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394 Challenging Concepts in Urological Surgery
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References
1. Galvagno SM Jr, Nahmias JT, Young DA. Advanced Trauma Life Support(®) Update
2019: management and applications for adults and special populations. Anesthesiol Clin.
2019;37(1):13– 32.
2. Kitrey ND, Djakovic N, Hallscheidt P, et al. EAU guidelines on urological trauma. European
Association of Urology. 2020. https:// uroweb.org/ wp- content/ uploads/ EAU- Guidelines- onUrological- Trauma- 2020.pdf
3. Moore EE, Moore FA. American Association for the Surgery of Trauma Organ
Injury Scaling: 50th anniversary review article of the Journal of Trauma. J Trauma.
2010;69(6):1600– 1601.
4. Santucci RA, Doumanian LR. Upper urinary tract trauma. In: Wein AJ, Kavoussi LR,
Campbell MF, eds. Campbell- Walsh Urology. 10th ed. Philadelphia, PA: Elsevier Saunders;
2012:1169– 1189.
5. Kunkle DA, Kansas BT, Pathak A, et al. Delayed diagnosis of traumatic ureteral injuries. J
Urol. 2006;176(6 Pt 1):2503– 2507.
6. Cass AS. Blunt renal pelvic and ureteral injury in multiple- injured patients. Urology.
1983;22(3):268– 270.
7. Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for oc-
cult pneumothoraces in victims of major trauma. J Trauma. 2005;59(4):917– 924.
8. Gill IS, McRoberts JW. New directions in the management of GU trauma. Mediguide Urol.
1992;5:1– 8.
9. Hirshberg A, Wall MJ Jr, Mattox KL. Planned reoperation for trauma: a two year experience
with 124 consecutive patients. J Trauma 1994;37(3):365– 369.
10. Velmahos GC, Degiannis E, Wells M, Souter I. Penetrating ureteral injuries: the impact of
associated injuries on management. Am Surg 1996;62(6):461– 468.
11. Wiesner C, Thuroff JW. Techniques for uretero- intestinal reimplantation. Curr Opin Urol.
2004;14(6):351– 355.
12. Minervini A, Boni G, Salinitri G, et al. Evaluation of renal function and upper urinary
tract morphology in the ileal orthotopic neobladder with no antireflux mechanism. J Urol.
2005;173(1):144– 147.
13. Matlock KA, Tyroch AH, Kronfol ZN, McLean SF, Pirela- Cruz MA. Blunt traumatic bladder
rupture: a 10- year perspective. Am Surg. 2013;79(6):589– 593.
14. Urry RJ, Clarke DL, Bruce JL, Laing GL. The incidence, spectrum and outcomes of trau-
matic bladder injuries within the Pietermaritzburg Metropolitan Trauma Service. Injury.
2016;47(5):1057– 1063.
15. Morey AF, Brandes S, Dugi DD 3rd, et al. Urotrauma: AUA guideline. J Urol.
2014;192(2):327– 335.
16. Alli MO, Singh B, Moodley J, et al. Prospective evaluation of combined suprapubic and
urethral catheterization to urethral drainage alone for intraperitoneal bladder injuries. J
Trauma. 2003;55(6):1152– 1156.
17. Volpe MA, Pachter EM, Scalea TM, et al. Is there a difference in outcome when treating
traumatic intraperitoneal bladder rupture with or without a suprapubic tube? J Urol.
1999;161(4):1103- 1105.
18. Thomae KR, Kilambi NK, Poole GV. Method of urinary diversion in nonurethral traumatic
bladder injuries: retrospective analysis of 70 cases. Am Surg. 1998;64(1):77– 80.
19. Parry NG, Rozycki GS, Feliciano DV, et al. Traumatic rupture of the urinary bladder: is the
suprapubic tube necessary? J Trauma. 2003;54(3):431– 436.
20. Margolin DJ, Gonzalez RP. Retrospective analysis of traumatic bladder injury: does
suprapubic catheterization alter outcome of healing? Am Surg. 2004;70(12):1057– 1060.
21. Inaba K, McKenney M, Munera F, et al. Cystogram follow- up in the management of trau-
matic bladder disruption. J Trauma. 2006;60(1):23– 28.
22. Kim B, Roberts M. Laparoscopic repair of traumatic intraperitoneal bladder rupture: case
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report and review of the literature. Can Urol Assoc J. 2012;6(6):E270– E273.
23. Burks FN, Santucci RA. Management of iatrogenic ureteral injury. Ther Adv Urol.
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2019. https:// www.ncbi.nlm.nih.gov/ books/ NBK507817/
395Case 40 Bladder and ureteric trauma
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CASE
41
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Penile fracture
Huw Garrod, Sacha Moore, and
Iqbal Shergill
Expert commentary Christian Seipp
Case history
A 47- year- old male presented to the emergency department with a vague history of
falling out of bed, in the middle of the night. He had a grossly swollen, bruised penis.
He denied any haematuria. He stated the injury occurred approximately 8 hours previously, possibly when he had an early morning erection, but would not elaborate any
further on the mechanism of injury.
