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37 Etiology, Mechanism, andAnatomopathology ofPenile Injury
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7. Özçift B, Ağras K. Hair tourniquet syndrome of penis: a rare situation in boys with serious complications if not recognized. Turk J Urol. 2018;45(4):322–4. https://doi.org/10.5152/
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ogy.2004.11.031. PMID: 15913731.
10. Janak JC, Orman JA, Soderdahl DW, Hudak SJ.Epidemiology of genitourinary injuries among male U.S. service members deployed to Iraq and Afghanistan: early ndings from the trauma outcomes and urogenital health (TOUGH) project. J Urol. 2017;197(2):414–9. https://doi.
org/10.1016/j.juro.2016.08.005. Epub 2016 Aug 6. PMID: 27506692.
11. Etabbal AM, Hussain FF, Benkhadoura MO, Banni AM.War-related penile injuries in Libya: single-institution experience. Arab J Urol. 2018;16(2):250–6. https://doi.org/10.1016/j.
aju.2018.01.005. PMID: 29892491; PMCID: PMC5992784.
12. Al-Azzawi IS, Koraitim MM.Urethral and penile war injuries: the experience from civil violence in Iraq. Arab J Urol. 2014;12(2):149–54. https://doi.org/10.1016/j.aju.2013.11.002. Epub 2014 Jan 23. PMID: 26019940; PMCID: PMC4434606.
13. Tiftikcioglu YO, Erenoglu CM, Lineaweaver WC.A systematic review of penile replantations: may it guide us in penile allotransplantation? Turk J Plast Surg [serial online]. 2018 [cited 2022 Oct 27];26:97–102. http://www.turkjplastsurg.org/text.asp?2018/26/3/97/235785
14. Maxwell BG, Chouhan JD, Lundeberg MR, Liu JJ.National patterns of injury and outcomes of gunshot wounds to the penis: a trauma quality programs retrospective cohort analysis. Acute Med Surg. 2021;8(1):e636. https://doi.org/10.1002/ams2.636. PMID: 33747534; PMCID: PMC7962619.
15. Adamyan RT, Aleshina ON, Abdeeva EI, Sinelnikov MY. Reconstructive surgery for high-voltage injury of genitoperineal area and upper extremities: the uromanual trauma concept. Plast Reconstr Surg Glob Open. 2021;9(10):e3842. https://doi.org/10.1097/
GOX.0000000000003842. PMID: 34616643; PMCID: PMC8489895.
16. Sahadev R, Jadhav V, Munianjanappa NB, Shankar G.Penile dislocation with inversion: a rare complication of blunt pelvic injury. J Indian Assoc Pediatr Surg. 2018;23(2):90–2. https://doi.
org/10.4103/jiaps.JIAPS_71_17. PMID: 29681700; PMCID: PMC5898211.
17. Palagonia E, Castellani D, Ronchi P, Dell’Atti L, Galosi AB. Hidden penis: a rare case of delayed complication after a pelvic blunt trauma. Transl Androl Urol. 2021;10(8):3524–8.
https://doi.org/10.21037/tau- 21- 333. PMID: 34532276; PMCID: PMC8421820.
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18. Simonis LA, Borovets S, Van Driel MF, Ten Duis HJ, Mensink HJ.Erectile dysfunction due to a ‘hidden’ penis after pelvic trauma. Int J Impot Res. 1999;11(1):53–5. https://doi.org/10.1038/
sj.ijir.3900362. PMID: 10098955.
19. Masuda H, Azuma H, Segawa N, Iwamoto Y, Inamoto T, Takasaki N, Katsuoka Y.Surgical correction of buried penis after trafc accident—a case report. BMC Urol. 2004;4:6. https://
doi.org/10.1186/1471- 2490- 4- 6. PMID: 15182380; PMCID: PMC434514.
20. Maruschke M, Lehr C, Hakenberg OW. Traumatic penile injuries—mechanisms and treat­ment. Urol Int. 2008;81(3):367–9. https://doi.org/10.1159/000151421. Epub 2008 Oct 16. PMID: 18931560.
21. Barros R, Hampl D, Cavalcanti AG, Favorito LA, Koifman L.Lessons learned after 20 years’ experience with penile fracture. Int Braz J Urol. 2020;46(3):409–16. https://doi.org/10.1590/
S1677- 5538.IBJU.2019.0367. PMID: 32167705; PMCID: PMC7088490.
