Urological Emergencies in Clinical Practice стр.89

Very occasionally a patient presents with a history of sudden pain during intercourse with bruising and swelling of the penis, but at penile exploration the tunica albuginea is found to be intact. Such cases represent rupture of the dorsal

5. TRAUMATIC UROLOGICAL EMERGENCIES 119

Urological Emergencies in Clinical Practice

FIGURE 5.28. Penile fracture. (See this figure in full color in the insert.)

vein of the penis, and all that needs be done is simple ligation of the vein.

Investigations

Dipstick the urine looking specifically for blood. If blood is present, or if the patient complains of pain or difficulty on voiding or inability to void, arrange a retrograde urethrogram to see if the urethra has ruptured. Agrawal et al. (1991) recommend urethrography in all cases of penile rupture and this is also our policy.

Cavernosography, the intracorporeal injection of contrast to demonstrate a fracture and penile ultrasound have been used to confirm the diagnosis where uncertainty exists. Magnetic resonance imaging (MRI) can accurately demonstrate the presence and site of a rupture, but this seems an overly complex way of investigating a condition where the diagnosis is usually obvious from the characteristic history (snapping sound, sudden detu-mesence, and pain during intercourse) and findings on clinical examination (marked swelling and bruising of the penis).

Treatment

Two broad categories of management are available—conservative and surgical.

Conservative treatment consists of the application of cold compresses to the penis, analgesics, and antiinflammatory drugs

120 J. REYNARD

and abstinence from sexual activity for 6 to 8 weeks after the injury to allow healing at the fracture site.

Surgical treatment consists of exposing the fracture site in the tunica albuginea, evacuating the haematoma, and closing the defect in the tunica. The fracture site can be exposed by deglov-ing the penis via a circumcising incision made around the sub-coronal sulcus (Fig. 5.29). Alternatively, an incision can be made directly over the defect, assuming that the degree of swelling is not too great to prevent accurate identification of this site. However, if there is a urethral injury, then a degloving injury usually allows better exposure of the urethra for subsequent repair. An alternative is a midline incision extending distally from the midline raphe of the scrotum, along the shaft of the penis. This latter incision, along with a degloving incision, allows excellent exposure of both corpora cavernosa so that an unexpected bilateral injury can be repaired easily, as can a urethral injury, should this have occurred.


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