He had no significant past medical history and took no regular medication.
He underwent an exploration within 24 hours via a circumferential penile incision
and degloving which allowed evacuation of an extensive haematoma and repair of
a defect in the corpora. No urethral injury was identified and he was discharged the
following day.
Learning point Epidemiology
In Western series, >90% of cases of penile fracture have been attributed to sexual intercourse. A 2014
Brazilian analysis of 30 cases of penile fracture confirmed that ‘female on top’ was the position most
commonly associated with penile fracture. It has also been reported to occur during masturbation.
In the Middle East, a practice called Taghaandan, the deliberate bending of the erect penis to achieve
rapid detumescence, is associated with presentation of penile fracture. However, recent reports
suggest a trend towards intercourse- related incidents as seen in the West.
Expert comment Exploration
technique
Since the site of the injury was
unknown in this patient, a degloving
incision allowing thorough
inspection was appropriate. When
the site of injury is identified
preoperatively, a more limited
penoscrotal incision could be
considered.
Learning point Clinical presentation
Penile fracture is a rare urological emergency with an incidence of approximately 1 in 175,000. It is
defined as a rupture of the tunica albuginea in one or both corpora cavernosa and is associated with
urethral injury in 10– 22% of cases.1 Sexual intercourse is the most common precipitating factor where
the penis slips out of the vagina and strikes the symphysis pubis or perineum.
Presentation
Penile fracture presents with a very characteristic set of symptoms and is generally considered a
clinical diagnosis. Symptoms include:
● Sudden penile pain and swelling (‘aubergine/ eggplant’ sign; Figure 41.1)
● Rapid detumescence
● Cracking or popping sound
● Haematuria (indicating possible urethral injury).
When these features are not present, the clinician should consider alternative diagnoses such as penile
contusion, suspensory ligament rupture, and superficial vein rupture.
398 Challenging Concepts in Urological Surgery
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Figure 41.1 ‘Aubergine’- looking penis suggestive of penile fracture.
Examination
Alongside the features described previously described, there may be a tender palpable defect
overlying the site of the defect in the tunica albuginea. If Buck’s fascia is intact then the bruising will
be confined to the penis. Rupture of Buck’s fascia is associated with more extensive bleeding into the
scrotum, perineum, and lower abdominal wall. Urethral injury may present as blood at the meatus,
Clinical tip Importance
of clinical history
Penile fracture is a clinical
diagnosis with a very characteristic
history of a cracking or popping
sound, severe pain, swelling,
and immediate detumescence.
Reports of haematuria should raise
suspicion of a urethral injury.
frank haematuria, painful voiding, or urinary retention.
Evidence base Fracture aetiology
A systematic review and meta- analysis by Amer et al. in 2016 assessed the aetiology of penile fracture
in 1948 patients from 38 studies.2 Bending and buckling of the penis during sexual intercourse was the
most common single aetiology of penile fracture; this is typically caused by the blunt trauma of the
penis hitting the perineum. Other more common causes include:
● Pressure during masturbation
● Forced flexion
● Rolling over onto the erect penis.
Learning point
Pathophysiology
The thickness of the tunica
albuginea reduces to 2 mm during
tumescence making it more
vulnerable to traumatic injury— for
this reason true penile fractures
only occur with an erect penis.
Tears to the tunica albuginea are
possible in a flaccid penis but are
considered separate from penile
fracture. Injuries most commonly
occur on the ventrolateral area
of the tunica where it is thinnest.
Urethral injury is associated with
penile fracture in between 20% and
50% of cases.
More uncommon causes reported in the literature include electrocution, firearm trauma, and
utilization of a vacuum cleaner for the purposes of masturbation.
Additionally, meta- analysis of five studies assessing the effect of sexual position on likelihood of
penile fracture demonstrated no significant impact on relative risk for any single position (n = 76;
p = 0.53; I2 = 42%).
Learning point Investigation
Penile ultrasound is highly sensitive for detecting a defect in the tunica albuginea but is largely
reserved as a ‘rule out’ procedure in cases where the history or clinical findings are not in keeping
with a penile fracture. When an injury is identified, the sonographer should mark the site to help with
surgical planning.
Penile magnetic resonance imaging (MRI) (Figure 41.2) has been advocated by recent guidelines
when there is diagnostic doubt. It can identify smaller defects in the tunica than ultrasound and it can
identify urethral injuries. It does however, remain a specialist investigation and will not be available in
all centres.
399Case 41 Penile fracture
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Figure 41.2 MRI demonstrating a penile fracture. There is a penile fracture half way down the
penis, towards the dorsal surface of the right corpus cavernosum. There is a 11 mm defect in the
tunica albuginea with a 24 × 16 mm haematoma in the subcutaneous tissue.
Despite the high risk, formal evaluation of the urethra is underutilized. To assess for a urethral injury,
the urologist can perform a flexible cystoscopic examination at the time of surgery or a retrograde
urethrogram preoperatively or on table.
