Penile fracture associated with complete urethra and bilateral corpora cavernosa transection

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis. It occurs due to the forcible bending of the turgid erect penis against resistance leading to tunica albuginea tear. The rupture of tunica albuginea surrounding the corpora cavernosa leads to hematoma formation and classical ‘aubergine’ deformity. Timely intervention is essential to improve sexual function. Urethral injury may occur concomitantly in case of severe trauma. Blood at the meatus, inability to void and haematuria are distinctive features. We describe a case of 36-year-old man who presented to the emergency department with penile fracture during sexual intercourse associated with blood at the meatus and voiding difficulty. On surgical exploration, complete bilateral corpora cavernosa tear and penile urethral transection was noted. The patient was successfully managed with timely repair. This case highlights the need for suspicion of an associated urethral injury in patients of penile fracture with blood at the meatus.     

Complete urethral injury in the penile fracture: a case report and literature review

Penile fracture is described as a traumatic rupture of the tunica albuginea caused by blunt injury to the erect penis. It usually occurs as a single rupture of the tunica albuginea in one of two corpora cavernosa; a rupture with urethral injury is an extremely rare condition. Although its diagnosis is usually clinical, ultrasound plays an important role in confirming diagnosis and identifying the site of the injury. Here, we presented a case of penile fracture with complete urethral injury. A 43-year-old male was admitted to the hospital because of trauma to the genital and dysuria following sexual intercourse. After admission, the patient was diagnosed with double penile fracture and complete urethral injury after the physical and B-ultrasound examinations. Emergency surgery to remove the hematoma and repair the urethra was performed. The patient recovered smoothly and was discharged on the third day after operation. After two months’ follow-up, the patient urinated smoothly and achieved an adequate erection without other complications. In this case, consistent with previous studies, emergency surgery for penile fracture is necessary and can preserve the urethral function and sexual function. In addition, there are two lesions in tunica albuginea in this case, so careful search for the penile shaft during the surgery is important to avoid the missed injuries. This report provides evidence of an uncommon and underreported clinical case.     

SURGEON EXPERIENCE WITH PENILE FRACTURE

PURPOSE: The experience of a single surgeon with a series of 34 penile fractures, including 29 corrected surgically and 5 managed conservatively, at 3 large inner city medical centers in an 11-year period is presented. Standard diagnostic and therapeutic modalities are described that have evolved with time. MATERIALS AND METHODS: Between 1989 and 1999, 34 patients 18 to 38 years old (mean age 27 at presentation) were evaluated after blunt trauma to the erect penis. The interval from injury to presentation was between 6 and 72 hours. Of these patients 32 and 2 had been injured during sexual intercourse and masturbation, respectively. Surgery in 29 cases involved a degloving incision, and intraoperative evaluation of the corpora and urethra by radiography or saline injection. Five patients were treated conservatively for presumed penile fracture after they refused diagnostic confirmation and/or surgery. RESULTS: Injury involved unilateral and bilateral corporeal rupture in 25 and 3 cases, respectively, and urethral injury in 5. Urinalysis in 6 patients demonstrated microscopic hematuria with 5 to 10 red blood cells, although there were several false-negative urethrograms and cavernosograms. At followup 33 of the 34 patients available reported erection adequate for intercourse without erectile or voiding dysfunction, while 2 reported mild to moderate curvature. CONCLUSIONS: A degloving procedure with a urethral catheter in place provides the best exposure and orientation. In addition, saline injection may demonstrate additional corporeal body and/or urethral pathology as well as assess the integrity of repair. Although surgical repair was not associated with serious sequelae, a small subgroup of patients with presumed penile fracture also had no sequelae.     

Penile fracture with complete urethral rupture

We report a rare case of penile fracture with complete urethral rupture in a 25-year-old male who sustained the injury during sexual intercourse. He presented with a tense haematoma on the ventral aspect of the penile shaft, associated with per urethral bleeding. Despite the injury, he was able to void painfully. Retrograde urethrography revealed complete obstruction at the proximal third of the urethra. Exploration and repair of the penile fracture and urethra were performed. The patient made an uneventful recovery with good erectile and voiding function. This case illustrates the value of retrograde urethrography in assessing urethral injuries in patients with penile fracture.     

Penile fracture with bilateral corporeal rupture and complete urethral disruption: case report and literature review

Penile fracture is a rare injury most commonly sustained during sexual intercourse. We report the case of a 35-year-old man who presented with bilateral rupture of the corpora cavernosa and complete disruption of the urethra. A review of the literature on penile fracture is also presented. Urgent surgical exploration was performed and the injuries repaired primarily. In follow-up, the patient reported satisfactory erectile function. This case highlights the importance of early surgical repair and evaluation for concomitant urethral injuries in cases of penile fracture.     

