case Report:1-9

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Case 1-9
1. Patient 1 (Fig.1 ) developed severe pain in his penis whist having sexual
intercourse; he immediately lost his erection and noticed blood at his urethral
meatus. Patient 2 (Figure2a, b ) had a similar history but there was no blood at
the meatus. What do the images below demonstrate and what is the diagnosis?
2. What is the role of imaging in these patients?
3. What is the optimal management and what complication may occur?

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figure2

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Answers to Case 1-9
1. The history in both patients is consistent with a diagnosis of a fractured penis. In
patient 1 the history suggests a concomitant urethral injury and the urethrogram
(Fig.1 ) confi rms this by showing a urethral distraction injury. In patient 2 the
history, Doppler ultrasound (Fig..2a ) and intraoperative fi ndings (Fig.2b )
show an intact urethra, a transverse tear is seen on the ventral surface of the corporal
bodies.
Fractured penis occurs due to blunt trauma to the erect penis, usually following
sexual intercourse. The corpora cavernosum is surrounded by the tunica
albuginea. During tumescence as the corpora fi ll with blood and become more
rigid the tunica albuginea thins to 0.25-0.5mm. Sudden blunt trauma to the erect
penis may result in an audible ‘crack’ as the thinned tunica tears. Typically sudden
detumescence occurs due to leakage of blood into the surrounding tissues,
resulting in the so-called ‘egg-plant (aubergine) deformity’. Up to 30% of patients
have blood at the urethral meatus; these patients need investigation with either a
preoperative urethrogram or intraoperative urethroscopy. If both corpora are
involved urethral injury is more likely.
2. Ultrasonography and MR image may help identify tunical rupture, though with
a good history and typical examination fi ndings their negative predictive value
may not negate the need for surgery. Retrograde urethrography is useful to
exclude a urethral injury, fi nally corporal cavernosography may confi rm a tear,
though is seldom used.
3. Immediate surgical exploration is the treatment of choice; good outcomes were
reported in 92% of men treated surgically versus 59% treated conservatively.
Operative intervention involves either a circumferential incision 1 cm proximal
to the glans down to Buck’s fascia and then degloving the penis or an incision
directly over the defect. The haematoma is evacuated and after careful inspection
to assess the degree of injury the corporal bodies and if necessary the urethra are
repaired. Complications arising from penile fracture include erectile dysfunction
(which may be due to a cavernosal-spongiosal fi stula), penile curvature, painful
nodular fi brotic plaques and urethral-cutaneous or corporo-urethral fi stulae.

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