Editing Lower Urinary Tract Trauma (section)

==== Penile fracture ====

===== Definition =====

* '''<span style="color:#ff0000">Penile fracture: disruption of the tunica albuginea with rupture of the corpus cavernosum</span>'''

===== Pathogenesis =====
* '''<span style="color:#ff0000">Most commonly occurs during vigorous sexual intercourse</span>''', when the rigid penis slips out of the vagina and strikes the perineum or pubic bone, producing a buckling injury.
** Campbell's 11th edition: In the Middle East, self-inflicted fractures predominate owing to the practice of taqaandan, in which the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence.
** Review article
*** 21 studies from Middle East and Central Asia published 2003-2014
*** Results:
**** Etiologies of penile fracture
***** Vigorous sexual intercourse (41%)
***** Manual bending of erect penis (29%)
***** Vigorous masturbation (10%)
***** Rolling over in bed (14%)
***** Blunt trauma (6%)
*** [https://pubmed.ncbi.nlm.nih.gov/26229311/ Majzoub, Ahmad A., and Talib A.] Raidh Onder Canguven. "Alteration in the etiology of penile fracture in the Middle East and Central Asia regions in the last decade; a literature review." ''Urology annals'' 7.3 (2015): 284.
*'''<span style="color:#ff0000">When the erect penis bends abnormally, a laceration can occur and it is usually</span>'''
*# '''<span style="color:#ff0000">On proximal shaft, distal to the suspensory ligament</span>'''
*# '''<span style="color:#ff0000">Transverse</span>'''
*# '''<span style="color:#ff0000">Unilateral</span>'''
*#* '''Tears in both corporeal bodies occur in 10% of injuries'''.
*# '''<span style="color:#ff0000">Ventral or lateral</span>'''
*#* '''<span style="color:#ff0000">Tunica albuginea is the thinnest between the 5 o’clock and 7 o’clock positions</span>'''
*#* Recall that Peyronie's Disease usually occurs dorsally
*#* Laceration location in manual bending will depend on direction of bend
*# 1-2 cm in length

===== Diagnosis and Evaluation =====

* '''<span style="color:#ff0000">Diagnosis of penile fracture can me made reliably by history and physical exam</span>'''

====== History and Physical Exam ======
* '''<span style="color:#ff0000">History</span>'''
** '''<span style="color:#ff0000">Indicators of penile fracture</span>'''
**# '''<span style="color:#ff0000">Penile ecchymosis or swelling</span>'''
**# '''<span style="color:#ff0000">Cracking, popping, or snapping sound during intercourse or manipulation and immediate detumescence.</span>'''
* '''<span style="color:#ff0000">Physical exam</span>'''
** '''<span style="color:#ff0000">Penis</span>'''
***'''<span style="color:#ff0000">Swollen</span>'''
***'''<span style="color:#ff0000">Ecchymotic</span>'''
****'''<span style="color:#ff0000">If Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical “eggplant deformity.”</span>'''
**** '''<span style="color:#ff0000">If Buck fascia is disrupted, the hematoma can extend to the scrotum, perineum, and suprapubic regions (see above “butterfly hematoma”).</span>'''
***'''<span style="color:#ff0000">Fracture line in the tunica albuginea may be palpable</span>'''
***'''<span style="color:#ff0000">Deviates to the side opposite the tunical tear</span> because of hematoma and mass effect'''

====== Imaging ======
*'''<span style="color:#ff0000">Indication (1)</span>'''
**'''<span style="color:#ff0000">History and physical examination are equivocal for penile fracture</span>'''
***'''<span style="color:#ff0000">Usually unnecessary as diagnosis can often be made based on history and physical exam</span>'''
*'''<span style="color:#ff0000">Options (2):</span>'''
*#'''<span style="color:#ff0000">Ultrasound (preferred)</span>'''
*#* '''Preferred over MRI because it is rapid, readily available, noninvasive, inexpensive, and accurate'''
*#* 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
*# '''<span style="color:#ff0000">Penile-perineal MRI</span>'''
*#* '''<span style="color:#ff0000">Most accurate test</span>'''
*#* '''Can be considered if ultrasound equivocal to prevent unnecessary surgical exploration'''.
** '''<span style="color:#ff0000">Both penile Doppler and cavernosography have very high false negative rates and are not recommended in the evaluation of suspected penile fracture.</span>''' [SASP 2016]
* '''<span style="color:#ff0000">If imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed</span>'''

