UROLOGICAL SURVEY
Urogenital Trauma
Management of penile fracture
El-Taher AM, Aboul-Ella HA, Sayed MA, Gaafar AA
Urology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
J Trauma. 2004; 56: 1138-40
BACKGROUND: Penile fracture is not a frequent event. It consists of rupture of the tunica albuginea of the corpora cavernosa. Fracture occurs when the penis is erect, as the tunica is very thin and not flexible.
METHODS: This prospective study was carried out over a period of 1 year and included 12 patients presenting with penile fracture.
RESULTS: Diagnosis was made clinically, and there was no need to perform cavernosography in any case. The most common cause of fracture was trauma to the erect penis during intercourse. Mean age of patients was 29.5 (+ /- 8.96) years, and mean time of presentation was 15.5 (+/- 8.04) hours. Subcoronal circumferential degloving incision was done in all cases. Nine patients were operated on, and three patients refused surgery and were treated conservatively. Repair consisted of evacuation of hematoma and repair of the tunical defect with absorbable sutures. The mean operative time was 33.9 (+/- 8.2) minutes. Preoperative and postoperative antibiotics were used, and all operated cases were discharged on the second postoperative day. All operated cases were able to achieve full erection with straight penis except one, in whom mild curvature and pain during erection was observed.
CONCLUSION: Penis fracture is a true urologic emergency. It should be treated surgically as early as possible to ensure a better outcome.
Editorial Comment
This Egyptian study is a nice review that emphasizes the importance of prompt surgical repair for the management of penile fractures. Fractures that were repaired had no organic impotence and had straight, painless erections. Those who were managed conservatively developed penile nodules and plaques, and/or penile curvature and erectile dysfunction. Penile fracture is the result of axial forces to the erect penis that result in a tear in the tunica and/or Buck's fascia of the penis. The tear in the fascia is typically transverse, involves the mid to proximal penis and is on ventral to lateral aspect. The tear can be close to or travel under the urethra, and in rare instances can extend into the corpus spongiosum or into urethra (partial or complete transactions). Patients with blood at the meatus or any degree of hematuria and penile fracture need to have the urethra evaluated for concomitant injury. This can be done preoperatively with a retrograde urethrogram or intraoperatively by flexible cystoscopy or by injecting blue-tinged saline retrograde and evaluating for extravasation. The diagnosis of penile fracture is based on history and physical examination. In rare instances, rupture of the dorsal vein can mimic a penile fracture. Otherwise, the diagnosis is often easy to make. Cavernosography is cumbersome, invasive, rarely ever performed, and generally unnecessary to make the diagnosis. In equivocal cases, magnetic resonance imaging may have a role in the diagnosis of penile fracture, since it is a noninvasive and sensitive and specific modality.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
Treatment of pelvic fracture-related urethral trauma: a survey of current practice in the UK
Andrich DE, Greenwell TJ, Mundy AR
Institute of Urology, London, UK
BJU Int. 2005; 96: 127-30
OBJECTIVE: To quantify experience of pelvic fracture-related urethral trauma (PFUT), a condition not often encountered and managed by urologists.
METHODS: The consultant urologists of the UK and Ireland were contacted informally to establish their experience with PFUT and its management, both immediate and delayed. In addition, particular individuals thought to have a specific interest in PFUT were targeted for more data.
RESULTS: The overall response rate was 49% (235 responders), representing 78% of urological departments, including all the targeted individuals. Of the responders, 129 (55%) had never seen PFUT in 1-25 years of consultant practice. Only four urologists (2% of responders) saw three or more cases a year. Another four (2%) saw one or two cases per year and the remaining 98 (41%) saw PFUT less frequently. Acutely, 69% of urologists who treated PFUT did so by placing a urethral catheter. Subsequent strictures were treated endoscopically for as long as this was possible. The other 31% inserted a suprapubic catheter and referred the patient for reconstructive surgery if needed. Those who used urethroplasty for strictures after PFUT were identified and targeted; half used urethral mobilization and spatulated anastomosis alone. Only three surgeons performed more than five procedures a year.
CONCLUSION: Whatever a specialist reconstructive unit might do, practice in the wider urological community is different. Even within specialized units, PFUT is rare and the surgical management is often significantly different from published 'expert' opinion.
Editorial Comment
This British paper eloquently states what those of us who specialize in trauma and urethral reconstructive surgery have experienced in practice for years. Despite a wealth of literature supporting that managing urethral distractions by a "reconstructive ladder" is antiquated and prone to failure, this is the most common method practiced by contemporary British and Irish urologists. Furthermore, most UK urologists manage only a handful of urethral distraction injuries their entire career, and even fewer have performed a posterior urethroplasty. It is this general lack of experience and knowledge of the literature that makes minimally invasive methods of management disproportionably popular. Posterior urethral injury from pelvic fracture is a distraction injury where the space between the separated ends of the urethra fills with scar. Thus, posterior urethral distraction injuries are not really urethral strictures, and thus minimally invasive methods and "cut to the light" procedures do not have any durable success.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
Publication Dates
-
Publication in this collection
05 Oct 2005 -
Date of issue
Aug 2005
