PENILE FRACTURE.pptx

Penile fracture

1. PENILE FRACTURE

2. Introduction One of very few surgical emergencies that causes embarrassment to a man Misnomer Defined as blunt traumatic rupture of corpus cavernosum of an erect penis , particularly the tunica albuginea surrounding it This may be of one or both of corpus cavernosa .

3. Traumatic injuries to the genitalia are uncommon B ecause of the mobility of the penis and scrotum- Blunt phallic traumatic injury is usually of concern only with an erect penis, when fracture of the tunica albuginea may result. In general, prompt surgical reconstruction of most penile injuries usually leads to adequate and acceptable cosmetic and functional results

4. Cross section of penis

5. Etiology Fracture typically occurs during vigorous sexual intercourse, when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury .

6. Usual age 30-40 yrs Vigorous sexual intercourse – especially with doggy style position Masturbation Rolling over Fall over injuries with erect penis In the Middle East, self-inflicted fractures predominate resulting from the practice of “ taqaandan ,” in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence after coitus

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

8. PATHOPHYSIOLOGY Injury to flaccid penis is rare due to its flexibility and mobility Erect penis is less mobile and tunica albuginea reduces in thickness from 2mm to 0.25mm in erect rigid penis S udden longitudinal trauma / forceful lateral bending of erect penis will result in tear / rent in tunica albuginea With tear of cavernosa , there will be loss of extracorporeal blood into the loose fasciab of penis with rapid detumescence . There is subsequent hematoma formation , abnormal shape of penis and pain If copus spongiosum is inviolved , may manifest with urethral injury.

9. The tunical tear is usually transverse and 1 to 2 cm in length. The injury is usually unilateral, although tears in both corporeal bodies occur in 10 % of injuries. Bilateral corporeal injuries are more commonly associated with urethral injury.

10. Although the site of rupture can occur anywhere along the penile shaft, fractures are most often distal to the suspensory ligament. Injuries associated with coitus are usually ventral or lateral, where the tunica albuginea is the thinnest.

11. Clinical presentation Present as emergency Pain Swelling Loss of erection Popping sound Urethral injury

12. Examination Discomfortable and anxious patient Egg plant deformity Lateral bend of phallus if one side is involved Butterfly pattern ecchymosis Bleeding per urethra Tenderness Rolling sign – firm immobile clot seen as tender swelling over which penile skin can be rolled .

13. If Buck’s fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity .” If Buck’s fascia is disrupted, the hematoma can extend to the scrotum, perineum , and suprapubic regions. The swollen, ecchymotic phallus often deviates to the side opposite the tunical tear because of the resultant hematoma and mass effect.

14. The incidence of urethral injury is significantly higher in the United States and Europe (20%) than in Asia, the Middle East, and the Mediterranean region (3%), probably because of the different etiology—intercourse trauma versus self-inflicted injury. Most urethral injuries are associated with gross hematuria, blood at the meatus, or inability to void, although the absence of these findings does not definitively rule out urethral injury

15. Diagnosis Often straightforward with history and physical examination Patients usually describe a cracking or popping sound as the tunica tears, followed by pain, rapid detumescence , and discoloration and swelling of the penile shaft. Supporting investigations Urethrography MRI Cavernosography

16. In cases that are suspicious of penile fracture with concomitant urethral injury, urethral evaluation is compulsory. Given that urethral injury occurs frequently , preoperative urethrography can be considered when urethral injury is suspected However because urethrography can be time-consuming and inaccurate, intraoperative flexible cystoscopy is now often performed routinely just before catheter placement at the time of penile exploration when urethral injury is suspected.

17. However, when the history and physical examination are equivocal for penile fracture , ultrasonography can establish the diagnosis. Ultrasonography has become the preferred imaging study to evaluate for equivocal penile fracture. Penile ultrasonography is most useful for ruling out fracture in patients with low clinical suspicion or to identify the location of the tear, potentially guiding the choice of incision.

18. Magnetic resonance imaging (MRI) has been reported to be a noninvasive and accurate alternative means of demonstrating disruption of the tunica albuginea . Not being employed regularly in obvious cases Role in equivocal cases alone

19. Cavernosography is discouraged in the evaluation of a suspected penile fracture because it is time-consuming and unfamiliar to most urologists and radiologists.

20. DD s Rupture of dorsal penile artery or vein False fracture – may require MRI / surgical exploration Rupture of suspensory ligament of penis

21. Management Medical management – not recommended Suspected penile fractures be promptly explored and surgically repaired Because most penile fractures occur ventrally or laterally, a ventral vertical penoscrotal incision is usually preferred for direct exposure to the fracture. Alternatively, small lateral incisions may be used for localized hematomas or palpable tunical defects

22. The distal circumcising incision may be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments Closure of the tunical defect with interrupted 2-0 or 3-0 absorbable sutures is recommended D eep corporeal vascular ligation and excessive debridement of the delicate underlying erectile tissue should be avoided.

23. Although a ventral vertical incision is preferred, if a distal circumcising incision is required , performing limited circumcision at the conclusion of the repair should be strongly considered.

24. Induction of artificial erection with saline / coloured dye may help Partial urethral injuries – oversewn with fine absorbable suture over urethral catheter. Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free manner over a catheter.

25. Post op care Usually discharged after 5 days Erection suppression drugs – Stillbestrol , Diazepam After urethral repair, the catheter is often maintained for 2 to 3 weeks Broad spectrum antibiotics 1 month of sexual abstinence

26. Complications ( less than 5%) Erectile dysfunction Penile deformity Urethral strictures Painful erection Painful intercourse Skin necrosis Fistulas – A-V/ urethrocutaneous Priapism Peyronnies disease

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