Short Paper Penile Fracture Repair: Assessment of Early Results and Complications Using Color Doppler Ultrasound

Short Paper Penile fracture repair: assessment of early results and complications using color Doppler ultrasound

P Gontero1*, PS Sidhu2 and GH Muir1

1Department of Urology, King's College Hospital, London, UK and 2Department of Radiology, King's College Hospital, London, UK

The aim of this study was to determine early results and complications of penile fracture treated with immediate surgical repair by means of color Doppler ultrasound study. Four patients with the clinical features of penile fracture were submitted to immediate surgical exploration via a subcoronal incision with repair of the torn cavernosal albuginea (unilateral in three cases, bilateral in one case) and anastomosis of the transected urethra (one case). Color Doppler ultrasound (CDUS) was performed by means of an Acuson 128XP=10 using a 7 ± 10 MHz extended frequency linear array transducer. Erectile function at ®ve months follow-up was reported as normal by two patients (age 59 and 55 y), slightly decreased in one case (bilateral partial cavernous fracture total urethral transection in a 32 y old) and weak in one case (51 y old). In the latter two, the investigation included a dynamic phase following a 10 mcg PGE injection. B-mode ultrasound showed no ®brotic changes in relation to the long-term absorbable suture material. Baseline CDUS demonstrated full length integrity of the cavernous arteries in all patients. The CDUS dynamic study was entirely normal in the patient with weak erection while showed a continuos venous leak in the patient with bilateral cavernosal rupture and transected urethra. We conclude that despite the onset of erectile failure in two out of four patients, there was no evidence of arteriogenic impotence in any patients with major penile fracture and thus we advocate early simple repair without any microsurgical exploration of the cavernosal arteries. International Journal of Impotence Research (2000) 12, 125±129.

Keywords: penile fracture; color Doppler ultrasound; impotence

Introduction cavernosography, with a low but signi®cant risk of a false negative ®nding described with the latter.5 A report of retrospective evaluation of patients mana- Fracture of the penis, due to traumatic rupture of the ged conservatively have suggested a high rate of tunica albuginea, is a rare injury. In a review, Porst1 impotence.6 Immediate surgical exploration of the found that sexual intercourse accounted for 28% of penis with repair of the ruptured albuginea is the 296 cases, forced masturbation being the main therefore regarded as the ideal treatment. Further- precipitating factor. Fracture is normally manifest more this is supported by a long-term follow-up by a `cracking sound' accompanied by immediate study con®rming the preservation of potency in a severe pain and detumescence, followed by rapid majority of patients based on interview.5,7 Penile swelling and widespread ecchymosis. An isolated curvature or induration similar to Peyronie's disease urethral injury2 or rupture of the deep dorsal vein3 is reported in most series which does not generally may also occur. Preoperative imaging, to delineate a affect sexual performance.5,8 Currently, color Dop- ruptured tunica albuginea, include (MRI)4 and pler ultrasound (CDUS) is the most useful non- invasive technique for evaluating vascular dynamics of the erection mechanism.9 To our knowledge, a CDUS study of erectile performance following *Correspondence: P Gontero, Dipartimento di Discipline penile fracture repair has not been undertaken. Medico-Chirurgiche, Universita' di Torino, C.so Dogliotti, 14 Torino, Italy. We report the CDUS ®ndings at ®ve months E-mail: [email protected] following surgical repair in four cases of penile Received 15 June 1999; accepted 14 September 1999 fracture. Penile fracture repair assessed using color Doppler ultrasound P Gontero et al 126 Patients and methods with bilateral partial cavernous fracture complicated by urethral transection (patient 3) and weak in the other (patient 4). Patients

