Penile Fracture and Trauma Workup

Updated: Jan 16, 2019
  • Author: Richard A Santucci, MD, FACS; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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Workup

Approach Considerations

Imaging studies to assess penile trauma are not usually required and should be used with reservation. They increase medical costs and delay definitive therapy. The physical examination findings alone are often sufficient to establish the diagnosis. Some debate surrounds the usefulness of imaging studies in diagnosing cavernosal injury. Imaging studies have a limited role in the detection of penile fractures and should be reserved for cases in which clinical history does not correlate with examination findings or for those in which no injury is apparent and imaging would confirm nonoperative management. [14]

MRI provides excellent anatomic images of the penis and has been shown to be highly accurate in the detection of penile fractures. However, it appears to minimally affect treatment outcomes, is expensive, and is subject to limited availability in some institutions, especially after-hours.

Penile ultrasonography, although widely available and inexpensive, heavily depends on the operator and requires specific expertise in the technique. False-negative rates are common.

The most recent debate surrounds the use of penile cavernosography. False-negative findings are common, tissue reaction to the contrast material and increased corporal fibrosis are risks. Most authors report using penile cavernosography if physical examination findings are equivocal but the history indicates a possible injury. In most cases, prompt surgical exploration should be accomplished in lieu of preliminary penile imaging (other than urethrography).

Retrograde urethrography is the only imaging study for which there should be a low threshold of use. Retrograde urethrography should be performed if urethral injury is suspected based on the presence of blood at the meatus, hematuria of any form, dysuria, or urinary retention. [8] The test is easy to perform and inexpensive.

 

 

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Laboratory Studies

Although no specific laboratory studies are required for penile trauma, a standard preoperative laboratory panel should be considered on a case-by-case basis in all patients. This includes the following:

  • Electrolytes
  • Complete blood count
  • Coagulation studies
  • Type and screen
  • Urinalysis

Microscopic hematuria should raise suspicion of a possible urethral injury. Urine culture should be considered in those with obvious signs of a urinary tract infection.

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Imaging Studies

Retrograde urethrogram reveals the extravasation of contrast material from the urethra into the penile soft tissues, indicating urethral injury. It can be performed by insertion of a 12-14F Foley catheter into the fossa navicularis (distal urethra). The Foley balloon is inflated with 1-2 mL of sterile water. Contrast is injected from a 60-mL piston syringe with the penis placed on stretch. Oblique radiographs are taken and the continuity of the urethra is examined. An alternative technique is forgoing placement of a catheter with intubation of the urethral meatus with a piston syringe and injection of contrast directly into the urethra.

Penile cavernosography reveals extravasation of contrast material from the corpus cavernosum into the penile soft tissues, indicating an injury of the tunica albuginea. It can be performed by direct injection of 15-70 mL of quarter–to–half-strength nonionic contrast into the uninjured corpora until penile tumescence is achieved. Fluoroscopic images during injection and 10 minutes postinjection reveal filling defects or extravasation. This technique is thought to cause corporal scarring and should be used with reservation. Cavernosography rarely precludes surgical exploration in both penetrating trauma and fracture of the penis. Its use should not delay definitive surgical treatment.

An MRI of the penis provides excellent delineation of anatomy and thus can reveal tunical tears and urethral injury. The technique is expensive and time-consuming. Its availability is often limited depending on time of patient presentation and can cause undue delay in definitive surgical management. It is best reserved for patients in whom injury appears absent and who would support nonoperative treatment. [15]

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