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You are called to see a 25 year old male who presented to the

By Alvin Ruiz,2014-06-11 06:56
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You are called to see a 25 year old male who presented to the

    You are called to see a 25 year old male who presented to the emergency department with sudden onset of severe pain in his penis during intercourse. He has severe penile bruising. How would you

    manage him? What are the long term sequelae? 4/04

Likely diagnosis = penile fracture

    DDx = rupture of penile veins, rupture of dorsal penile artery, rupture of penile suspensory ligament

Management:

History:

    Timeframe of injury how long ago (pt often delays presentation because of embarrassment)

    Mechanism?

    - usually erect penis impacting on the perineum or pubic symphysis

    - patient may recall a pop or snap of penis immediately followed by penile pain and

    detumescence

    Difficulty voiding urine?

    - Hematuria

    - Urinary retention

    PHx:

    - previous injury

    - existing curvature of penis

    - diabetes, smoking

    Medications, allergies

    Fasting status

Examination:

    Penis hematoma

    - “egg-plant” deformity, confined by Buck’s fascia

    - If Buck’s fascia disrupted, hematoma may spread to scrotum, perineum or pubic area

    - Penis often deviates away from side of fracture (hematoma and mass effect)

    - Palpate blood clot against fracture site

    Evidence of urethral damage (10-20% cases of penile fracture)

    - blood at urethral meatus

    - high riding prostate on DRE

    - NB urethral injury can occur in the absence of these signs

Investigations:

    - penile fracture is a clinical diagnosis and a surgical emergency

    - improved results if repaired earlier: less curvature, less erectile dysfunction, improved

    recovery time

    - SIU guidelines recommend retrograde urethrogram in all cases of penile fracture. If RGU not

    easily available, perform on table flexible cystoscopy.

    - I would take patient to operating theatre without other further tests

    - Other tests which can be considered:

    1. MRI more accurate than US, cavernosography to detect small tears in tunica

    - consider in patients without typical presentation/physical findings of penile fracture

    2. Ultrasound

    3. Cavernosgraphy

    - both US and cavernosography can miss small tears or when clot fills fracture site (i.e.

    false negative rate high, poor sensitivity)

    - cavernosography is also unfamiliar to most radiologists/urologists

Treatment:

Analgesia, Ice

    Perioperative ABx

    IDC/SPC for acute retention

Prompt surgical repair (<24hrs) a/w

    - faster recovery, ? morbidity, lower complication rates (e.g. abscess)

    - lower incidence of long-term curvature

Surgical repair

    - circumferential distal penile shaft incision

    - deglove penis to expose corpus cavernosum and spongiosum/urethra

    - evacuate hematoma, control hemorrhage, minimal debridement

    - repair tear in tunica albuginea with interrupted, absorbable suture (e.g. 2/0 or 3/0 vicryl)

    - avoid suturing erectile tissue within corpora

    - urethral injury?

    - Complete: mobilize urethra, debride, tension-free anastomosis over catheter

    - Partial: urethral catheter, SPC, primary repair over catheter

    - Suppress post-operative erections with pseudoephedrine

    - Post-operative erection however is good prognostic sign for erectile function in the

    future

    - Sexual abstinence for 1/12

Long term sequelae:

    - erectile dysfunction

    - Peyronie’s disease: plaque, curvature, painful erections

    - Decreased sensation

    - Urethral injury repaired: urethral stricture, penile shortening

Important to counsel patient that these long term sequelae are as a result of the injury, not of the

    operation.

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