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Case Report |
From the Department of Clinical Surgical Sciences, The University of the West Indies, St Augustine, Trinidad, Trinidad and Tobago.
| Correspondence to: Seetharaman Hariharan, Senior Lecturer, Department of Clinical Surgical Sciences, Faculty of Medical Sciences, The University of the West Indies, Eric Williams Medical Sciences Complex, Mount Hope, Trinidad, Trinidad and Tobago (e-mail: uwi.hariharan{at}gmail.com). |
| Received for publication May 8, 2009; accepted for publication August 14, 2009. |
Early surgery has been recommended by most authors for fractured penis.
Because of gross swelling of the penis, early surgery might have to be
performed with an extensive degloving incision of the penis to enable better
exposure. We report a case in which the man presented late with deformity and
pain. Simple repair at that stage provided a good result in this patient;
hence, it might be possible to repair a fractured penis at a later stage
without degloving the penis. Additionally, this presentation could probably
explain the pathogenesis of the "rolling sign" described by us
earlier.
Case Report
A 26-year-old man presented to our hospital more than 3 weeks after
sustaining an injury to his penis. During sexual intercourse, he twisted his
penis which rapidly became swollen, detumescent, and painful. Immediately
after the injury, he was admitted to another hospital, managed conservatively,
and discharged after 3 days. He was followed up in the outpatient clinic of
the same hospital 21 days after trauma. At this time, much of the swelling had
subsided and he was advised not to have surgery. However, 2 days later, he
attended our hospital because of pain and angulation of the penis during
erection (Figure 1).
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Under ring block anesthesia with 2% lidocaine, a transverse incision was made directly over the lump. The skin and subcutaneous tissue were normal. The Buck fascia was bulging because of the clot, which was trapped between the fascia and the torn corpus cavernosum (Figure 2). The Buck fascia was incised and the clot was exposed (Figure 3). When the clot was evacuated, the fracture site could be easily identified. The floor of the cavity was exposed and repaired with 3 interrupted 3-0 vicryl sutures (Figure 4).
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However, it is a well-known fact that the vast majority of patients have a small unilateral tear of the corpus cavernosum (Ishikara et al, 2003; El Etat et al, 2008). Only a small percentage have urethral injury. In fact, in the largest series published on this subject, only 5 of 300 patients had evidence of urethral injury (El-Etat et al, 2008). Because the vast majority of cases have a small, unilateral, often proximal cavernosal tear, it appears unnecessary to deglove the entire penis to expose and repair this injury. The extensive degloving dissection could cause injury to more blood vessels, nerve, and tissue, prolonging the surgical duration and often necessitating general anaesthesia. Additionally, this extensive degloving procedure might carry a high risk of complications, such as wound infection, abscess formation, and subcoronal skin necrosis (Mansi et al, 1993). In this particular case in which the fracture site is quite distal, a circumcisional approach might be used because extensive degloving would not be needed. However, the direct approach we employed involves only one-third of the penile circumference and no undermining of the tissues. It is cosmetically acceptable, as seen in Figure 5.
The relatively late presentation of our patient at 23 days after penis fracture could demonstrate that much of the penile swelling, commonly thought to be a hematoma, is mainly edema fluid and no cellular elements of blood. The real hematoma consisting of cellular elements is well trapped between the Buck fascia and the fractured cavernosum. Thus, when most of the swelling settles, the clot at the fracture site persists and becomes much more evident clinically. If the rolling sign is not discernable on immediate presentation, it is likely to become more obvious after 7–12 days (Naraynsingh and Raju, 1985). If the patient presents late, as in our case, the sign might be even more obvious.
Our patient definitely benefited from the late repair because his painful erection and the angulation of the penis would not have been corrected without surgery. There is little doubt however, that the best treatment option is immediate surgery and that late repair be reserved for uncommon cases, such as ours, in which surgical repair is still beneficial. The long-term consequences of late repair are unknown; follow up of several cases would be needed to assess the sequelae, in that penile fracture could lead to fibrosis and penile plaque formation. Although conservative management has been suggested as a treatment option, this might result in complications, such as painful erection and angulation (Muentener et al, 2004). If these complications are recognized before the onset of fibrosis, as in our patient, surgical exploration and repair should be done. If, however, these complications are not evident during conservative treatment, there may be no need for late exploration.
The present report suggests that simple repair of fractured penis by a small incision directly over the fracture site likely could produce good results. The degloving technique should be reserved for those cases with associated urethral injury or when the diagnosis remains uncertain, even after 7–12 days. Additionally, in symptomatic patients presenting late after penile injury, late surgical repair should be undertaken.
References
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