Paediatric penile trauma

OBJECTIVE: To report our experience with paediatric penile trauma in a retrospectively evaluated series. PATIENTS AND METHODS: The records of 64 boys (mean age 7 years, sd 4) who were hospitalized over the last 20 years because of penile trauma were reviewed. The cause of trauma was circumcision in 43 (67%), a human hair-tie strangulation injury in 10 (16%), an animal attack in four (6%), a bicycle accident in four (6%), a zipper injury in two (3%) and electrical injury in one (2%). Patients were managed according to the severity of the injury. Eight (12%) with minimal skin loss or meatal injury underwent primary skin closure or meatoplasty; 40 (62%) with urethrocutaneous fistulae underwent repair and five (8%) with a glans hanging on a thin pedicle had the glans and the urethra reconstructed. Patients with partial or complete amputation of the glans (10) underwent primary haemostasis and meatoplasty; the penis was lengthened in one. One child with complete avulsion of the penis underwent perineal urethrostomy. RESULTS: Fifty-four patients (84%) were followed for a mean (sd) of 5.7 (4) years; there were good cosmetic and functional results in 45 (83%). Fifteen patients are now adults; 13 (86%) reported normal sexual function. Of the 40 patients assessed with circumcision-related injuries, six (15%) had functional disability (short penis in one and fistulae in five). Of the 10 patients with a hair-tie injury, none lost their glans. Of the four injuries caused by animal attacks, three had poor results (emasculation in one, short penis in one and severe curvature in the remaining patient). There was no functional disability in the remaining forms of trauma. CONCLUSIONS: In our region, ritual circumcision and hair-tie strangulation injuries are the most common causes of penile trauma in children. Good functional and cosmetic results are possible in most cases. However, animal attacks are associated with the highest rate of long-term functional and cosmetic disability.     

Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome

OBJECTIVE

To review the preoperative diagnostic evaluation and surgical treatment of penile fracture, as the condition is a urological emergency that requires immediate surgical exploration and repair.

PATIENTS AND METHODS

Between January 2003 and October 2007 eight patients presented to the emergency department with penile fracture after sexual intercourse. The clinical presentation, preoperative evaluation and imaging, surgical technique, and postoperative care were assessed to determine the optimal patient outcome.

RESULTS

Seven of the eight patients were treated surgically and one refused surgical intervention. Four cases involved unilateral corporal injury, two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury. Although retrograde urethrogram were taken of all three urethral injuries, none of them revealed the injury. Diagnostic cavernosography or magnetic resonance imaging were not used in any of the patients. No complications occurred in the patients treated surgically.

CONCLUSIONS

Preoperative imaging should not delay surgical repair. If an associated urethral injury is suspected, flexible cystoscopy is recommended in the operating room, as opposed to a retrograde urethrogram. A subcoronal circumcising incision is recommended to deglove the entire penile shaft and have complete access to all three corporal bodies, as well as the neurovascular bundle. Saline mixed with indigo carmine can be injected both into the corpora cavernosum or corpus spongiosum via the glans penis, after a tourniquet is placed at the base of the penis, to evaluate the surgical repair and to determine if there are any missed injuries.     

The diagnosis of acute urethral trauma

Background

During trauma resuscitation, blind catheterization of an injured urethra may aggravate the injury by disrupting a partially torn urethra. In busy trauma centers, retrograde urethrograms (RUG) prior to catheterisation for all patients with unstable pelvic fractures presents a challenge during trauma resuscitation, and the procedure is not commonly practiced despite Advanced Trauma Life Support (ATLS) and World Health Organisation recommendations. The aim of this study was to determine the presenting clinical features of patients with urethral injuries and to predict major trauma patients needing further investigation to exclude this injury.

Methods

A retrospective review of adult major trauma patients diagnosed with urethral injuries during an 8-year period at a major trauma centre, was conducted.

Results

There were 998 major trauma patients with fractures of the pelvis over the study period, of whom 223 had pubic symphysis disruption. There were 29 patients with urethral injuries. The sensitivity of any one of the traditional signs of urethral trauma was 66.7% (95% CI: 46.0-82.8). After exclusion of patients with penetrating trauma and iatrogenic injuries, pubic symphysis disruption on initial pelvis AP X-ray and/or the clinical signs of urethral injury had a sensitivity of 100% (95% CI: 84.4-100.0) for urethral trauma.

