Introduction
Penile fracture is defined as rupture of corpus cavernosum because of trauma to the erect penis. Penile fracture with or without urethral injury is an uncommon urological emergency.1 It often occurs by unusual sexual intercourse or masturbation. Penile fracture usually associated with snapping sound, severe pain and rapid detumesence. Gross hematuria or voiding difficulty symptoms suggest associated urethra injury. Isolated urethral and spongiosum injury are very rare and might occur without any symptoms. It is usually diagnosed on the basis of clinical findings and surgical exploration. We report a case of isolated penile urethral injury following sexual intercourse.
Case Report
A 35- year-old male presented to the emergency department complaining of pain, progressive penile swelling and deformity with 6 hours duration. The penile trauma occurred while doing sexual intercourse with his wife after taking alcohol. He forcefully tried to insert penis into the vagina and hit the pubic symphysis of the wife in normal (supine) position. He felt rapid detumescence and bleeding per urethra. He presented to causality 6hrs after the incident. He passed blood stained urine mainly at the beginning of the stream, after that penile swelling was gradually increasing in size. Physical examination revealed a swollen, deformed, dusky coloured flaccid phallus with blood at the tip of the meatus (Figure 1).
The ultrasound showed breach in the corpus spongiosum with haematoma in the distal penile region. With the provisional diagnosis of penile fracture, patient agreed for emergency surgical exploration under spinal anaesthesia.
After giving prophylactic antibiotic intravenously, a subcornal circumferential incision was made and degloved upto the base of the penis. A small hematoma was found on the ventral surface of the penis. The tunica albugenia over the corpus cavernosum found to be intact. On further debridement of haematoma revealed a vertical full thickness.
Tear of size 3*2 cm noted over the ventral surface of penile urethra (Figure 2). Primary Urethral repair was done using 4-0 vicryl in two layers over 14F foleys catheter (Figure 3). The circumcisional Incision was closed with interrupted sutures. Penile dressings applied in penis elevated position. Post op period was uneventful. Patient was discharged with foley catheter on postoperative day 8.
The foley catheter was removed after 28days, and patient was able to void to completion without difficulty. On recent follow-up after 6weeks, his erectile function was preserved without any urinary complaints.
Discussion
Antomically the penis is composed of three columns of tissues, dorsally two columns of corpus cavernosum and ventrally corpus spongiosum. The two columns of copus cavernosum covered by tunica albugenia. These corpus cavernosal strctures composed of sinusoids, which contributes to penile rigidity. The corpus spongiosum contains the urethra and does not contributes for penile rigidity.2
Penile fractures are mostly due to abnormal sexual postions like female superior position (reverse). Because of sudden blunt trauma to the penis, tear in the tunica albuginea will occur.3 Penile fractures most commonly occurs on the ventrolateral aspect of the penis. Usually concomitant urethral injury is greatly associated with bilateral corporal injury than unilateral corporal injury.
The clinical diagnosis of penile fracture mainly made by a “pop” sound, followed by rapid detumescence, pain, swelling and “egg-plant” penile deformity. Ulltasonography, cavernosography, magnetic resonace imaging can be used for diagnosis in equivocal cases for assessing the degree of injury.4 Retrograde urethrography or urethroscopy can be used to demonstrate urethral injury, which has been described in the literature.5
Emergency surgical exploration is the definitive diagnostic procedure for penile factures. Immediate exploration yields few complications and better long-term results than conservative treatment. The main principles of repair include degloving of penile skin, evacuation of hematoma, repair of tunica albuginea tear, urethral injury repair and urethral catherisation.5
Usually one month absentice from sex is advised following penile fracture. Erectile dysfunction, painful erection, penile deviation, wound infection, urethral stricture and urethrocutaneous fistula formation are the usual complication following penile fractures with or without surgical repair.6 In our case, isolated urethral injury was properly diagnosed and repaired on emergency surgical exploration. We have not observed any complications after surgery in our patient till now.
Conclusion
This case highlights the high index of suspicion for isolated penile urethral and corpus spongiosum injury during sexual intercourse. based on clinical findings and following the management principles of penile fractures and urethral injury , this rare entity of isolated urethral injury can be diagnosed and managed successfully without any complications.
