penis.1 There marked tenderness on palpation of the penoscrotal have been numerous cases reported in the literature. junction. No palpable abnormalities were noted. Penile fractures typically present with a ‘cracking’ The patient was able to void. A complete blood sound, rapid detumescence of the penis and often count, serum electrolytes and urine analysis pain, swelling and ecchymosis. Approximately 10– revealed no abnormalities. 20% of penile fractures involve the urethra. These An ultrasound of the penis was obtained and fractures present similarly with associated urinary revealed no sonographic evidence of disruption symptoms such as blood at the meatus, a positive of the corpora. However, at the base of the right urinalysis for blood and/or urinary retention.2 Here cavernosum, there was a hypoechoic area measuring we present a case of a classically presenting penile 6.4 Â 4.4 Â 2.2 mm (Figure 1). The tunica albuginea fracture that exclusively involved the corpus spon- appeared intact bilaterally on the ultrasound. giosum, without any injury to the tunica albuginea. The patient was monitored overnight. The follow- ing day, he complained of increased swelling and pain. As a result, he was taken to the operating room for exploration and repair of a presumptive penile Case presentation and management fracture. Prior to degloving the penis, an intraoperative cavernosogram was performed. During the A 28-y-old man presented to the emergency depart- exam, a filling defect was noted (Figure 2) at the ment with pain and swelling in his penis after right base and felt to be a tear of the tunica. Penile sexual intercourse. He was in good health with no exploration was then undertaken, using a degloving significant past medical or surgical history. The incision. No obvious tunica fracture was noted and patient reported that he was engaging in intercourse therefore, an artificial erection was created, which the previous evening when he suddenly heard a demonstrated no defects in the tunica albuginea ‘pop’ and his penis went flaccid after he hit his bilaterally. Upon further exploration proximally, a hematoma was noted at the right base of the penis overlying a tear in the corpus spongiosum at the level of Correspondence: Dr P Agarwal, Department of Urology, Case Western Reserve University, 11100 Euclid Ave, the penoscrotal junction. The urethra appeared to be Cleveland, OH 44139, USA. essentially intact; however, it was thin with the E-mail: [email protected] foley catheter easily visible behind the attenuated Received 16 November 2004; revised 30 April 2005; tissue (Figure 3). The defect was closed primarily accepted 14 July 2005; published online 8 September 2005 with 3-0 absorbable suture, with the Foley catheter Penile fracture with isolated corpus spongiosum injury JS Cerone et al 219

Figure 1 An ultrasound of the penis demonstrating a hypo- Figure 3 An intraoperative photo demonstrating the defect in echoic area measuring 6.4 Â 4.4 Â 2.2 mm at the base of the right the corpus spongiosum. cavernosum.

Penile fractures account for approximately one in 175 000 emergency department visits.3 There are 1642 published cases in the literature.4 A total of 10–20% of these fractures involve the urethra, in conjunction with the cavernosal/tunica injury. Nymark and Kristensen in 1983 reported 92 cases of penile fractures. Of these, only 23 had urethral injuries. If the urethra is injured, primary urethro- plasty can be performed. Most patients demonstrate minimal hospital stay and return of nonpainful sexual function.5,6 Prevailing literature and opinions on the management of penile fracture suggest rapid evaluation and surgical treatment of suspected penile fractures.7–11 Controversy exists as to whether any additional studies such as a cavernosogram and/or artificial erection are warranted when the clinical presentation suggests an injury. Others suggest that the corpus spongiosum should be evaluated when bilateral corporal injury occurs as well.12 In our case, none of the tests performed revealed an abnormality. Furthermore, the patient’s injury was only noted on direct intraoperative exploration. Figure 2 An intraoperative cavernosogram demonstrating a filling defect on the right. Therefore, surgical exploration remains the gold standard. Our case report highlights the importance of operative exploration in cases where the degree of in place. The Foley catheter was left in for 1 week. clinical suspicion is high for an associated injury. The patient was seen in follow-up with no difficul- Limited long-term follow-up data suggest that ties in voiding 6 weeks after the catheter was prompt evaluation and treatment of penile fractures removed. may avoid impotence, Peyronie’s disease, penile curvature of deformity, painful erections and urethral stricture formation. Discussion References We present a case of penile fracture that presented 1 Jack GS, Garraway I, Reznichek R, Raiffer J. Current treatment as a prototypical cavernosal/tunica injury. However, options for penile fractures. Rev Urol 2004; 6: 114–120. the final outcome was that the patient suffered an 2 Tsang T, Demby AM. Penile fracture with urethral injury. isolated injury to the corpus spongiosum. J Urol 1992; 147: 466–468.

International Journal of Impotence Research Penile fracture with isolated corpus spongiosum injury JS Cerone et al 220 3 Fetter FR, Gartman E. Traumatic rupture of the penis. Am J 8 Seftel AD, Haas CA, Vafa A, Brown SL. Inguinal scrotal Surg 1936; 32: 371. incision for penile fracture. J Urol 1998; 159: 182–184. 4 Eke N. Fracture of the penis. Br J Surg 2002; 89: 555–565. 9 Mydlo JH. Surgeon experience with penile fracture. J Urol 5 Nymark J, Kristensen JK. Fracture of the penis with urethral 2001; 166: 526–529. rupture. J Urol 1983; 129: 147–148. 10 Mydlo JH, Harris CF, Brown JG. Blunt, penetrating and 6 Kowalczyk J, Athens A, Grimaldi A. Penile fracture: an ischemic injuries to the penis. J Urol 2002; 168: 1433–1435. unusual presentation with lacerations of bilateral corpora 11 Ruckle HC, Hadley HR, Lui PD. Fracture of penis: diagnosis cavernosa and partial disruption of the urethra. Urology 1994; and management. Urology 1992; 40: 33–35. 44: 599–601. 12 Fergany AF, Angermeier KW, Montague DK. Review of 7 Zargooshi J. Penile fracture in Kermanshah, Iran: report of 172 Cleveland clinic experience with penile fracture. Urology cases. J Urol 2000; 164: 364–366. 1999; 54: 352–355.

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