Discussion

Reliance on clinical features alone to predict urethral injury results in a substantial proportion of missed injuries in major trauma patients. RUGs did not appear to be needed in patients with no disruption of the pubic symphysis on initial pelvis X-ray or where no signs of urethral injury are present. In the absence of clinical signs and pubic symphysis disruption, blind urethral catheterisation may be attempted.     

Lower genitourinary trauma in modern warfare: The experience from civil violence in Iraq

Background

Reports on genitourinary (GU) trauma during the Iraqi conflict have been limited to battlefield injuries. We sought to characterise the incidence, mechanism of injury, wounding pattern, and management of lower GU injuries sustained in civil violence during the Iraqi war.

Patients and methods

A total of 2800 casualties with penetrating trauma to the abdomen and pelvis were treated at the Yarmouk Hospital, Baghdad from January 2004 to June 2008. Of the casualties 504 (18%) had GU trauma including 217 (43%) with one or more injuries to the lower GU organs.

Results

Among the 217 patients there were 262 lower GU injuries involving the bladder in 128 (48.8%) patients, bulbo-prostatic urethra in 21 (8%), penis in 24 (9.2%), and scrotum in 89 (34%). Injuries to the anterior urethra and genitals were inflicted by Improvised Explosive Devices (IEDs) in 53–67% of cases and by individual firearms in 33–47%, while injuries to the posterior urethra and bladder were inflicted by IEDs in 17–22% of cases and by firearms in 78–83%. All penile wounds were repaired save 3 (12.5%) patients who underwent total penectomy. Of 63 injured testicles 54 (86%) could be salvaged and 9 (14%) required unilateral orchiectomy. The leading cause of death was an associated injury to major blood vessels in 26 (84%) of 31 patients who died.

Conclusions

Injuries to the anterior urethra and genitals were commonly caused by IEDs, while injuries to the posterior urethra and bladder were usually caused by individual firearms. Testis injury was almost always salvageable. Associated trauma to major blood vessels was the leading cause of death in these casualties.     

The penis transposed to the perineum with penile-prostatic anastomotic urethroplasty for the treatment of a long segment complex urethral strictures

BackgroundTo present our experience of transposing the penis to the perineum, with penile-prostatic anastomotic urethroplasty, for the treatment of complex bulbo-membranous urethral strictures.MethodsBetween January 2002 and December 2018, 20 patients with long segment urethral strictures (mean 8.6 cm, range 7.5 to 11 cm) and scarred perineoscrotal skin underwent a procedure of transposition of the penis to the perineum and the penile urethra was anastomosed to the prostatic urethra. Before admission 20 patients had unsuccessful repairs (mean 4.5, range 2 to 12); five patients were associated urethrorectal fistula; 16 patients reported severe penile erectile dysfunction (PED) or no penile erectile at any time and four reported partial erections.ResultsThe mean follow-up period was 45.9 (range 12 to 131) months. Nineteen patients could void normally with a mean Qmax of 22.48 (range 15.6 to 31.4) mL/s. One patient developed postoperative urethral stenosis. After 1 to 10 years of the procedure, nine patients underwent the second procedure. Of the nine patients, four underwent straightening the penis and one-stage anterior urethral reconstruction using a penile circular fasciocutaneous skin flap, and five underwent straightening the penis and staged Johanson urethroplasty. Seven patients could void normally, one developed urethrocutaneous fistula and one developed urethral stenosis.ConclusionsTransposition of the penis to the perineum with pendulous-prostatic anastomotic urethroplasty may be considered as a salvage option for patients with complex long segment posterior urethral strictures.     

Pelvic Fracture and Associated Urologic Injuries

Successful management of patients with major pelvic injuries requires a team approach including orthopedic, urologic, and trauma surgeons. Each unstable pelvic disruption must be treated aggressively to minimize complications and maximize long-term functional outcome. Commonly associated urologic injuries include injuries of the urethra, corpora cavernosa (penis), bladder, and bladder neck. Bladder injuries are usually extraperitoneal and result from shearing forces or direct laceration by a bone spicule. Posterior urethral injuries occur more commonly with vertically applied forces, which typically create Malgaigne-type fractures. Common complications of urethral disruption are urethral stricture, incontinence, and impotence. Acute urethral injury management is controversial, although it appears that early primary realignment has promise for minimizing the complications. Impotence after pelvic fracture is predominantly vascular in origin, not neurologic as once thought.     

Severe penile injuries: a problem of severity and reconstruction

OBJECTIVES

To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation.

PATIENTS AND METHODS

We analysed retrospectively 43 patients (mean age 28 years, range 5–52 years) with severe penile injuries referred to us from March 1999 to August 2007. The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self‐amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury.