Four patients, aged 32 ± 59 y (median 48,5 y) with Ultrasound the typical clinical features of acute penile fracture presented to the Accident and Emergency Depart- CDUS was performed using an Acuson 128 X P=10 ment at Kings College Hospital between April and (Mountain View, CA, USA) using a 7 ± 10 MHz May 1998. Severe penile swelling was associated extended frequency linear array transducer. A full with a degree of subcutaneous haematoma in all B-mode examination of the penis was conducted cases. Traumatic bending of the shaft had occurred in all four patients looking for areas of ®brosis, during sexual intercourse in all patients, with a clear evidence of surgery, continuity of the cavernosal `cracking sound' heard by three patients. No arteries and the urethra. All examinations were discontinuation of the albuginea tunica could be conducted by a single operator (PS). In the two detected through manual palpation of the shaft. No patients with erectile dysfunction, a dynamic study preoperative imaging was available. of the cavernosal arteries was performed after intracavernosal injection of 10 mg PGE1. This in- volved a baseline scan to record the peak systolic Surgery velocity (in cm=s) of blood ¯ow and the diameter in millimetres of the right cavernosal artery. Follow- All patients were consented for a surgical explora- ing intracavernosal PGE1 administration, the right tion which was carried out via a subcoronal cavernosal artery peak systolic velocity (PSV), end approach. The torn regions of the corpora cavernosa diastolic velocity (EDV) and vessel diameter were were all ventral, unilateral in three cases (with recorded at 5, 10, 15 and 20 min post-injection. A partial involvement of the corpus spongiosum in PSV of greater than 30 cm=s and a EDV of less than two of them) and bilateral in one case. In the latter, 7cm=s at any time during the study was taken to be a normal response for the arterial input and venous despite no evident urethral bleeding reported, the 10 urethra was completely transected (Figure 1). All drainage respectively. patients were treated via a circumcising incision. A more extensive degloving of the penis by means of an additional incision at the peno-scrotal angle was Results required for a better surgical exposure in two patients. The torn albuginea was repaired with a 3 ± 0 PDS suture. All patients were reviewed in Table 1 summarizes the clinical, B-mode ultrasound the clinic at ®ve months. Erectile function was and CDUS features for each patient. At 5 months reported as normal by two patients (patient 1 and post-surgery, manual palpation revealed a focal area patient 2), slightly decreased in the 32 y old man of induration at the site of previous rupture of the tunica albuginea. The B-mode ultrasound demonstrated hyperechogenic areas with distal acoustic shadowing in the region of the induration, produced by the long-term absorbable suture material. There were no underlying changes of ®brosis or calci®ca- tion suggestive of Peyronie's disease (Figure 2). Baseline CDUS demonstrated full length integrity of the cavernous arteries in all patients. Intracavernous injection of 10 mcg PGE1 was promptly followed by a grade 4 ± 5 erection in the patient with bilateral cavernosum rupture and urethral damage (patient 3). A PSV greater than 35 cm=s was reached at 5 min from the injection while the EDV was persistently above 8 cm=s even at 20 min, suggesting a continuos venous leak (Figure 3). No alteration in micturition was noted by the patient despite the urethral re- anastomosis and ¯owmetry showed a peak ¯ow rate of 25 ml=s. The CDUS dynamic study was entirely Figure 1 Intraoperative ®nding after degloving of the penis in patient 3, showing the fractured tunica albuginea of both normal in the patient complaining of complete cavernosa corpora. Two catheters are inserted in the two edges erectile failure (patient number 4). A grade 5 of the transected urethra. erection was developed within a few minutes

International Journal of Impotence Research Penile fracture repair assessed using color Doppler ultrasound P Gontero et al

Table 1 127

B-mode

Patient Extent of fracture Artery Urethra Shaft CDUS Spontaneous erections

1 Unilateral cavernosum N N Suture ND N 2 Unilateral cavernosum N N Suture ND N 3 Bilateral cavernosum N No stricture Suture Venous leakage Slightly decreased Urethral transection 4 Unilateral cavernosum N N Suture Normal Absent

N normal pattern In table 1 the B-mode and CDUS patterns are compared with the degree of damage found at the time of surgery and with the degree of erectile performance regained thereafter.

Discussion and conclusions

The diagnosis of penile fracture is essentially clinical. Some authors advocate preoperative cavernosography to delineate the corporeal rupture11,12 but this invasive procedure may increase the incidence of haematoma, infection and is often not diagnostic.4 MRI has been reported to demonstrate discontinuation of the tunica albuginea.4 Penile fracture is a clinical emergency with early surgical repair essential to prevent later complications. MRI and cavernosography as diagnostic procedures prior to surgery are unproven and only delay an obliga- tory operation. Surgical exploration remains the main diagnostic tool to con®rm the clinical suspi- Figure 2 Longitudinal section through the base of the penis cion, enabling simultaneous repair of the tunica demonstrating area of high re¯ectivity (arrows) with distal albuginea. On this basis, no preoperative investiga- acoustic shadowing corresponding to suture material. tion preceded surgery in the present series. Associated urethral injury is less common, occur- ring in 10 to 20% of patients. Complete transection of the urethra and disruption of both corpora have been described in only four cases.2 Subcoronal circumferential degloving has been recommended as the standard surgical approach.5,7 This technique allows for a thorough exposure of both the cavernosa and corpus spongiosum. The inguinal scrotal approach13 or alternatively surgery via a small longitudinal incision at the base of the penis4 have the advantage of being less traumatic. Both these approaches are, however, dependent on the preoperative localization of the fracture. The return of erectile performance following surgery in these patients is normally taken for granted. Karadenitz et al 5 reported penile curvature as the only complication in three out of 19 patients, attributed to a signi®cant delay between the initial Figure 3 Color Doppler ultrasound of the cavernosal artery. injury and the operative procedure. Four patients Spectral waveform demonstrates a peak systolic velocity of treated by Fedel et al 4 resumed sexual activity 44 cm=s and an end diastolic velocity of 8 cm=s suggesting a within two months of repair. Uygur7 reported that venous leakage. all patients interviewed at follow up (22 out of 32 patients) experienced coitus without dif®culty with- following the PGE1 administration and no CDUS in a few weeks of surgical repair. Kowalczyk14 abnormalities could be detected (PSV greater than reported excellent preservation of sexual function 0.35 m=s at 5 min with EDV less than 0.04 m=sat10 in a single case with bilateral corpora cavernosa min). lacerations and partial disruption of the urethra;

