Authored by Mukesh Chandra Arya*
Abstract
Introduction: Penile fracture is an emergency condition. Common presentation is classical history of trauma to erect penis followed by detumescence, penile swelling, ecchymosis and discoloration. Management is primarily surgical. We report our experience of such cases including a subgroup of patients with unexplained recurrent nocturnal urethral bleed without penile swelling and normal voiding.
Material and methods: This a retrospective study performed at our institution. Records of penile fracture cases managed over last 6 years were reviewed. Total of 63 patients were managed either by surgical (53 patients) or conservative (10 patients) approach. Sexual outcomes were measured with abbreviated International Index of Erectile Function (IIEF 5) questionnaire and compared with preoperative scores.
Results: Most common aetiology was coital trauma, seen in 88.9 % of patients. Mean age was 34.95 years. Urethral injury was present in 5 (9.4%) patients in the surgical group. Most common site of injury was ventrolateral {32 (60.4%)} over proximal shaft {49 (92.5%)}. Mean follow up was 19.27 months ranging from 6 to 41 months. Erectile function was preserved (no deterioration in IIEF 5 category) in 96.3 % and 100% of patients from surgical and conservative groups.
Conclusion: Unexplained recurrent nocturnal urethral bleed as a presentation of penile fracture, should be kept in mind. Such peculiar presentation, to our knowledge, has not been reported in literature. This subgroup of patients can be managed conservatively with good sexual and voiding functional outcome.
Keywords: Nocturnal urethral bleed; Penile fracture; Conservative management; Erectile dysfunction
Abbreviations: IIEF: International Index of Erectile Function; ED: Erectile Dysfunction
Introduction
Penile fracture is an emergency urological condition defined as rupture of tunica albuginea of corpora cavernosa because of trauma to erect penis as a result of sudden increase in intra-corporeal pressure. Typically it occurs during coitus when the phallus strikes against the pubis or perineum of partner producing a buckling injury [1]. It can also occur during self-manipulation, rolling over or falling onto erect penis or due to practice of “taqaandan” [2,3]. Patient usually describes a “cracking” or “popping” sound followed by detumescence, pain, swelling and discoloration of penile shaft. If the Buck’s fascia remains intact the hematoma is limited to shaft. If it is also disrupted the hematoma can reach to perineum and suprapubic area. Diagnosis is clinical and management is primarily surgical. We report our experience of managing penile fracture cases over last 6 years with especial impression upon a group of patients having an unusual clinical presentation with unexplained recurrent nocturnal urethral bleeding without penile swelling.
Materials and Methods
Introduction
This is a retrospective analytical study of cases of penile fracture treated at our institution from August 2014 to September 2019. Patients with penile fracture with diagnosis based on classical history of trauma on erect penis followed by sudden detumescence were included. They underwent routine hematology and biochemistry investigations. Pretrauma erectile function was documented using IIEF 5 questionnaire. They were managed either with surgery (N=53) or conservative treatment (N=10).Patients with minimum 6 months follow up were included. Patients with false penile fracture due to rupture of dorsal vein were excluded. Dorsal venous injury could be differentiated from penile fracture as the former does not lead to sudden detumescence, patient can cohabitate further and the site of hematoma being limited to dorsal surface of penis. Data was retrieved from institutional registry of penile fracture patients. Diagnosis of the condition was virtually clinical. Institutional protocol is of emergency repair of such cases without any delay. Conservative management was opted in a special subgroup of patients who presented with unexplained recurrent nocturnal urethral bleeding and either not diagnosed or misdiagnosed and treated for hematuria of unknown cause before being referred to us. This treatment plan was based on shared decision making. On enquiring further these patients had classical history of sexual trauma with “popping” sound and sudden detumescence but no penile swelling. The temporal association of proper history with their symptoms helped us to clinch the diagnosis. Classically all of them had no penile swelling and were voiding well. To document tunical rupture in this subgroup, imaging studies were performed. Ultrasound of penis in 8 /10 cases confirmed the diagnosis. MRI documented it in the remaining 2 cases. Conservative management included compressive dressing, Foley catheterization, antibiotics, anti-inflammatory and antierotic drugs (conjugated estrogen 0.625 mg PO twice daily for 1 week). Many of them refused admission and were managed on outpatient basis. The catheter was kept for 7 days. The surgical management included penile exploration under anaesthesia by a circumcoronal incision, penile degloving, inspection of corporeal tear, repair with delayed absorbable sutures (using PDS 3-0 with knots buried inside) followed by repair of Buck’s fascia over it and circumcision at conclusion of procedure. Circumcoronal incision allowed survey of whole penile shaft and also avoided overlying suture lines with sound healing. Delayed absorbable suture provides ample time for corporeal and tunical tissue to heal without abnormal feeling of knot post operatively. If Bucks fascia is intact and exploration is being performed, one can reach the site of tunic tear only after incising the fascia. Foley catheter was kept and compressive dressing applied. Concomitant urethral repair was undertaken if found injured except in one case in which the repair was staged. Apart from postoperative antibiotics (third generation Cephalosporin and aminoglycoside), anti-inflammatory drugs all patients were given conjugated estrogen 0.625 mg PO twice daily for 1week to prevent erections and advise was given to refrain from sexual activity for 6 weeks. Patients who had not undergone urethral repair were discharged on post-operative day 2nd after removal of dressing and Foley catheter. Catheter was kept for 2 weeks if urethral repair was contemplated. Follow up included history for any voiding or sexual symptoms and local physical examination. Erectile function was assessed at 6 months with IIEF 5 score [4].
Result
Total of 63 patients were included in the study. Mean age was 34.95 years ranging from 18 to 60 years. Most common mode of injury was coital trauma in 88.9 % of patients. Presentation was in different combinations of “popping” sound, sudden detumescence, penile swelling, ecchymosis, deviation and urethral bleed (Table 1).
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