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FRACTURE OF ANOTHER SORT

THERE’S A VERNACULAR term that likens the erect penis to a bone and, as a few illfated men discover, the comparison is apt in more than one respect: like an actual bone, a blood-engorged corpus cavernosum may sometimes break because it cannot bend. Nor does the similarity end there: like management of a fractured bone, management of a fractured penis, according to three Virginia urologists, is best guided by x-ray findings.
“A patient with a penile fracture is generally pretty embarrassed, so he’ll make up some excuse fora presenting symptom, such as stomach pain,” says Dr. Frederick A. Klein, assistant professor of urology at the Medical College of Virginia in Richmond. “When you go in to see him, however, he’ll tell you the real problem: his erect penis was forcibly bent — in most cases during sexual intercourse — he heard a ‘crack’ or ‘pop,’ andhis penis immediately detumesced and then swelled painfully and turned black and blue.” Typically the penis is deviated to the side opposite the injury; if the left corpus cavernosum is ruptured, for example, the penis will be deviated to the right.

If the appearance of the penis and the patient’s account suggest a serious injury, the first possibility to consider is urethral damage. Find out whether the patient has blood in the urethra or has voided blood, which indicates urethral laceration, or has voided normally, which rules it out. “If he hasn’t voided, you can wait an hour or two in hopes that he will,” advises Dr. Klein, “or you cando a retrograde urethrogram. Inject 50 ml of an iodinated contrast medium up the urethra and take AP and oblique x-rays. If you see gross extravasation, we recommend putting in a suprapubic catheter for urinary diversion and letting it heal. If the urethrogram shows only minor extravasation, we treat with urethral catheter drainage for five to seven days.”

Treatment of the penile fracture itself can be surgical or conservative — and the choice is a controversial one. Dr. Klein bases his decision on the severity of the injury, as indicated by contrast studies of the corpus cavernosum. “If a corpus cavernosogram shows extravasation of contrast material, there’s a significant tear in the tunica albuginea that encapsulates the corpus cavernosum and the injury ought to be surgically repaired; otherwise, blood will go out of the corporeal body every time the patient gets an erection and eventually he’ll wind up with an infection or so much scarring that the penis will be curved or deformed. If there is no extravasation, you can treat the injury conservatively.”

Although corpus cavernosography is an underutilized technique, it’s extremely simple and faily benign and should be standard procedure in penile fractures, says Dr. Klein. “To perform it, first take an oblique scout film of the pelvic area and penis. Cleanse the penis with povidone-iodine and anesthetize the injured corpus cavernosum with 1% lidocaine. Load a 21-gauge butterfly needle with 70 ml of half-strength iodinated contrast medium and insert it into the corpus cavernosum — you know the needle’s in the corporeal body when you get a return of blood. It’s best to inject the contrast medium under fluoroscopy because then you can stop as soon as you see a leak. Otherwise, take one static film during the injection and another after injecting 50 ml. Reposition the patient in the opposite oblique position, inject another 10 or 20 ml, and take another x-ray. Wash out the contrast with 50 ml of saline, wait 10 minutes, and take a final supine AP film. A rupture will appear as a filling defect on early films and as extravasation on washout films.”

Corpus cavenosography determined treatment in three penile fracture cases that Dr. Klein and Drs. M. J. Vernon Smith and Norman Miller report in the Journal of Trauma (vol. 25, 1090). Two patients with negative cavernosograms were treated conservatively and one with a positive film was treated surgically; all now function normally. The investigators also report 14 traditionally managed cases gathered by questionaires sent to other Virginia urologists: all five patiens treated surgically have normal erections but two of the nine treated conservatively have curvatures. That fits the picture usually seen in the literature, say the investigators, and it illustrates the problem with basing treatment on a clinical diagnosis. “Surgery gives uniformly good results but is unnecessary in many patients,” says Dr. Klein. “Conservative treatment without radiologic assessment results in a high incidence of late complications — scarring, secondary Peyronie’s disesae, calcification of Buck’s fascia, penile deformity, and resultant problems with intercourse.”

The only contraindication to corpus cavernosography is allergy to the contrast medium. Complications are rare. “Some people believe that the contrast material can cause scarring,” says Dr. Klein, “which is the reason for diluting it. There isn’t much data on that and it’s hard to say that any fibrosis isn’t a result of the injury. Hematoma at the injection site is possible but unlikely.”