133 Genital and Lower Urinary Tract Trauma

Question 1

Disrupted with the rupture of the corpus cavernosum in penile fractures.

Answer 1

Tunica albuginea

Question 2

Layers of the tunica albuginea

Answer 2

The tunica albuginea is a bilaminar structure (inner circular, outer longitudinal)

Question 3

Composition of the tunica albuginea

Answer 3

Collagen and elastin

Question 4

Most common location of penile fractures

Answer 4

Ventrolaterally (because it has the thinnest tunica albuginea)

Question 5

MOA of penile fracture

Answer 5

When the erect penis bends abnormally, the abrupt increase in the intracavernosal pressure exceeds the tensile strength of the tunica albuginea, and a transverse laceration of the proximal shaft usually results.

Question 6

Most common sexual position where penile fractures occur.

Answer 6

Doggy style

The objective of the study was to evaluate the relationship between the sexual position and severity of penile fracture (PF). We studied 90 patients with PF. The mechanism of injury and the sexual position was assessed. We divided our sample by the etiology of the fracture in six groups: (a) masturbation or penile manipulation; (b) ‘man-on-top’ position; (c) ‘doggy style’ position; (d) ‘woman-on-top’ position; (d) blunt trauma; and (e) ‘rolling over’ fracture. We used the χ2-test for contingency analysis of the populations under study (P<0.05). The patient’s age ranged from 18 to 66 years (mean 39 years). Investigation of the injury mechanism identified sexual trauma as the main etiological factor, involved in 69 cases (76.5%). The sexual position at the time of injury varied, with 23 cases (25.5%) occurring in the ‘man-on-top’, 37cases (41%) in the ‘doggy style’ and 9 cases (10%) in the ‘woman-on-top’. We do not observe differences between the severity of the PF between the ‘doggy style’ and ‘man-on-top’ (P=0.9595), but the ‘doggy style’ had more severity of PF when compared with ‘woman-on-top’ (P=0.0396) and penile manipulation (P=0.0026). The ‘man-on-top’ and ‘doggy style’ positions showed more associations with bilateral fractures of the corpus cavernosum and urethral lesions.

Question 7

Mechanisms of penile fracture

Answer 7

Sexual intercourse
Rolling over or falling over onto the erect penis
Stressful situations such as extramarital sex

Question 8

Self-inflicted fractures in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence after coitus.

Answer 8

Taqaandan

Question 9

Most common location of penile fractures

Answer 9

Most often distal to the suspensory ligament

Question 10

Usual location of penile fractures caused by coitus

Answer 10

Ventral or lateral where the tunica is the thinnest

Question 11

Main modality to make the diagnosis of penile fracture

Answer 11

The diagnosis of penile fracture is often straightforward and can be made reliably by HISTORY AND PE.

The typical history and clinical presentation of penile fracture usually make adjunctive imaging unnecessary.

Question 12

Usual scenario in penile fractures

Answer 12

A cracking or popping sound is heard as the tunica tears –> followed by pain, RAPID DETUMESCENCE and discoloration and swelling of the penile shaft.

Question 13

Hematoma after penile fracture is contained between the skin and tunica resulting in an “eggplant deformity,” what remained intact?

Answer 13

Buck’s fascia

Question 14

If the Buck’s fascia is disrupted in penile fractures, where can the hematoma extend to?

Answer 14

The scrotum, perineum, and suprapubic regions.

Question 15

Signs of urethral involvement in penile fractures.

Answer 15

Gross hematuria
Blood at the meatus
Inability to void

– in cases that are suspicious of penile fracture with concomitant urethral injury, urethral evaluation is COMPULSORY

Question 16

Diagnostic modality used in determining urethral injuries in EQUIVOCAL penile fracture cases.

Answer 16

Preop urethrography can be considered, albeit it being time consuming and inaccurate.

Intraoperative flexible cystoscopy can be used routinely just before catheter placement at the time of penile exploration when urethral injury is suspected.

Question 17

Diagnostic modality used when diagnosis of penile fracture is equivocal.

Answer 17

Ultrasonography – rapid, readily available, noninvasive, inexpensive, accurate.

Question 18

Aside from ultrasonography, which diagnostic modality can demonstrate tunica albuginea disruption in penile fractures?

Answer 18

MRI – also used when the diagnosis of penile fracture is equivocal.

Question 19

Reasons why cavernosography is no longer recommended in diagnosing penile fractures.

Answer 19

Time-consuming

Unfamiliar to most urologists

Question 20

Condition that may mimic penile fracture.

Answer 20

Rupture fo the dorsal penile artery or vein during sexual intercourse.

Question 21

Main management of penile fractures.

Answer 21

AUA Urotrauma Guidelines – penile fractures should be promptly explored and surgically repaired.

Question 22

Preferred incision in penile explorations for penile fractures.

Answer 22

Ventral vertical penoscrotal incision is usually preferred for direct exposure to the fracture, because most penile fractures occur ventrally or laterally.

Small lateral incisions may be used for localized hematomas or palpable tunical defects.

Question 23

The location of the penile fracture is uncertain, what incision is best done to provide exposure to all three penile compartments?

Answer 23

A DISTAL CIRCUMCISING INCISION

Question 24

Recommended closure of the tunical defect in penile fractures

Answer 24

Interrupted 2-0 or 3-0 absorbable sutures.

Avoid excessive debridement of the delicate underlying erectile tissue.

Question 25

What maneuver may aid in locating corporal lacerations in penile fractures?

Answer 25

Induction of an artifical erection with saline or colored dye

Question 26

Management of partial urethral injuries in penile fractures

Answer 26

Oversewing with fine absorbable sutures over a catheter

Question 27

Why is a distal circumcising incision not recommended in uncircumcised patients with penile fractures?

Answer 27

The distal prepuce becomes at risk for ischemia.

Question 28

Preferred incision in uncircumcised patients with penile fractures

Answer 28

VENTRAL VERTICAL INCISION – low risk for ischemia of the prepuce.

Although limited circumcision can be considered post repair.

Question 29

Benefits of surgical reconstruction of penile fractures

Answer 29

Faster recover
decreased morbidity
lower complication rates
lower incidence of long-term penile curvature

Question 30

Percentage of penile fracture patients who get penile curvatures post repair.

Answer 30

5%

Question 31

Percentage of penile fracture patients treated with conservative means who get penile curvatures.

Answer 31

> 10%

Question 32

Percentage of penile fracture patients treated with conservative means who develop abscesses or debilitating plaques

Answer 32

25-30%

Question 33

Is surgical repair of penile fractures time-bound?

Answer 33

NO.

Although surgery is better than conservative management, surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair.