Penile fracture with urethral trauma

Clinical History

A generally healthy male with bleeding from the meatus and scrotal swelling following trauma during sexual intercourse.

Imaging Findings

A generally healthy male presented with bleeding from the meatus and scrotal swelling. The symptoms developed following trauma to the penis during sexual intercourse, while under the influence of stimulants. This was accompanied by urinary retention, which had to be relieved by insertion of a suprapubic catheter. An ascending urethrogram was performed to assess the extent of urethral injury. This showed complete urethral rupture at the proximal penile urethra, with extravasation of urine into the scrotum. An MRI scan was also performed to assess the extent of injury prior to surgical intervention. The patient was then taken to theatre where the tunica albuginea was repaired and primary anastomosis of the urethra was achieved.

Discussion

Penile fracture is defined as tearing of the tunica albuginea in an erect penis. The tunica is composed of collagen tissue and surrounds both corpora cavernosa. In the process of erection it undergoes significant thinning and loss of elasticity. Direct trauma can therefore cause a laceration with or without cavernosal damage. Accompanying injury to the urethra is seen in up to 38% of cases.

Penile fracture is a rare condition, with trauma during sexual intercourse reported as the most common cause. Rarer causes include direct trauma and injury due to falling out of bed. The diagnosis is usually straightforward on the basis of history and physical examination. Patients usually report hearing or feeling a crack followed by pain and loss of erection. Up to 20% of patients complain of urinary symptoms, including haematuria, dysuria and urinary retention. Examination often reveals bruising, marked tenderness, swelling and blood at the meatus.

In typical cases, with no suggestion of urethral injury, no imaging is required as it unnecessarily delays operative treatment. If urethral compromise is suspected, then an ascending urethrogram is mandatory. This will show extravasation at the site of injury. Penile cavernosography can reveal lacerations that are not detected surgically, but is a painful and invasive procedure.

In atypical cases, or in instances where the site of rupture is obscured by haematoma, MRI can be invaluable due to its multiplanar capability. The tunica albuginea is of low signal intensity in both T1- and T2-weighted images, and even small discontinuities can often be visualised. Haematomas appear as inhomogeneous structures of mixed signal intensity. Better tissue contrast can be obtained by the use of gadolinium, but its routine use remains controversial.

The recommended treatment of this condition is surgical. The haematoma is evacuated, followed by correction of the defect in the tunica albuginea and repair of the urethral injury. Complications of penile fracture include erectile dysfunction, persisting abnormality of the shape of the penis and formation of fistulae. However, with prompt diagnosis and surgical intervention the prognosis is excellent.

Differential Diagnosis List

Final Diagnosis

Acute penile fracture with urethral rupture

URL:	https://www.eurorad.org/case/1499
DOI:	10.1594/EURORAD/CASE.1499
ISSN:	1563-4086