22. http://remacle.org/bloodwolf/satire/Martial/livre11.htm
23. Amer T, Wilson R, Chlosta P, AlBuheissi S, Qazi H, Fraser M, Aboumarzouk OM.Penile frac­ture: a meta-analysis. Urol Int. 2016;96(3):315–29. https://doi.org/10.1159/000444884. Epub 2016 Mar 9. PMID: 26953932.
24. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current management of penile fracture: an up-to-date systematic review. Sex Med Rev. 2018;6(2):253–60. https://doi.org/10.1016/j.
sxmr.2017.07.009. Epub 2017 Sep 2. PMID: 28874325.
25. Zargooshi J.Sexual function and tunica albuginea wound healing following penile fracture: an 18-year follow-up study of 352 patients from Kermanshah, Iran. J Sex Med. 2009;6(4):1141–50.
https://doi.org/10.1111/j.1743- 6109.2008.01117.x. Epub 2008 Dec 4. PMID: 19138357.
26. Hughes S, Elbaroni W, O’Donoghue J, Williams M.Atypical presentation of a vertical penile fracture. BMJ Case Rep. 2021;14(6):e243353. https://doi.org/10.1136/bcr- 2021- 243353. PMID: 34187802; PMCID: PMC8245442.
27. Phillips EA, Esposito AJ, Munarriz R.Acute penile trauma and associated morbidity: 9-year experience at a tertiary care center. Andrology. 2015;3(3):632–6. https://doi.org/10.1111/
andr.12043. PMID: 26013107.
28. Young E, Ashra AN, Kahokehr AA.Tri-tubular penile fracture: a case of complete rup­ture of urethra and bilateral corpus cavernosa. IJU Case Rep. 2021;4(3):143–5. https://doi.
org/10.1002/iju5.12264. PMID: 33977241; PMCID: PMC8088889.
29. Barros R, Ribeiro JGA, da Silva HAM, de Sá FR, Júnior AMF, Favorito LA.Urethral injury in penile fracture: a narrative review. Int Braz J Urol. 2020;46(2):152–7. https://doi.org/10.1590/
S1677- 5538.IBJU.2020.99.02. PMID: 31961620; PMCID: PMC7025847.
30. EAU guidelines. Edn. Presented at the EAU annual congress Amsterdam March 2022. isbn:978-94-92671-16-5. https://d56bochluxqnz.cloudfront.net/documents/full- guideline/
EAU- Guidelines- on- Urological- Trauma- 2022_2022- 03- 24- 104100_fwda.pdf
31. Morey AF, Brandes S, Dugi DD 3rd, etal. Urotrauma: AUA guideline. J Urol. 2014;192:327.
https://www.auanet.org/guidelines- and- quality/guidelines/urotrauma- guideline
32. el-Sherif AE, Dauleh M, Allowneh N, Vijayan P.Management of fracture of the penis in Qatar. Br J Urol. 1991;68(6):622–5. https://doi.org/10.1111/j.1464- 410x.1991.tb15427.x. PMID:
1773294.
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Symptoms, Signs, Diagnostic Means,
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Differential Diagnosis, andGrading
38
ofPenile Injury
38.1 Symptoms andSigns
Once again, as open penile injury or constricting devices are readily observed in physical examination, more attention will be given to penile fracture in this discus­sion. The diagnosis of a penile fracture can be made from the classic clinical triad of an audible crack during sexual activity, detumescence, and the appearance of hematoma [1].
Hematoma is present in all cases*, and in the majority of patients, there is detu­mescence (82.6%), a history of a snapping sound (76.3%), and pain (66.3%). Urethral bleeding is rare (12.8%) and urinary retention is exceptionally observed, both of these signs being correlated with some degree of urethral injury [2, 3].
*
We have encountered an exceptional case in our practice that presented with sudden onset of bleeding per urethra and mild pain immediately after a sexual inter­course. The 38-year old patient did not have any obvious penile hematoma (Fig.38.1a) and there was no palpable defect on palpation. Based on the suspicious history, an ultrasonography was requested, revealing a defect on the ventral aspect of the right corpus cavernosum at the mid penile shaft (Fig.38.1b). On exploration, no hematoma was seen on either aspect (dorsally and ventrally) (Fig.38.1c, d). After mobilizing the urethra from the ventral aspect of the corpora, a 2-cm tear was noted at the dorsal urethra (UC: Urethral catheter) and another 2-cm tear was noted at the ventral aspect of the right corpus cavernosum (CT: Cavernosal tear) (Fig.38.1e). The absence of a noticeable hematoma in this case can be explained by the perfect apposition of the two tears (closely facing each other) allowing direct outside drainage of the blood from the corpus through the urethra.
