International Journal of Impotence Research (2011) 23, 165–172 & 2011 Macmillan Publishers Limited All rights reserved 0955-9930/11 www.nature.com/ijir

ORIGINAL ARTICLE Relationship between penile fracture and Peyronie’s disease: a prospective study

A Acikgoz1, E Gokce2, R Asci3, R Buyukalpelli3, AF Yilmaz3 and S Sarikaya3

1Department of , Gazi State Hospital, Samsun, Turkey; 2Department of Radiology, Maternity and Children’s Hospital, Samsun, Turkey and 3Department of Urology, School of Medicine, Ondokuz Mayis University, Samsun, Turkey

Peyronie’s disease is postulated to be initiated by repetitive minor traumas to the fully or partially erect penis. We investigated Peyronie’s disease prospectively in cases treated for penile fracture (PF) within the last 20 years. Medical records of 63 cases treated for PFs were reviewed. Subjects were required to self-assess their current penile morphologies and sexual functions. Penile nodules and Peyronie’s plaques were also evaluated with physical examination, ultrasonography and magnetic resonance imaging (MRI), and penile curvatures with auto-photography, and sexual function with international erectile function index (IIEF). Of the 63 cases (mean age 37 years), 46 who had mean follow-up of 63 months were re-evaluated. The mean IIEF-5 score was 23.2±3.1. Painful (n ¼ 5), penile nodules (n ¼ 5) and also penile curvatures o201 (n ¼ 2) were investigated. No Peyronie’s plaque was palpated in any of the cases. Ultrasound and MRI showed fibrotic nodules of 5 mm in diameter, which extended into the subtunical area in the rupture site in 54% of the cases, although any thickening and Peyronie’s plaque were not found in the and intracavernosal septum of the cases examined. In PF patients treated surgically, the erectile function and penile morphology were preserved. In our cases PFs did not induce the development of Peyronie’s disease. International Journal of Impotence Research (2011) 23, 165–172; doi:10.1038/ijir.2011.24; published online 9 June 2011

Keywords: Peyronie’s disease of tunica albuginea (penile and clitoral); blunt trauma and ; diagnostic testing; history; physical examination

