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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

Tuesday, February 10, 2015

Penile Fracture : Is it possible?

Yes, Penile trauma can lead to PENILE FRACTURE. This is a rare injury, but as Emergency Physicians we need to know about this (presentation/Investigations and Rx) to liaise with the Urologists. Lets see how it presents and what we need to look for:

Fracture of the penis is a surgical emergency that results from blunt trauma to the erect penis.
When flaccid, the penis can withstand a certain amount of stress due to the thick tunica albuginea. However, when the penis is erect, the tunica albuginea stretches over the engorged corpora cavernosa, making it vulnerable to rupture when placed under significant strain. Unfortunately, medical care is often delayed, due to the embarrassing nature of the condition.



The majority of penile fractures result from vigorous vaginal intercourse, can also occur following manipulation of the penis during masturbation, and rarely, following trauma.

Classical history - i.e. vigorous sexual intercouse which is interrupted by sudden pain in the penis, often in association with a popping sound; this is followed by immediate detumescence, and swelling and bruising of the penis. Urinary symptoms such as dysuria, poor stream, urinary retention and meatal bleeding, may be seen if the injury involves the penile urethra.

On examination, an ‘egg-plant deformity’ of the penis is typically seen due to the combination of swelling of the penis, and bruising and deviation to the side opposite to the tear. The bruising is often contained within Buck’s fascia and therefore appears localised to the penile shaft. If the fascia has also been damaged, blood may track down into the scrotum, supra pubic area or the perineum.

On palpation, a hematoma may be located over the site of the tear, or the tear may be palpable as a defect; the 'rolling sign' (where the penile skin can be rolled above a firm immobile hematoma on the shaft) may also be present.

The diagnosis of penile fracture is mainly clinical. Investigations are warranted only if the clinical features are equivocal, if signs and symptoms suggestive of urethral injury are present, or if the patient presents late. Bilateral tears also warrant investigations, as the chance of urethral injury is much higher in these patients.

In such individuals, retrograde urethrography, cavernosography, ultrasonography and magnetic resonance imaging (MRI) may prove to be of use.

Retrograde urethrography is quick and inexpensive, and can easily identify urethral tears; however, current evidence does not support its routine use in all patients with penile fracture.

The technique of penile cavernosography involves injection of contrast medium into the corpora cavernosa by direct injection. A series of fluoroscopic images is subsequently obtained, with the presence of contrast leakage across the tunica albuginea being confirmatory of the condition; this will also help localize the exact location of the tear. Note that the procedure is not without complications; priapism, allergic reactions and fibrosis of the corpus cavernosa have been observed.

Ultrasound imaging is less informative but may prove advantageous in pediatric patients; while MRI has the ability to visualize the anatomy clearly, the time and cost may be an issue.

From the ED Management perspective, we need to give them adequate analgesia (Meds, Cold Compression) and get Urology ASAP. Most authorities agree that urgent surgical exploration and repair is the first-line treatment in these patients. Overall, surgical repair has an excellent outcome.

Complications: permanent penile deviation due to fibrosis, fistulae formation between the urethra and skin or the corpora cavernosa, urethral strictures, painful erections, and erectile dysfunction.

Conservative measures such as ice packs, foley catheterization and anti-inflammatory agents have been used in the past, success rates were low, and complication rates high. Now, these are only used as an adjunct to surgery.


Take home:
1. Penile fracture is a clinical diagnosis (Investigate only if C/F equivocal, suspected uretheral injury, delayed presentation)
2. The presence of associated urinary symptoms should raise strong suspicion of urethral injury.
3. Urgent surgical exploration and repair is the cornerstone of management.

References
1. EKE N.. Fracture of the penis. Br J Surg [online] 2002 May, 89(5):555-565 [viewed 20 June 2014] Available from: doi:10.1046/j.1365-2168.2002.02075.x
2. JACK GS, GARRAWAY I, REZNICHEK R, RAJFER J. Current Treatment Options for Penile Fractures Rev Urol [online] 2004, 6(3):114-120 [viewed 20 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472832
3. MURRAY KATIE S., GILBERT MICHAEL, RICCI LAWRENCE R., KHARE NARENDRA, BROGHAMMER JOSHUA. Penile fracture and magnetic resonance imaging. Int. braz j urol. [online] 2012 April, 38(2):287-288 [viewed 20 June 2014] Available from: doi:10.1590/S1677-55382012000200019

4. Amer, Tarik, et al. "Penile Fracture: A Meta-Analysis." Urologia internationalis96.3 (2016): 315-329.


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