Urology Examination Flashcards
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Mechanism of penile fracture
-the erect penis is relatively more prone to injury - the penile erection is maintained by two fibro-elastic tubes (tunica cavernosa) which are filled with blood (at a pressure of 100-200mm Hg)
-if there is a sudden shearing force is applied to the erect penis or the erect penis is suddenly bent then there may a consequent rupture of the tunica cavernosa (as the intracavernosal pressure momentarily rises to supramaximal levels)
-in most cases of penile fracture the cavernous bodies are only affected. However, urethral injury may also develop in 1% to 48% of the cases, possibly depending on the mechanism and severity of the trauma (2)
Clinical features of penile fracture
-generally occurs as a ‘sexual injury’; may also occur in other situations e.g. bending the penis downwards to void with an early morning erection
-clinically there is generally no initial pain - there is however often a loud ‘crack’ due to the explosive decompression of the tunica. There is instant deflation of the erection and the erection cannot be regained
-in the few hours following the injury blood gradually seeps out of the ruptured tunica cavernosa and results in extensive bruising of the penis, scrotum and lower abdomen. At this stage there is also the development of pain - this may reflect damage to the penile nerves associated with the bruising and swelling
-clinical examination may reveal the ‘aubergine sign’, also known as the ‘eggplant sign’ - this sign summarizes the typical findings at presentation of penile fracture and consists of penile swelling, ecchymosis and penile deviation. Note though that a patient may present atypically with a straight phallus and the majority of swelling and ecchymosis occurring in the scrotal area instead of the penile shaft (3)
=the defect in the tunica is often palpable
=in some patients the penile skin can be rolled over the blood clot stuck in the defect
Diagnosis and management of penile fractures
-generally by history and examination; some authors recommend the use of ultrasound, MRI or cavernosography (2) to confirm diagnosis - however often this may only delay treatment (1)
=a study concerning the use of corpus cavernosography (2) concluded that in the context of men with blunt penile trauma, the clinical presentation can be misleading and may result in unnecessary surgery. The study indicated that cavernosography may be helpful in selecting the treatment approach in these cases
-if urethral injury is suspected then a retrograde urethrogram is a useful investigation
-treatment
=early surgical repair is considered the most appropriate treatment for penile fractures
Overview of fractured pelvis
The sacrum and the two innominate bones form a ring. The ring is weak anteriorly at the pubic symphysis and strong posteriorly due to the sacroiliac and iliolumbar ligaments.
In the adult with a rigid pelvis a fracture at one point of the ring is invariably accompanied by a second fracture elsewhere. This is not the case in children whose symphysis and sacroiliac joints are more flexible. This second fracture is however not always visible because it is either reduced immediately, impacted, or through a joint.
Pelvic fractures may be stable or unstable. A fracture is stable as long as the sacroiliac elements are not completely disrupted.
P: severe shock due to visceral damage and significant haemorrhage
local bruising and swelling extending into the thigh, perineum, scrotum or labia
bleeding from the urethra
abdominal tenderness
pain on springing of the pelvis
abnormal position of or pain in the sacrum and coccyx on per rectum examination
high riding prostate indicating urethral tear on rectal examination in men
neurological damage to the lumbosacral plexus