Introduction observed.9 Surgical treatment of penile fracture which includes the drainage of the hematoma and Penile fracture (PF), defined as a rupture of the repair of the rupture in the tunica albuginea was first tunica albuginea of one or both corpora cavernosa reported by Fenstrom.10 Due to faster recovery, caused by blunt trauma to the erect penis, is a rare shorter hospitalization and perfect long-term out- urological emergency.1 Concomitant urethral inju- comes, surgical repair has become the first choice ries may occur in 10–20% of the cases.2–4 Sudden of treatment.11,12 However, complications such as distortion of the erect penis during sexual inter- penile curvature, nodule formation in the repair course or or violent scrubbing of the region and penile numbness have been also penis in the flask state or an acute penile kinking are reported.11,12 the most commonly reported mechanisms for the Various factors including genetic predisposition, penile fracture.5–8 trauma and tissue ischemia have a role in the In penile fracture patients conservatively treated pathogenesis of the Peyronie’s disease (PD). It is with cold compresses and anti-inflammatory widely recognized that micro-traumas leading to the drugs, significant complications such as infection bleeding within the tunica albuginea, the accumula- and have been previously tion of fibrin and the migration of inflammatory cells into the injured area, induce upregulation of cytokine and growth factors and excess increase in the matrix protein which in combination result in Correspondence: Dr A Acikgoz, Department of Urology, 13 14 Gazi State Hospital, 55200 Ilkadim, Samsun 55200, the development of a plaque. Jarow and Lowe Turkey. reported that frequency of penile trauma in patients E-mail: [email protected] with PD is significantly higher. On the other hand, 15 Received 10 October 2010; revised 2 February 2011; Zargooshi used only physical examination as a accepted 22 April 2011; published online 9 June 2011 diagnostic tool and concluded that PD does not Penile fracture and Peyronie’s disease A Acikgoz et al 166 develop years after PF or with the habit of strongly penile pain, curvature, loss of tactile sense and bending the erected penis (called taqaandan in Iran) erectile dysfunction at least twice, on 45 days and at for detumescence. 3 and 6 months, and first year postoperatively. An instantaneous strong trauma leading to the To determine postoperative penile morphology rupture of the tunica albuginea may cause occur- and sexual function, all cases were re-invited to the rence of PD in the rupture site, intracavernosal clinic between January 2006 and March 2008. Their septum and away from the rupture site of tunica current histories were obtained, and the complaints albuginea in the long term. In recent studies, on and urination were questioned. Sexual development of the Peyronie’s plaque in cases with functions were evaluated with the validated Turkish PF treated surgically was assessed using only version of the International Erectile Function physical examination.15–17 In this study, potential Index-5 (erectile function domains) (IIEF-5). Penile development of sequelas in tunica albuginea and nodules and Peyronie’s plaques were sought with intracavernosal septa of the cases treated surgically physical examination, and the degree of penile for PF within the last 20 years have been evaluated curvatures was evaluated using auto photographic with physical examination, ultrasonography (US) images from two different angles at erect position. and magnetic resonance imaging (MRI). Monitoring schedule was shown at Table 1. Tunica albuginea and cavernosal morphologies of the cases who gave informed consent were examined with US (General Electric Logiq Pro 5, Seoul, South Patients and methods Korea) and MRI (1.5T Siemens, Magnetom Symph- ony, Erlangen, Germany). Radiological examinations Baseline medical histories, physical examination were performed by a radiologist (EG), who was blind findings, diagnoses, and previous treatment meth- to the operational findings. MRI was performed in ods of 63 subjects, who were treated surgically for the supine position using body coil while the penis PF between 1 March 1986 and 31 December 2006 in was in the natural position and T1- (time to repeat the Department of Urology, School of Medicine, (TR): 738 msec, time to echo (TE): 13 msec) and Ondokuz Mayis University, were reviewed. T2-weighted (TR: 5060 mec, TE: 100 msec) images Medical treatments including oral analgesics, with section thickness of 3 mm, matrix volume of antibiotics, compressed dressings, cold compresses 256x256 pixels and FOV of 100 cm on the axial and and recommendation of sexual abstinence for over a sagittal planes were obtained and interpreted. Penile period of 1 week were prescribed for the patients ultrasonographic examination was performed in the who had normal erectile functions, small penile supine position by the same radiologist using hematomas and those refusing surgical treatment. 10 MHz linear array transducer in the Mode B. Surgical repair was performed after intravenous Erect and non-erect penile US and MRI images of injection of the first generation cephalosporins. the patients and five randomly selected healthy comprised of a subcoronal circumferential cases without any penile abnormalities and/or degloving incision, evacuation of the hematoma, history of trauma (control group) were compared. identification of the site and number of the defect(s) and closure of the defect(s) by interrupted absorb- able, inverted-knot sutures. Urethral rupture (if any) was repaired on a urethral catheter using inter- Results rupted 4/0 polyglactin sutures and urethral catheter was removed after 7 days, postoperatively. The The mean patient age at the time of injury was presence of extravasation on the rupture site and 37±11.75 years (range 16–63). Time from the penile curvature were checked intraoperatively by incident to initial presentation ranged from 2 h to 6 creating artificial erection with intra-cavernosal days (median 6 h, mean 16.7±24.16 h). The causes saline injection. After recommended sexual absti- of the fracture were shown in Table 2. In the physi- nence for 6 weeks, the cases were examined for cal examination, although hematoma, ecchymosis

Table 1 Monitoring schedule of the patients

3 months 1 year 2 years 5 years 10 years

Cases (n ¼ 46)1012108 6 IIEF-5 All All All All All PE All All All All All Autophotographs If indicated If indicated If indicated If indicated If indicated US 10 10 7 5 5 MRI 3 3 3 2 1

Abbreviations: IIEF-5, International Index of Erectile Function (5 domains); MRI, magnetic resonance imaging; PE, physical examination; US, ultrasound.

International Journal of Impotence Research Penile fracture and Peyronie’s disease A Acikgoz et al 167 Table 2 Etiology of the penile fracture Table 3 Surgical findings (n: 56)

Causes of fracture n % Localization of tunical laceration n %

Sexual intercourse 28 41 Right ventrolateral mid 29 51.8 Masturbation 14 24 Left ventrolateral mid 16 28.6 During sleep 9 15 Left dorsolateral mid 5 8.9 Hand manipulation of erected penis 9 15 Right dorsolateral proksimal 4 7.1 Pushing the penis against a hard object 3 5 Urethral rupture 4 7.1 Total 63 100 Bilateral ventral mid 3 5.3 Superficial dorsal vein rupture 1 1.8

months and 158 months (mean 63±17.25 months). During physical examination, no Peyronie’s plaque was palpated in any of the cases. A penile curvature of 20 degrees deviating towards the ruptured side was found in two cases by means of autophotography. Mean IIEF-5 score of the cases who underwent surgical treatment was found to be 23.2±3.1. There were two cases (5.4%) with ED. One of these cases was 62 years old who was examined 5 years after the surgical repair. His ED which became apparent 3 years after the surgical repair (IIEF-5 score: 14) was attributed to his worsening hyperlipidemia and atherosclerosis. The second case was 58 years old Figure 1 (a) Penile and scrotal ecchymosis and swelling due to who was examined 11 years after the repair (IIEF-5 penile fracture. (b) Urethral rupture (urethral catheter is seen) in same patient. score: 6). His ED was attributed to severe chronic obstructive pulmonary disease and coronary artery disease he was suffering. and swelling along the penile shaft were observed in Median IIEF-5 score (22.65) of 17 patients who all cases, scrotal ecchymosis and swelling were were operated more than 24 h after the PF, was lower noted only in nine (14%) cases (Figure 1). In four than that of 39 patients (23.78) who were managed (6%) cases with urethrorrhagia, penile urethral surgically within 24 h of the incident, without any rupture was detected using retrograde urethrogra- statistically significance difference between two phy. Tunical extravasation was not observed in three groups. cases who underwent cavernosography. Surgical Two patients who initially received medical repair was performed in 56 (88.8%) cases. Among treatment were re-evaluated and ED, penile curva- seven cases, one who refused the surgical repair, ture or nodule was not observed. three patients without any extravasation detected in the cavernosography and three cases with local hematomas and ruptures measuring less than 1 cm Radiological findings in length as noted in the MRI received medical Penile morphologies of 46 patients were re-evalu- treatments. ated by means of US (n ¼ 37) or MRI (n ¼ 12), and Locations of tunical ruptures determined intra- their findings were compared with those of five operatively were shown in Table 3. The majority healthy subjects. Patients who had received medical (85.7%) of tunical ruptures occurred in the ventral treatment refused any radiological examination. aspect of penises with a transverse orientation. The At 3 months postoperative, MRI or penile US was length of tunical ruptures ranged from 1 to 4 cm performed for 3 and 10 cases, respectively. In the (mean 2.3±0.74). One of the cases who underwent ultrasonographic examination, irregular thickening surgical treatment had superficial dorsal vein rup- and increased echogenity were found in the repair ture with an intact tunica. Urethral rupture was also site (Figure 2c). In the T1- and T2-weighted series of observed in four (6%) cases. MRI, increased signal intensity and fusiform thick- Urinary infection occurred in one case in the early ening in the repair region and intracavernosal postoperative period. Hospitalization period ranged nodular appearance with low signal intensity were from 1 to 11 days (mean 2.5±1.14 days). observed in all of the cases (Figures 2a and b). None We have got in touch with 46 (73%) cases who of the cases had intra-cavernosal hematoma. Thick- had undergone surgical (n ¼ 44) or medical (n ¼ 2) ness of tunical albuginea of the repaired site was treatment whose follow-up periods varied between 3 similar to that of the control group.

International Journal of Impotence Research Penile fracture and Peyronie’s disease A Acikgoz et al 168

Figure 2 (a) Sagittal T1 magnetic resonance imaging (MRI), arrows indicate tunical irregularities on fracture lines. MRI at the third month. (b) Sagittal T2 MRI, arrows indicate tunical irregularities and thinning. MRI at the third month. (c) Axial ultrasound, arrows indicate echogenities of posterior shadow belonging to operative material. Ultrasound at the third month.

signal intensity and intracavernosal nodular appear- ance caused by scar tissue with low signal intensity (Figures 4a–c). None of these cases had Peyronie’s plaque. At 2 years postoperative, MRI or penile US was performed for 3 and 7 cases, respectively. In the ultrasonographic examination, mild thinning in the tunica albuginea of the fracture site, heterogeneous hyperechoic nodular appearance with small calcifi- cations, and tiny hypoechoic areas and irregular intracavernosal borders, and penile curvatures deviating towards extra-tunical field in the penis were detected (Figures 5a and b). In concordance with ultrasonographic findings, MRI revealed narrowing and curvature in the tunica and irregular intracavernosal nodular appearances with hypoin- Figure 3 (a) Sagittal ultrasound, the arrow shows the nodule. tense areas in the center manifesting increased Ultrasound at the first year. (b) Axial ultrasound, the arrows show signal intensities in two, whereas tunical irregula- the nodule. Ultrasonography at the first year. rities and increased signal intensities in one cases, respectively (Figures 5c and d). Thickness and At 1 year postoperative, MRI or penile US was appearance of tunica albuginea outside the repair performed for 3 and 10 cases, respectively. In the site were similar to those of the control group. ultrasonographic examination, irregular thickening Penile US or MRI was performed at 5 years in the repair site and nodular scar tissue appearance postoperative for 5 and 2 cases, respectively; at 10 with heterogeneous echogenity, extending from years postoperative for 5 and 1 cases, respectively. tunica into the cavernous body with irregular Mild thinning in the tunical albuginea within borders and tiny hypoechoic halo were found rupture site and nodular appearances with irregular (Figures 3a and b). In the MRI, T1- and T2-weighted intracavernosal borders, fine hypoechoic halo, series of repair site revealed fusiform thickening in penile curvatures deviating towards extra-tunical the tunica albuginea accompanied by increased field, mild tunical irregularities with increased