====== Other ======
* '''<span style="color:#ff0000">Urethral evaluation (urethroscopy or retrograde urethrogram)</span>'''
** '''<span style="color:#ff0000">Urethral injury occurs in 10-22% of cases of penile fracture</span>'''
*** '''<span style="color:#ff0000">Bilateral corporeal injuries are more commonly associated with urethral injury</span>'''
**'''<span style="color:#ff0000">Indications</span>''' 
***'''<span style="color:#ff0000">Penile fracture or penetrating trauma with</span>'''
***#'''<span style="color:#ff0000">Blood at the urethral meatus</span>'''
***#'''<span style="color:#ff0000">Gross hematuria</span>'''
***#'''<span style="color:#ff0000">Inability to void</span>'''

===== Management =====
* '''<span style="color:#ff0000">Suspected penile fractures should be promptly explored and surgically repaired</span>'''
* '''<span style="color:#ff0000">Surgical reconstruction results in (7):</span>'''
*# '''<span style="color:#ff0000">Faster recovery</span>'''
*# '''<span style="color:#ff0000">Decreased morbidity</span>'''
*# '''<span style="color:#ff0000">Lower complication rates</span>'''
*# '''<span style="color:#ff0000">Lower risk of erectile dysfunction</span>'''
*# '''<span style="color:#ff0000">Lower incidence of long-term penile curvature</span>'''
*# '''<span style="color:#ff0000">Reduced risk of cavernosal diverticulum (may be pulsatile)</span>'''
*# '''<span style="color:#ff0000">Reduced risk of chronic penile pain</span>'''
* '''<span style="color:#ff0000">Surgical delay of up to 7 days after the time of injury does not adversely affect the results of repair</span>'''

====== Technique ======
* '''<span style="color:#ff0000">Approach (2)'''
*#'''<span style="color:#ff0000">Ventral vertical penoscrotal incision'''
*#*Usually preferred for direct exposure to the fracture because most penile fractures occur ventrally or laterally.
*# '''<span style="color:#ff0000">Distal circumcising incision''' 
*#*May be appropriate when the location of the fracture is uncertain because it provides exposure to all three penile compartments.
*See [https://www.youtube.com/watch?v=T0hoHpDxeCE Video]
*Equipment
**Sutures
***2-0 or 3-0 PDS
***3-0 Vicryl
***4-0 Chromic
**Penrose to use as tourniquet
**Injectable saline with methylene blue
**25 Gauge butterfly needle
**Local anesthetic
*Step by step with distal circumcising incision
**Place holding stitch on dorsal aspect of glans, close to coronal sulcus.
**Hold penis on stretch
**Use marking pen to denote a circumferential incision approximately 2cm proximal to the coronal sulcus
***Skin will need to be very dry for ink to be applied properly
**Use a scalpel to cut down on incision. 
***Cut down to level of Buck's fascia
***Be careful near urethra
** Place holding stich at 12 o'clock on cut penile skin edge.
**Deglove penis
***Use Metzenbaum scissors to dissect skin off of tunica albuginea. Use closed scissors and then spread. Then cut attachments.
****Be careful near urethra
***Use gauze for blunt dissection
***Continue to deglove penis until area of fracture is exposed
** Evacuate hematoma
***Dissection must be carried down until the hematoma within Buck's fascia is exposed and evacuated
**'''Identify defect'''
***Proximal corpora is the most common site of rupture
****'''<span style="color:#ff0000">Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration♦'''
***Laceration usually transverse in direction
***Obtain adequate exposure of defect
**Repair defect
***Repair defect in tunica albuginea with interrupted 2-0 or 3-0 PDS sutures.
** '''If urethral injury'''
***'''Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter'''
***'''Complete urethral injuries should be debrided, mobilized, and repaired in a tension-free fashion over a catheter'''
** Test repair
***Apply tourniquet proximal to repaired defect
***Use a 25 Gauge butterfly needle to inject saline mixed with methylene blue into the corporal body distal to the defect
***If leak noted, place additional interrupted sutures.
**Repair Buck's fascia overlying defect
**Obtain hemostasis
**Reduce foreskin and reapproximate cut edges of skin with 4-0 chromic
***Start by placing stitches in 4 corners and leave tails long to use as handle
****Place box/U stitch in area of frenulum
***Position penis using stay stitches to align skin edges and perform interrupted stitches
**[https://www.ncbi.nlm.nih.gov/books/NBK535389/ Penile block]
***Dorsal penile nerve block
***Ring block
**Apply dressing
*Post-operative management
**Therapy with broad-spectrum antibiotics
**'''1 month of sexual abstinence'''