ORIGINAL ARTICLE Vol. 44 (3): 550-554, May - June, 2018 doi: 10.1590/S1677-5538.IBJU.2017.0520 Sexual complications of penile frature in men who have sex with men _______________________________________________ Rodrigo Barros 1, Gabriel Lacerda 1, Alex Schul 1, Paulo Ornellas 1, Leandro Koifman 1, Luciano A. Favorito 2, 3 1 Hospital Municipal Souza Aguiar, Rio de Janeiro, RJ, Brasil; 2 Universidade Estadual do Rio de Janeiro (UERJ), RJ, Brasil; 3 Hospital Federal da Lagoa, Rio de Janeiro, RJ, Brasil ABSTRACT ARTICLE INFO ______________________________________________________________ ______________________ Objectives: Evaluate the demographic data, etiology, operative findings and results of Keywords: surgical treatment of penile fracture (PF) in men who have sex with men(MSM) with Penis; Homosexuality; Coitus emphasis on sexual complications. Materials and Methods: We studied 216 patients underwent surgical correction of PF Int Braz J Urol. 2018; 44: 550-4 at our hospital. Patients self-identified as MSM were followed for at least 6 months. Demographic data, presentation, operative findings, International Index of Erection _____________________ Function - 5 (IIEF-5) and the Premature Ejaculation Diagnostic Tool. Submitted for publication: Results: Of 216 PF cases, 4 (1.8%) were MSM. All cases resulted from sexual activity September 24, 2017 and all patients reported using the “doggy style” position during anal intercourse. _____________________ Unilateral or bilateral injury of corpus cavernosum was found in 2 patients each. One Accepted after revision: (25%) patient had complete urethral injury associated with bilateral corpus caverno- January 22, 2018 sum lesion. During the follow-up period, all patients developed some type of sexual _____________________ complication. One patient reported penile pain during intercourse. Another patient Published as Ahead of Print: experienced low sexual desire and premature ejaculation. This patient was also dis- February 23, 2018 satisfied with the aesthetic result of the surgical scar and complained about decreased penis size after surgery. The third case developed delayed ejaculation. The fourth pa- tient experienced mild to moderate erectile dysfunction. This same patient presented with penile curvature. Finally, palpable fibrotic nodules in the operative area were observed in all cases. Conclusions: Sexual activity in the “doggy style” position was the commonest cause of PF in MSM. Sexual dysfunction is always present in gay man after surgery for PF. However, additional studies with larger samples should be coinducted. INTRODUCTION Determining the number of men who have ever had sex with another man (msm) is difficult. Penile fracture (pf) is an uncommon form In a study conducted in the united states, at le- of urologic trauma. Sexual intercourse is the com- ast 5% of men, reported having ever had sex with monest cause of fracture of the penis (1). Imme- men (3). This population is also at a risk of pf. diate surgical exploration is the current standard Nevertheless, most studies on pf have only inclu- treatment and aims at restoring the anatomical ded heterosexual patients. Moreover, msm have and functional integrity of the penis. However, received limited attention in sexual medicine li- this approach is not free from complications and terature and non-heterosexual orientation is an sexual dysfunctions can occur (2). exclusion criterion in many large scale studies in 550 IBJU | PENILE FRACTURE IN MEN WHO HAVE SEX WITH MEN sexual medicine (4, 5). Moreover, the majority of years old (mean, 41 years) and all patients were sin- instruments for the assessment of sexual problems gle. Time between trauma and surgery varied from have not been validated in homosexual patients (6). 4 to 18 hours (mean, 12.7 hours). All cases resulted An internet-based survey with men who have sex from sexual activity and all patients reported using with men (msm) found that 79% of men reported the “doggy style” position during anal intercourse. at least one sexual dysfunction symptom such as With respect to the clinical presentation, low sexual desire, erection problems, and perfor- all patients experienced immediate penile detu- mance anxiety (7). Accordingly, we believe that se- mescence. Penile pain and a cracking sound du- xual dysfunction may be present in msm operated ring trauma were noticed by 3 (75%) patients. Ex- on for pf. The aim of this study is to evaluate the tensive penile edema was observed in all cases. demographic data, etiology, operative findings and Only one (25%) patient experienced urethral ble- results of surgical treatment of pf in msm, with em- eding and surgical exploration revealed urethral phasis on sexual complications. injury in this patient (Figure-1). MATERIALS