International Journal of Impotence Research Penile fracture and Peyronie’s disease A Acikgoz et al 169

Figure 4 (a) Sagittal T2 magnetic resonance imaging (MRI), the arrow shows fracture repair region in the tunica, the signal increase, irregularity and thickening in the tunica. MRI at the first year. (b) Axial T1 MRI, the arrow shows the hypointense nodule. MRI at the first year. (c) Axial T2 MRI, the arrow shows fracture repair region in the tunica, the singnal increase, irregularity and thickening in the tunica. MRI at the first year.

Figure 5 (a) Sagittal ultrasound, tiny (in mm) echogenities of calcifications and posterior shadows are seen. Ultrasonography (US) at the second year. (b) Sagittal US, the nodule-causing resilience in the tunica on penile shaft is seen. Ultrasound at the second year. (c) Sagittal T1 magnetic resonance imaging (MRI), tunical irregularity on the penile shaft and slightly hypointense nodule related with the tunica. MRI at the second year. (d) Sagittal T2 MRI, slightly hypointense nodule in the tunica on penile shaft. MRI at the second year. echogenity were observed. None of the cases had Discussion Peyronie’s plaque. Sizes of the penile nodules as determined by MRI The main cause of PF is blunt trauma or sudden are shown in Table 4. increase in intracorporeal pressure due to accidental

International Journal of Impotence Research Penile fracture and Peyronie’s disease A Acikgoz et al 170 Table 4 The thickness of tunica albuginea in MRI (non-erected suture repair) on rat tunica albuginea can induce penis) histological changes similar to the acute phase of PD but not the overt picture of the chronic phase Tunical thickness 23 (mm) (mean (ranges)) of PD. It can also result in an early but transient up-regulation of TGF-B1 protein expression in the 23 Cases Control rat penis. During PF, tunical ruptures at the site (n:12) (n:5) exposed to maximal shearing forces. Furthermore, tunica albuginea just across the rupture site may Rupture-side tunica 1.5 (1.1–1.9) also be traumatized at a lesser degree during Tunica in the rupture area 1.4 (0.8–2.3) bending of the penis. Although it is possible to Cotralateral tunica 1.5 (1.2–2.0) close the tunical defect by surgical repair, whether Cavernosal nodul size (mm) 5.0 (2.0–9.0) Septal thickness 1.5 (1.2–2.0) 1.6 (1.4–2.0) or not tunical trauma in the non-ruptured regions Right and left cavernosal tunica 1.6 (1.3–2.1) might lead to the development of PD is an issue of concern. For this purpose, the use of ultrasonogra- Abbreviation: MRI, magnetic resonance imaging. phy and penile MRI in addition to physical examination has been considered satisfactorily effective in determining the long-term alterations or intentional bending of the erect penis.12,14 PF in the tunica albuginea and cavernosal tissue occurs mainly (33–60%) during sexual inter- associated with the trauma related to the fracture course.5–8,18 However, manual bending of the erect and also its repair process. penis for ensuring detumescence particularly in the Zargooshi15 could not determine PD with physical Middle East countries (called ‘taqaandan’ in Iran) is examination in 193 PF patients who underwent the other most frequently encountered regional surgical treatment, and followed for a mean duration etiologic factor.19,20 Zargooshi21 reported the results of 85 months. The same researcher palpated nodules of 172 cases in Iran with PF, and stated that the within the repair site in 93.7% of 352 patients with cause in 69.1% of the cases was ‘taqaandan’. In our PF, who had undergone surgical treatment and series, was the etiologic factor in monitored for 93.6 months without any physical 41% of the cases. examination evidence of Peyronie’s plaque.16 Simi- Older publications on the management of PF larly, in another study, no Peyronie’s plaque could had supported the conservative treatment methods be found in 37 cases who were surgically treated for involving local cold compresses, compressed dres- PF and followed for about 18 months.17 On the other sings, antibiotics, anti-inflammatory and fibrinolytic hand, in two separate controlled studies including medications.13,14,19 However, in long-term follow-up 82 and 134 patients with PD, respectively, none of studies, the incidence of complications such as the cases had PF history.24,25 Similarly, no history of fibrotic nodules, penile curvatures, painful erec- PF was reported in a retrospective study on 307 tions, arteriovenous fistulas and erectile dysfunc- patients with PD.26 In all of these clinical studies, tion were found to be higher (10–53%) in cases who Peyronie’s plaque was diagnosed with medical received conservative treatment.18,19,22 On the con- history and physical examination. In contrast, in trary, early- and long-term results of immediate our study, penis morphologies of the patients were surgical repair are highly satisfactory. Erectile func- evaluated by physical examination, US and MRI tions of the patients who have applied to the clinics imaging methods in more detail after surgical within the first 24 h following the fracture are treatment. Nodules detected in rupture site in the preserved better when compared with the findings physical examination were intracavernosal nodules of late-comers and/or the patients who have been in US and MRI and were differently imaged from followed with conservative measures. Complica- Peyronie’s plaques. In our series, physical examina- tions such as penile curvature, fibrotic plaque tion revealed no plaque in 44 patients who were formation and painful erection are largely pre- treated surgically and followed-up for a mean vented, sexual functions are preserved and hospita- duration of 63 months. The findings were verified lization period is substantially shortened with the with US and MRI. early (within 24 h after the penile fracture) surgical In the ultrasonographic examination, tunica albu- repair.18,19,21 Although early surgical repair has ginea is observed as a homogenous and regularly promising outcomes, complications such as penile surfaced structure, which is mildly hypoechoic nodules, curvatures and sensory loss may be compared with the cavernous body. In the penile observed in some cases. In our series, the incidence ultrasonographic examination of 37 cases within the of palpable penile nodules was determined as 5% postoperative 3 months and 10 years, non-palpable and both penile curvature and temporary penile intracavernosal nodules, and specifically, milli- skin sensory loss was observed in 2% of the cases. metric calcifications were observed in 20 cases. In Trauma to the erect and non-erect penis is thought the late term, tunical irregularities, bending and to be an important etiologic factor for PD. Experi- intracavernosal nodules in rupture site of tunica mentally induced surgical trauma (incision and albuginea were observed. Intracavernosal nodules