International Journal of Impotence Research Penile fracture repair assessed using color Doppler ultrasound P Gontero et al 128 similar to patient 4 in the present series. The 2 Tsang T, Demby AM. Penile fracture with urethral injury. possibility of a cavernous artery injury was the J Urol 1992; 147: 466 ± 468. 3 Nicoly ER, Costabile RA, Moul JW. Rupture of the deep dorsal main concern in the present series. When injury is vein of the penis during sexual intercourse. J Urol 1992; 147: unilateral, this may not impair sexual function, 150 ± 152. particularly in the sexually active patient. CDUS 4 Fedel M, Venz S, Andreessen R, Sudhoff F, Loening SA. The demonstrated no interruption along the cavernous value of magnetic resonance imaging in the diagnosis of suspected penile fracture with atypical clinical ®ndings. J Urol arterial course in any of the patients. 1996; 155: 1924 ± 1927. Subjects who have a positive erectile response to 5 Karadeniz T, Topsakal M, Ariman A, Erton H, Basak D. Penile pharmacological stimulation with normal blood fracture: differential diagnosis, management and outcome. Br J ¯ow parameters on a CDUS, are thought to have a Urol 1996; 77: 279 ± 281. normal vascular system for achieving adequate 6 Volz LR, Broderick GA. Conservative management of penile 15 fracture may cause cavernous-venous occlusive disease and erection. A dynamic peak systolic velocity greater permanent erectile dysfunction. J Urol 1994; 151: 358A. than 30 cm=s implies good arterial in¯ow into the 7 Uygur MC, Gulerkaya B, Altug C, Germiyanoglu C, Erol D. 13 penis.15 An end diastolic velocity greater than the years' experience of penile fracture. Scand J Urol Nephrol 7cm=s threshold level is generally considered to be 1997; 31: 265 ± 266. indicative of venous leakage.16 Taking these para- 8 Asgari MA, Hosseini SY, Safarinejad MR, Samdzadeh B, Bardideh AR. Penile fractures: evaluation, therapeutic ap- meters into account, a single patient was found to proaches and long-term results. J Urol 1996; 155: 148 ± 149. have a venous leakage. However, despite sexual 9 Barra S, Iacono F. Echo-Doppler-¯owmetric asessment of intercourse being unaffected, the penile rigidity was penile dorsal arteries and their role in the erectile mechanism. described by the patient as `slightly decreased' Eur Radiol 1997; 25: 67 ± 73. 10 Patel U, Laes WR, Solibiati L, Rizzatto G. (eds) Penile following the operation. No vascular abnormality sonography in ultrasound of super®cial structures. Chap 11. could be detected by CDUS in a further patient who Churchill-Livingstone: London, 1995, pp 229 ± 242. claimed complete erectal failure despite early 11 Dever DP, Saraf PG, Catanese RP, Feinstein MJ, Davis RS. surgical repair. Although psychogenic factors may Penile fracture: operative management and cavernosography. Urology 1983; 22: 394 ± 396. play a signi®cant role in this category, the exact 12 Hadzi-Djokic J, Milutinovic D. Surgical repair of penile mechanism underlying the latter condition is not fractures with urethral injury. Int J Imp Res 1994; 6: 69 ± 73. fully understood. 13 Seftel AD, Haas CA, Vafa A, Brown SL. Inguinal scrotal An argument in favour of immediate surgical incision for penile fracture. J Urol 1998; 159: 182 ± 184. management of penile fracture is the relative high 14 Kowalczyc J, Athens A, Grimaldi A. Penile fracture: an unusual presentation with lacerations of bilateral corpora incidence of acquired Peyronie's disease reported cavernosa and partial disruption of the urethra. Urology 1994; with conservative treatment.1 CDUS ruled out any 44: 599 ± 600. early ®brotic or in¯ammatory reaction surrounding 15 Lue TF. Erectile impotence: diagnostic methods. Probl Urol the mono®lament suture material. 1991; 5: 519 ± 537. 16 Keogan MT et al. Doppler sonography in the evaluation of In conclusion, we found no evidence of arterio- corporovenous competence after penile vein ligation surgery. J genic impotence in four patients with major penile Ultrasound Med 1996; 15: 227 ± 233. fracture and thus would advocate early simple repair without any microsurgical exploration of the cavernosal arteries.

References

1 Porst H. Congenital and acquired penile deviations and penile fractures. In: Porst H. (ed) Penile disorders. Proceedings of the International Symposium on Penile Disorders. Hamburg, Germany. Springer-Verlag: Berlin Heidelberg, 1997.

Editorial Comment

The one essential issue missing in this article is repair promises the most favourable outcome and what is the time delay between occurrence of penile- the patients will be more likely to preserve potency fracture and consultation in the urological emer- than after conservative management. This is con- gency room. This is one of the most crucial points ®rmed in the present four case reports. concerning the indication for surgical or conserva- Unfortunately many patients seek help after a tive management. time delay of one to several days and, in these cases, I agree with the authors that in acute penile a so-called immediate surgical repair will not fractures, fractures not older than 12 ± 24 h, surgical necessarily be reasonable nor advisable. In these

International Journal of Impotence Research