Abstract

INTRODUCTION

Penile fracture is a rare urological emergency situation, and is defined as disruption of the tunica albuginea (TA) and corpus cavernosum (CC). It occurs almost exclusively as a result of blunt trauma to the penis in the erect position, usually during coitus. Other mechanisms of injury are direct external blunt trauma, abnormal bending of the penis during manipulation, forceful manipulation and rolling over in bed during erection (¹1 Suzuki K, Shimizu N, Kurokawa K, Suzuki T, Yamanaka H. Fracture of the penis: magnetic resonance imaging of the rupture of the corpus cavernosum. Br J Urol.1995;76:803-4.

2 Boudghene F, Chhem R, Wallays C, Bigot JM. MR imaging in acute fracture of the penis. Urol Radiol. 1992;14:202-4.

3 Murray KS, Gilbert M, Ricci LR, Khare NR, Broghammer J. Penile fracture and magnetic resonance imaging. Int Braz J Urol. 2012;38:287-8.-⁴4 Koifman L, Barros R, Júnior RA, Cavalcanti AG, Favorito LA. Penile fracture: diagnosis, treatment and outcomes of 150 patients. Urology. 2010;76:1488-92.). Disruption of the tunica albuginea or associated urethra injury are indications for surgical repair, whereas other cases of blunt penile injury may be treated conservatively. In general, the patient’s history and physical examination are sufficient to reach a provisional diagnosis of a penile fracture. The role of magnetic resonance imaging (MRI) in imaging penile fractures is to ascertain the integrity of the tunica albuginea. In this study we describe MRI findings at 15 patients with acute penile fracture and its healing process.

MATERIALS AND METHODS

From 1997 to 2012, fifteen patients (age range 17-48 years, mean age 37 years) with suspected penile fracture underwent MRI examinations. Ten patients were injured during sexual intercourse, whereas four patients were traumatized by non-physiological bending of the penis during self manipulation, one patient was traumatized falling from the bed. Investigations were performed with 1.5T MR unit (Magnetom Symphony, Siemens, Erlangen Germany). With the patient in the supine position, the penis was taped against the abdominal wall and surface coil was placed on the penis. All patients were studied with axial, coronal, sagittal T2-weighted TSE (5290/110 msn) and precontrast and postcontrast T1-weighted TSE (TR/TE:538/13msn) sequences.

All patients underwent surgical operation and repair via a longitudinal incision. The follow-up ranged from 3 months to 72 months.

RESULTS

In all patients CC fractures were clearly depicted on a discontinuity of the low signal intensity of TA. These findings were most evident on T1-weighted images (Figures 1a, 2a, 3a and b and 4a ) These findings were also depicted on T2-weighted images (Figures 1b and c, 2b, 3c and d and 4b). Images obtained shortly after contrast medium administration showed considerable enhance only in rupture site. Subcutaneous extratunical haematoma in all patients were also recognizable on T2-weighted images. They were much more significant at post-contrast T1-weighted images. On follow-up in 10 patients a shortening and thickening of TA were observed (Figures 1d and 2d). There were erectile difficulties in 2 patients and they did not complain of any voiding difficulties. In all patients MR imaging findings were confirmed at surgery.

DISCUSSION

Penile fracture has a typical clinical presentation. Patients report hearing a snapping sound during the sexual act, followed by immediate pain and penile detumescence, in addition to the emergence of large edema, hematoma, and penile deformity (⁵5 Eke N. Fracture of the penis. Br J Surg. 2002;89:555-65.). In general the diagnosis of penile fracture is easily established clinically.

The diagnosis is usually not difficult and often is based on history and physical examination. Patients with atypical clinical findings may require a common diagnostic procedure. Sonography could be also a useful imaging modality for the diagnosis of penile fracture because it is easy to perform, noninvasive, widely available and unexpensive (⁶6 Bhatt S, Kocakoc E, Rubens DJ, Seftel AD, Dogra VS. Sonographic evaluation of penile trauma. J Ultrasound Med. 2005;24:993-1000; quiz 1001.). However this technique is operator dependent, and the major obstacle is a lack of tissue contrast (⁷7 Choi MH, Kim B, Ryu JA, Lee SW, Lee KS. MR imaging of acute penile fracture. Radiographics. 2000;20:1397-405. Erratum in: Radiographics 2000;20:1818.). Other limitations of the sonography are that, edematous swelling of the penis and clots within the tear deteriorate the image contrast and can obscure the defect; furthermore, a rupture in the pendilous area cannot be visualised. Some authors advocate cavernosonography to delinate the corporal rupture, but this invasive and painful procedure may increase heamatoma and involves ionizing radiation with a risk of infection and sometimes a lack image contrast.

Because of MRI multiplanar capabilty and excellent tissue contrast, it can be useful as a diagnostic tool in the evaluation of patients with acute penile fracture (⁸8 Yokogi H, Mizutami M, Ishibe T. Magnetic resonance imaging of a penile fracture. Acta Urol Belg. 1992;60:93-5.).

But MRI has also some limitations, such as higher cost than ultrasound, and readily not available everywhere. Especially in patients that ultrasound is not conclusive, MR imaging can accurately depict the presence, location and extent of tunical tear which manifest as discontunity of TA (⁹9 Kirkham A. MRI of the penis. Br J Radiol. 2012;85:S86-93.). Moreover, because TA is well demonstrated as a low-signal intensity structure on T1 and T2 weighted images, MR imaging is optimal for the evaluation of the integrity of this anatomic structure even in patients with severe pain and swelling of penis as well as hematomas that appear as high signal intensity on both T1 and T2-weighted images (⁹9 Kirkham A. MRI of the penis. Br J Radiol. 2012;85:S86-93., ¹⁰10 Fedel M, Venz S, Andreessen R, Sudhoff F, Loening SA. The value of magnetic resonance imaging in the diagnosis of suspected penile fracture with atypical clinical findings. J Urol. 1996;155:1924-7.). Moreover, associated injuries to adjacent structures (eg. corpus spongiosum, urethra) can also be demonstrated (⁹9 Kirkham A. MRI of the penis. Br J Radiol. 2012;85:S86-93., ¹¹11 Uder M, Gohl D, Takahashi M, Derouet H, Defreyne L, Kramann B, et al. MRI of penile fracture: diagnosis and therapeutic follow-up. Eur Radiol. 2002;12:113-20.). MR imaging can demonstrate an intact TA and the presence of intracavernosal and extratunical haematoma. MRI may also detect other pathologies that mimic penile fracture (¹²12 Abolyosr A, Moneim AE, Abdelatif AM, Abdalla MA, Imam HM. The management of penile fracture based on clinical and magnetic resonance imaging findings. BJU Int. 2005;96:373-7.).

CONCLUSIONS

MR imaging is an excellent modality for evaluating patients with acute penile trauma. It can accurately demonstrate the integrity of the TA, as well as extent and location of tunical tear and of associated injuries to the CC and urethra.

REFERENCES

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