International Journal of Impotence Research Penile fracture and Peyronie’s disease A Acikgoz et al 171 with sizes ranging from 2 to 9 mm can be considered developed some time after early surgical repair, as patches of fibrotic scar tissue during the healing might have been attributed to the suture material process. In the ultrasonographic examination, these and a scar tissue as a result of healing process. In the nodules can be evaluated as tunica albuginea- US and MRI examinations, no thickening or plaque related heterogeneous structures having millimetric development was observed in the close proximity of calcifications, a thin hypoechoic halo with slightly the rupture line, in the tunica albuginea symme- increased echogenicity compared with the caver- trically across the rupture site, in the intracaverno- nous body. On the other hand, Peyronie’s plaque is sal septum and in the other tunica albuginea observed as a hyperechogenic diffuse thickening in regions. As surgical treatment of PF is associated the tunica albuginea in US images. However the with lower incidence of early- and long-term plaque is visualized as a hyperechogenic area complications, shorter hospitalization period and without a single acoustic shadow in the acute phase, patient satisfaction in terms of cosmetic appearance but with multiple acoustic shadows in the inter- of the penis as well as better preservation of sexual mediate phase and a more intense hyperechogenic functions in the long term, it should be the preferred plaque-like lesion with acoustic shadows in the treatment modality for cases with PF. chronic phase.27 PD is best viewed in T2-weighted images of MRI. Following the administration of intravenous gadoli- Conflict of interest nium, formation of contrast on plaques indicates an active inflammation.28 In the T1- and T2-weighted The authors declare no conflict of interest. sections of the MRI, tunica albuginea appears as a homogenous, regular-surfaced structure with low signal intensity, which surrounds the cavernous References bodies.28 Although cavernous and spongious bodies are iso-intense with muscular tissue (moderately 1 Nicolaisen GS, Melamud A, Williams RD, McAninch JW. intense) in T1-weighted series, they are hyper- Rupture of the corpus cavernosum: surgical management. J Urol 1983; 130: 917–919. intense compared with the muscular tissue in 28 2 Zenteno S. Fracture of the penis: a case report. Plastic Reconst T2-weighed series. In T1- and T2-weighted Surg 1973; 52: 669–671. images, Peyronie’s plaques are observed as irregu- 3 Joos H, Kunit G, Frick J. 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