RESULTS

The mean (range) follow‐up was 47 (10–108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two.

CONCLUSIONS

Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres.     

Urethral trauma: radiological aspects and treatment options

Experience with treatment of 38 patients in an early phase with urethral trauma is presented. The site of injury was the penile urethra in three cases, the bulbous urethra in seven, and the prostatomembranous urethra in 28. Different surgical procedures were used, according to the site and the extent of urethral damage and the presence of associated lesions. All patients with penile and bulbous urethral trauma were cured and only one has diminished sexual potency, while in the posterior urethral group nine were cured, and 19 developed strictures requiring further surgical treatment. Total impotence developed in 17 and partial impotence in one patient. Another case presents urinary urge incontinence.     

Trauma to the anterior urethra: diagnosis and management

Injuries to anterior urethra are uncommon, mainly due to blunt trauma, and rarely associated with pelvic fractures or life threatening multiple lesions. Straddle type injury is the most frequent lesion, in which the immobile bulbar urethra is crushed or compressed on the inferior surface to the pubic symphysis. Diagnosis of urethral injury is easy, suspected due to trauma circumstances, presence of urethrorragy or initial hematuria, and eventually difficult micturition and penile scrotal for perineoscrotal hematoma. It should always be confirmed and classified by retrograde urethro-gram, realized either immediately or after a few days. Initial acute management is suprapubic cystostomy, if possible before any attempt of urethral catheterization or miction. Urethral contusions only require this urinary diversion or urethral catheter for a few days and usually heal without any sequelae. Management of partial and complete disruptions remains controversial: suprapubic diversion only and secondary endoscopic or open surgical repair of the urethral stricture that occurs in the great majority of the cases (always after complete disruption), early endoscopic realignment and prolonged urethral catheterization (4 for 8 weeks according to the lesion), in partial disruptions, more controversial in complete disruptions; delayed (after a few days) open surgical repair (urethrorraphy) that is the preferred European and French attitude for complete disruptions. Penetrating anterior urethral trauma and urethral lesions associated with penile fracture require immediate surgical exploration and repair if possible. After anterior urethral disruption, the main morbidity is urethral stricture very often requiring surgical treatment (visual urethrotomy if the structure is short, end to end spatulated urethrorraphy, flap or graft urethroplasty if longer).     

Nonoperative treatment of patients with presumed penile fracture

PURPOSE: Immediate surgical intervention is the basis for treatment of penile fractures due to the high risk of complications associated with conservative management. Unfortunately, patient refusal to undergo surgery has led to conservative treatment of a small group of patients with presumed penile fractures at our institution. We followed these patients in regard to clinical outcome. MATERIALS AND METHODS: Between 1992 and 1999, 5 patients were evaluated after blunt trauma to an erect penis. Patient age at presentation ranged from 19 to 31 years (mean 25). The interval from time of injury to presentation was 24 to 72 hours. Of these patients 4 had been injured during sexual intercourse, while 1 had been injured during masturbation. All 5 patients refused immediate surgical exploration for presumed penile fracture. RESULTS: No patient had any immediate complications. At 6 and 12-month followup all patients reported erections adequate for intercourse without associated pain. One patient reported only mild curvature for which he did not seek treatment. CONCLUSIONS: We report on a subset of young males with presumed penile fracture who refused diagnostic evaluation and therapy, and were able to maintain normal erectile and voiding function. However, longer followup and radiographic evidence will be necessary to corroborate or refute these initial observations.     

Diagnosis and classification of urethral injuries

Urethral injuries are uncommon and rarely life-threatening in isolation. They are, how-ever, among the most devastating urinary system injuries because of significant long-term sequelae, including strictures, incontinence, erectile dysfunction, and infertility.Urethral trauma may be categorized by mechanism of injury (ie, blunt versus penetrating injury) and by location (ie, posterior versus anterior urethra). Injuries to the posterior urethra are classically associated with pelvic fractures, while anterior urethral trauma usually arises secondary to injudicious instrumentation or perineal straddle injury. This article reviews the major etiologies and mechanisms of urethral trauma, describes how these injuries are diagnosed, and explains classifications of urethral trauma. Timely and accurate diagnosis and classification of urethral injuries leads to appropriate acute management and reduced long-term morbidity.     