Expert comment Surgical repair
Once a diagnosis of penile fracture has been made, surgical repair should be carried out within
24 hours, or sooner if a urethral injury is suspected. Broad- spectrum antibiotics should be given
preoperatively. The traditional approach is a circumferential subcoronal incision allowing complete
degloving of the penis, exposing the injury and enabling identification of any associated injuries.
This degloving approach is favoured when the site of injury is unknown or in the distal shaft
(Figure 41.3a).
An alternative technique is a penoscrotal incision over the suspected injury, particularly in centres
that have access to sensitive preoperative imaging such as MRI. Once localized, the injury should be
repaired with a 0 or 2/ 0 absorbable suture such as PDS®, taking care to bury the knots (Figure 41.3b).
A Foley catheter should be inserted postoperatively, particularly as there may be persistent significant
penile swelling.
Expert comment Flexible
cystoscopy
Since almost all patients will be
proceeding to surgery, a flexible
cystoscopy on the table is easily
performed and widely available.
It has the additional benefit of
allowing guidewire insertion for
catheterization if a urethral injury is
identified.
400 Challenging Concepts in Urological Surgery
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Clinical tip Conservative
management
Conservative management of
penile fracture is not considered
best practice due to the high
incidence of long- term sequelae.
Impotence will be present in up
to 60% of men and fibrosis and
abnormal curvature in 35%. The
only scenario where conservative
management may be considered
is when the patient has presented
after an extended period of time
and the acute injury has already
settled.
Figure 41.3 Penile fracture exploration and repair. (a) Degloving of the penis revealing the fracture
site. (b) Repair of the defect using PDS®.
When a urethral repair is required, the edges should be exposed and closed with fine interrupted
Learning point Long- term
complications
Complications of penile fracture
include the formation of plaques
or nodules, penile curvature,
erectile dysfunction, and painful
erections. There is conflicting
evidence regarding the overall
incidence of each of these, but
prompt surgical management has
been demonstrated to significantly
reduce short- to medium- term
erectile dysfunction and penile
curvature.
sutures such as 5/ 0 Polyglactin. A Foley catheter should be left in place for 2 weeks and a urethrogram
performed before trial without catheter to ensure the urethra has fully healed.
Clinical tip Postoperative advice for patients
The British Association of Urological Surgeons 2018 consensus statement3 recommends the following
postoperative management plan for penile fracture patients:
● Patients should refrain from sexual activity for 6 weeks.
● Patients should be followed up in clinic 2 weeks after discharge.
● Patients with penile curvature or erectile dysfunction post fracture should be managed using the
standard management pathways for these conditions.
● Emergency referral to a specialist unit is indicated where there is severe urethral disruption.
A final word from the expert
Penile fracture is the traumatic disruption of the tunica albuginea and enclosed corpus
cavernosum as the result of blunt trauma to the erect penis. It is a rare yet easily recognized
urological emergency characterized by the typical set of symptoms of popping sound,
immediate detumescence, and rapid development of an increasing haematoma (‘eggplant
deformity’). Clinical presentation and physical examination are usually sufficient to establish the
diagnosis. Depending on the size of the haematoma, it may not always be possible to palpate
the ruptured tunica. Imaging such as ultrasound, penile MRI, or cavernosography can help in
identifying the underlying defect, but are rarely necessary in general clinical practice— particularly
as it may defer surgical exploration and management. Conservative management carries a
high risk of complications such as infected haematoma, abscess, erectile dysfunction, penile
curvature, and arteriovenous fistula. Once a patient is suspected of having sustained a penile
fracture, early surgical management— as opposed to delayed therapy— provides the best possible
outcome: degloving of the penile shaft through a circumferential subcoronal incision allows
adequate evacuation of the penile haematoma and provides unparalleled access to both
corpora and the urethra. The site of the fracture can be felt and it often shows large adherent
clots. Once these have been removed, the tunical edges can be freshened and closed with
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interrupted polydioxanone sutures.
It is important to remember that penile fractures are often associated with concomitant urethral
injuries. Haematuria or blood at the external urethral meatus are highly suggestive of a potential
urethral injury and should prompt an on- table flexible cystoscopy. Routine catheterization at the
time of surgery aids dissection and facilitates easy urethral repair in the event of a urethral tear.
Postoperative medication to suppress erections has not proven to be beneficial. It is sensible to
prohibit sexual activities during the first 6 weeks of recovery.
In summary, rapid diagnosis through history and clinical examination combined with swift
surgical intervention is the key for reconstruction with minimal long- term complications.
401Case 41 Penile fracture
References
1. Lynch TH, Martínez- Piñeiro L, Plas E, et al. EAU guidelines on urological trauma. Eur Urol.
2005;47(1):1– 15.
2. Amer T, Wilson R, Chlosta P, et al. Penile fracture: a meta- analysis. Urol Int.
2016;96(3):315– 329.
3. Rees RW, Brown G, Dorkin T, et al. British Association of Urological Surgeons (BAUS) consensus document for the management of male genital emergencies - penile fracture. BJU
Int. 2018;122(1):26– 28.
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SECTION 13
Renal transplantation
Case 42 Renal transplantation
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