If Buck’s fascia remains intact, the presence of hematoma remains circumscribed resulting in the characteristic “aubergine or eggplant deformity” [47] (Fig.38.2). When the Buck’s fascia ruptures, the eggplant deformity remains present, but it
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 S. A. AL-Mamari, Urogenital Trauma: A Practical Guide,
https://doi.org/10.1007/978-981-99-6171-9_38
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38 Symptoms, Signs, Diagnostic Means, Dierential Diagnosis, andGrading…

Fig. 38.1 (a) Urethral bleeding with no visible hematoma. (b) Ultrasonography showing a focal defect (x) at the ventral aspect of the right corpus cavernosum in the mid-distal shaft of the penis. (c) Dorsally intact corpora cavernosa seen after penile degloving, no hematoma seen. (d) No obvi­ous hematoma seen ventrally. (e) Both tears of the right corpus cavernosum (CT Cavernosal tear) and the urethra (UC Urethral catheter) seen after mobilization of the ureter
might sometimes be less marked since the hematoma would spread through the Dartos fascia plane toward the pubic and scrotal regions (Fig.38.3).
Many authors believe that there is no need for radiological investigations of penile fracture as the history and clinical presentation are sufcient for making the diagnosis [8]. Indeed, the typical history, signs, and symptoms are enough clues to make a correct decision in almost all cases and proceed to surgical exploration and repair. Herein, explorations of penile fracture based solely on clinical evaluation in an Iranian University Hospital conrmed the diagnosis in 97% of patients, and the three-percent error was attributed to inexperienced Junior residents who confused penile fracture with penile venous injury [9].
38.1 Symptoms andSigns
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Fig. 38.2 Typical eggplant aspect in a patient with penile fracture and urethral injury. (From Barros R etal. [7], Creative Commons Attribution License)
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Fig. 38.3 Penile fracture. Penile eggplant deformity with hematoma expanding to the scrotal and pubic regions. (Courtesy Kurian George, Retiree from the Urology Department, The Royal Hospital, Muscat, Oman)
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38 Symptoms, Signs, Diagnostic Means, Dierential Diagnosis, andGrading…
38.2 Imaging Means
As mentioned above, history and clinical examination are the cornerstones in mak­ing the diagnosis of penile fracture and imaging means are seldom required. However, in reality, there might well be some presentations susceptible to confuse even experienced practitioners (see the paragraph on differential diagnosis below), calling for radiological investigations. Therefore, many other authors suggest the use of various image modalities to conrm the diagnosis and the site of penile frac­tures, such as ultrasonography, cavernosography, retrograde urethrography, and MRI [1, 8].
1. Ultrasonography: The detection rate of penile fractures using Ultrasonography
has been found to be 88% which is an interesting value considering the low cost and the rapid completion of this study [10]. Ultrasonography with a 7.50 to
12 MHz linear probe is regarded as the preferred imaging modality by many authors, being non-invasive contrary to cavernosography, not expensive
and less time consuming than MRI, and readily available in all the modern medi­cal centers. It can be performed in the Emergency Department and provides in expert hands an accurate diagnosis, extent, and location of the tunica rupture, and was even proposed by some investigators as a reliable means to grade the injury [11, 12]. The use of ultrasonography is also supported by expert pan- els in equivocal signs and symptoms of penile fracture and has the additional advantage to locate the tunical tear and help plan an adequate surgical approach [3, 13].
2. Magnetic resonance imaging (MRI): MRI accurately detects a discontinuity of
the tunica albuginea and also demonstrates the eventual presence of associated injuries to adjacent structures (corpus spongiosum, urethra) [14]. It was shown to have 100% sensitivity, 77.8–87.5% specicity, a high negative predictive value of 100%, and a positive predictive value of 90.5–96.7% in the diagnosis of penile fracture [10, 15, 16].
3. Cavernosography: This investigation is rarely used, being considered invasive.
However, with the exclusion of patients with allergy or hypersensitivity to iodin­ated contrast media, it is a rather safe and simple procedure performed pre­operatively by injecting 15–30 cc of diluted contrast material through a 25-gauge buttery needle into the dorsolateral uninvolved corpus caverno­sum, under uoroscopic guidance. The diagnosis of penile fracture is made when there is extravasation of the contrast and hematoma is seen as a lling defect adjacent to the leak [1719] (Fig.38.4).
4. Urethrocystography: This study might be indicated only if there is a suspicion
of urethral injury.