AND METHODS Figure 1 - After a “doggy style” position the patient present Between january 1997 and december 2016, penile fracture, we can observe a great hematoma and the 216 patients underwent surgical correction of pf at typical aspect of eggplant deformity and meatal bleeding. During the surgery we identified a bilateral rupture of the CC our hospital. Patients self-identified as msm were and transection of the penile urethra. followed at the andrology outpatient clinic of this institution for at least 6 months. Epidemiological and clinical presentation data and operative findings were reviewed retros- pectively using the medical records. All patients were submitted to the surgical technique utilized in our department, which consists of making a circu- lar sub-coronal incision followed by further penile degloving and reconstruction of the corpus caver- nosum and urethra, as necessary (8). After the sixth postoperative month, pa- tients were interviewed and questioned about any sexual dysfunction. The evaluation of postoperative erectile function was carried out by filling out the international index of erection function - 5 (iief-5) and the premature ejaculation diagnostic tool was used for the screening survey to assess risk of pre- mature ejaculation. Minor modifications to syntax were made and specific terms for the subject’s par- tner were replaced with gender neutral pronouns to adapt it for msm. The study design was approved by the ethics and human research committee of the institution. RESULTS Of 216 pf cases treated in our emergency room between january 1997 and december 2016, 4 (1.8%) were msm. Their age varied from 36 to 46 551 IBJU | PENILE FRACTURE IN MEN WHO HAVE SEX WITH MEN All patients were submitted to surgery derate erectile dysfunction (iief-5 score = 14) and after clinical diagnosis, without the need for need oral treatment with phosphodiesterase type complementary tests. With regard to operative 5 inhibitor (pde5) with a satisfactory response. findings, unilateral or bilateral injury of corpus This same patient presented with penile curvature. cavernosum was found in 2 patients each. One Intracavernous prostaglandin injection showed a (25%) patient had complete urethral injury asso- curvature <30°. Penetration was not impaired and ciated with bilateral corpus cavernosum lesion. the treatment was conservative. Finally, palpable Follow-up time varied from 6 to 16 months fibrotic nodules in the operative area were obser- (mean, 10 months). During the follow-up period, ved in all cases (Table-1). all patients developed some type of sexual com- plication. It is worth noting that no patient had DISCUSSION sexual problems before the trauma. One patient reported penile pain during intercourse. Another There is evidence about the importance of patient experienced low sexual desire and prema- genetic, autoimmune, and neurohormonal factors ture ejaculation. This patient was also dissatisfied in the development of sexual orientation. Althou- with the aesthetic result of the surgical scar and gh homosexuality is widely established as a sexu- complained about decreased penis size after sur- al orientation, the majority of religious authori- gery. The third case developed delayed ejacula- ties, as well as some political institutions, consider tion. The fourth patient experienced mild to mo- sex with people of the same gender unnatural (9). Table 1 – Demographic data, presentation, operative findings and sexual complications. Patient 1 2 3 4 Age 36 45 46 37 Etiology Anal intercourse/ Anal intercourse/ Anal intercourse/ Anal intercourse/ “doggy style” “doggy style” “doggy style” “doggy style” position position position position Time between trauma and 18 04 15 14 surgery (hours) Presentation Pain, cracking sound, Cracking sound Pain, cracking sound, Pain, detumescence detumescence and detumescence, detumescence and and haematoma haematoma haematoma and haematoma urethral bleeding Type of lesion Unilateral corpus Bilateral corpus Bilateral corpus Unilateral corpus cavernosum cavernosum and cavernosum cavernosum urethra Sexual complications Penile pain and Premature Delayed ejaculation Erectile dysfunction, fibrotic nodule ejaculation, and fibrotic nodule penile curvature and low sexual fibrotic nodule desire, aesthetic dissatisfaction and fibrotic nodule 552 IBJU | PENILE FRACTURE IN MEN WHO HAVE SEX WITH MEN For this reason, many people are still unwilling to sexual lives of homosexual men (16). According report their sexual orientation. Moreover, patients to Lau, et al., msm who experienced discrimina- with pf may be too embarrassed to seek medical tion because of their sexual orientation were more attention in the emergency room (10). This may predisposed to erectile dysfunction and premature explain