Verletzungen des unteren Harntrakts und des Urogenitalsystems

Injuries of the lower urinary tract occur in patients with multiple injuries and trauma to the lower abdominal and pelvic region. Injuries of the male urethra including complete ruptures occur in 10% of pelvic fractures in males, while they are a rarity in females. Ruptures of the urinary bladder are either intra- or extraperitoneal. Ureteral injuries are relatively rare in blunt injuries and usually become manifest with infectious symptoms with a delay of days. Intraperitoneal ruptures of the urinary bladder always require urgent surgical repair while extraperitoneal ruptures can mostly be managed conservatively with catheter drainage of the bladder. In male patients with pelvic fractures any attempt of urethral catheterization which can otherwise make an urethral injury worse should be withheld until adequate urological examinations have led to the diagnosis or exclusion of urethral injury. The definitive surgical repair of a disruption of the male urethra should be undertaken with an interval of weeks to months. Long term sequelae of male urethral injury can be impotence and chronic stricture disease.     

Urethral injury in the multiple-injured patient

A total of 74 patients with urethral injury due to external trauma consisted of 48 posterior urethral injuries (25 complete rupture, 23 partial rupture) and 26 anterior urethral injuries (two complete rupture, 16 partial rupture, and eight contusion). The diagnosis was made by retrograde urethrography. All 48 patients with posterior urethral injury had associated injuries, including a fractured pelvis in 46, and a mortality rate of 33%. Only seven of the 26 patients with anterior urethral injury had associated injuries and a mortality rate of 14%. The management of posterior urethral injury is changing from primary realignment of the ruptured urethra to suprapubic cystostomy alone and followed later by urethral surgery for the resulting stricture. The impotence rate is significantly lower with management with suprapubic cystostomy alone. However, the type of pelvic fracture, the urethral injury itself disrupting neurovascular structures, and the surgical dissection (initial primary realignment or delayed urethroplasty) must be investigated before it can be determined whether the impotence associated with pelvic trauma is caused by the injury itself or by the surgical dissection undertaken to reconstruct the urethra.     

Urogenital injuries in childhood: A strong association of bladder trauma to bowel injuries

We analysed the inter-relationships of the cause and the type of trauma, the presence of pelvic fracture, the associated intraabdominal organ injuries,and the morbidity and mortality rates in 154 patients presenting and being treated for UGT between 1983 and 1997.The cause of injury was blunt in 77% of cases and penetrating in 13%. The most frequently injured organs were kidney followed by urethra and bladder. Bowels, liver and spleen were the most frequently associated injured organs. Moreover, bladder injuries were strongly associated with bowel injuries (p < 0.0001). Hemodynamically normal 49 children with minor or major kidney injuries were managed conservatively. Hemodynamically non-stable 11 patients were explored.The majority of urogenital injuries can be managed conservatively evenwhen associated with intraabdominal organ injuries. Solid genitourinary organ injuries may accompany more frequently to intraperitoneal solidorgan injury. Whereas, non-solid genitourinary organ injuries may more frequently associated with injuries of intraperitoneal hollow viscus. This revised version was published online in August 2006 with corrections to the Cover Date.     

The incidence,spectrum and outcomes of traumatic bladder injuries within the Pietermaritzburg Metropolitan Trauma Service

IntroductionThe purpose of this study is to provide a comprehensive overview of the incidence, spectrum and outcomes of traumatic bladder injury in Pietermaritzburg, South Africa, and to identify the current optimal investigation and management of patients with traumatic bladder injuries.MethodsThe Pietermaritzburg Metropolitan Trauma Service (PMTS) trauma registry was interrogated retrospectively for all traumatic bladder injuries between 1 January 2012 and 31 October 2014.ResultsOf 8129 patients treated by the PMTS over the study period, 58 patients (0.7% or 6.5 cases per 1,000,000 population per year) had bladder injuries, 65% caused by penetrating trauma and 35% by blunt trauma. The majority (60%) were intraperitoneal bladder ruptures (IBRs), followed by 22% extraperitoneal bladder ruptures (EBRs). There was a high rate of associated injury, with blunt trauma being associated with pelvic fracture and penetrating trauma being associated with rectum and small intestine injuries. The mortality rate was 5%. Most bladder injuries were diagnosed at surgery or by computed tomography (CT) scan. All IBRs were managed operatively, as well as 38% of EBRs; the remaining EBRs were managed by catheter drainage and observation. In the majority of operative repairs, the bladder was closed in two layers, and was drained with only a urethral catheter. Most patients (91%) were managed definitively by the surgeons on the trauma service.ConclusionTraumatic bladder rupture caused by blunt or penetrating trauma is rare and mortality is due to associated injuries. CT scan is the investigative modality of choice. In our environment IBR is more common than EBR and requires operative management. Most EBRs can be managed non-operatively, and then require routine follow-up cystography. Simple traumatic bladder injuries can be managed definitively by trauma surgeons. A dedicated urological surgeon should be consulted for complex injuries.