38.4 Grading ofPenile Injury
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Fig. 38.4 Cavernosogra­phy lm showing massive extravasation and depicting the extent of a right-sided tunical rupture. (From Beysel M etal. [19], with permission from Elsevier)
38.3 Differential Diagnosis ofPenile Fracture [18, 20, 21]
Deep dorsal vein rupture: The mechanism of its occurrence is the same as for
the rupture of corpora cavernosa (sexual activity, forceful bending), and its clini-
cal presentation is almost the same (with the exception of the cracking sound).
Moreover, the hematoma here remains contained beneath Buck’s fascia and
within the penile shaft like for penile fracture.
Supercial dorsal vein rupture: Here the hematoma spreads through the sub-
cutaneous tissue of the external genitalia, and the ecchymosis may extend up to
the scrotal wall.
Dorsal artery injuriesDartos bleedingPenile suspensory ligament injuriesIsolated urethral injury [22].
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In a retrospective series, isolated vascular injuries were the sole ndings in 18% of patients who presented with acute penile pain, swelling, and blueish discolor­ation following coitus [1].
38.4 Grading ofPenile Injury
The American Association for the Surgery of Trauma (AAST) has proposed the fol­lowing scale for penile injury [23] (Table 38.1).
Other more specic classications have been proposed, either limited to the description of the penile fracture using ultrasonography [12] (Table38.2), describ­ing lesions related to penile constricting ring injuries [24, 25] (Table 38.3), or describing avulsion injuries of the external genitalia according to the location of the native urethra at presentation [26] (Table38.4; Fig.38.5).
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38 Symptoms, Signs, Diagnostic Means, Dierential Diagnosis, andGrading…
Table 38.1
Grade
Penile injury scale
a
Description of injury
I Cutaneous laceration/contusion 1 II Buck’s fascia (cavernosum) laceration without tissue loss 1 III Cutaneous avulsion
Laceration through glans/meatus Cavernosal or urethral defect <2cm
IV Partial penectomy
Cavernosal or urethral defect >2cm
V Total penectomy 3
From Moore EE, etal. [23], with permission from Wolters Kluwer Health
a
Advance one grade for multiple injuries up to grade III
Table 38.2
graphic grading criteria for penile fractures
Ultrasono-
Grade Description of injury 0 Normal tunica albuginea I Defect in tunica albuginea. Defect in corpora
Cavernosa II Perialbugineal and Cavernosal hematoma III Hematoma of deep fascia. Involvement of
Corpus spongiosum IV Urethral injury. Vascular malformation
From Shukla et al. [12], with permission from JCDR Research and Publications Private Limited
AIS-90
3
3
Table 38.3 Grading of penile strangulation injury
Grade Description of the injury Grade 1 Oedema of distal penis. No evidence of skin ulceration or urethral injury Grade 2 Injury to skin and constriction of corpus spongiosum but no evidence of urethral
injury. Distal penile oedema with decreased penile sensation Grade 3 Injury to skin and urethra but no urethral stula. Loss of distal penile sensation Grade 4 Complete division of corpus spongiosum leading to urethral stula and constriction
of corpus cavernosum with loss of distal penile sensation Grade 5 Gangrene, necrosis, or complete amputation of the distal penis
From Bhat AL etal. [25], with permission from John Wiley and Sons
Table 38.4
Grading of penile avulsion
Type Description Type I Meatus was at the corporal stump Type II Loss of corpora with preservation of the crura leaving the meatus near the pubic
symphysis Type III Perineal urethrostomy Type IV Urinary diversion via a supra-pubic catheter is required
Adapted from Rashid etal. [26], with permission from Elsevier
ab
References
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323
c d
Fig. 38.5 Penile injury types: (a) Type I avulsion injury; (b) Type II avulsion injury; (c) Type III avulsion injury; (d) Type IV avulsion injury. (From Rashid et al. [26], with permission from Elsevier)
References
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S1677- 5538.IBJU.2019.0367. PMID: 32167705; PMCID: PMC7088490.
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8. Amer T, Wilson R, Chlosta P, AlBuheissi S, Qazi H, Fraser M, Aboumarzouk OM.Penile frac­ture: a meta-analysis. Urol Int. 2016;96(3):315–29. https://doi.org/10.1159/000444884. Epub 2016 Mar 9. PMID: 26953932.
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https://doi.org/10.1111/j.1743- 6109.2008.01117.x. Epub 2008 Dec 4. PMID: 19138357.
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38 Symptoms, Signs, Diagnostic Means, Dierential Diagnosis, andGrading…