Penile fracture with urethral injury

Clinical History

A 60 year old man presented to the emergency department complaining for dysuria, haematuria and penile pain that initiated six hours prior to his admission. His past medical history revealed a cardiac bypass surgery 2 years ago due to an acute myocardial infarction, dyslipidemia and hypertension.

Imaging Findings

Clinical history revealed that symptoms begun immediately after a vigorous sexual intercourse. The patient reported that during sexual activity his penis slipped out of the vagina and suffered a blunt impact against the female’s perineum. He heard a “cracking” sound followed by immediate pain, rapid loss of erection and development of swelling, haematoma and penile deformity. Physical examination showed a deformed, swollen penis with evidence of subcutaneous hematoma formation (Fig. 1). Suspicion of urethral trauma due to the presence of blood in the urethral meatus led the clinicians to request a retrograde urethrogram. Retrograde urethrography verified an incomplete bulbous urethral rupture (Fig. 2). An ultrasound was performed subsequently, which showed a traumatic rupture of the corpus spongiosum along with evidence of tear of the tunica albuginea and Buck’s fascia (Fig. 3-4). The partial urethral disruption was managed conservatively by gently placing an urethral catheter (Folley catheter). After 4 days of hospitalisation the patient was released and was scheduled in an outpatient basis for follow-up and removal of the catheter. A late complication occurred 2 weeks post catheter removal. The patient reported mild penile erectile dysfunction and voiding difficulty. Retrograde urethrography showed a stricture in the anterior urethra (Fig. 5) which was successfully treated with dilation.

Discussion

Penile fracture as a consequence of straddle injury is a relatively uncommon traumatic injury that occurs as a result of trauma to the erect penis. Clinical history and physical examination are characteristic for diagnosis. Most cases of penile fracture are an outcome of vigorous sexual intercourse, due to accidental impact of the penis upon the female symphysis pubis or the perineum. Typically the patient reports sharp pain and recalls a “cracking” sound. Immediate loss of erection followed by penile deformity and formation of a subcutaneous hematoma adjacent to the rupture are also characteristic features. Concomitant urethral rupture either partial or complete is an associated injury. Clinical examination reveals blood in the urethral meatus or haematuria. Goldman et al modified the Colapinto and McCallum classification for urethral injuries and categorized urethral injuries following blunt trauma based on the anatomic location. A type V injury is caused by straddle injury and occurs in the bulbous urethra. Furthermore if the Buck’s fascia remains intact, the haematoma is limited to the space between the Buck fascia and the tunica albuginea of the corpus spongiosum. On the contrary, rupture of the Buck’s fascia and the tunica albuginea is followed by larger hematoma formation confined by the Colle’s fascia. Retrograde urethrography (RUG) is considered to be the best imaging study for suspected urethral rupture following penile fracture. Blood in the meatus is a strong indication for imaging and RUG should be performed prior to any therapeutic attempt. The differentiation between a partial or complete tear is crucial for patient management. Partial tears can be managed conservatively while complete urethral ruptures demand a surgical treatment. Ultrasonography adds valuable information as to the degree of injury of the corpora cavernosa and corpus spongiosum. Evaluation of the penile fasciae can also be performed with US. Nonetheless, in complex or remote injuries of the penis an MRI exam offers more information due to its inherent superior soft tissue resolution. In conclusion, our case is an example of this uncommon penile injury, accompanied by rupture of the Buck’s fascia and the tunica albuginea, associated with concomitant partial urethral tear and finally complicated by urethral stricture.

Differential Diagnosis List

Final Diagnosis

Penile fracture with urethral injury

URL:	https://www.eurorad.org/case/8581
DOI:	10.1594/EURORAD/CASE.8581
ISSN:	1563-4086