Male Sexual Dysfunction Penile Fracture: Outcomes of Early Surgical Intervention Daniel E. W. Swanson, A. Scott Polackwich, Brian T. Helfand, Puneet Masson, James Hwong, Daniel D. Dugi III, Ann C. Martinez Acevedo, Jason C. Hedges, and Kevin T. McVary OBJECTIVE PATIENTS AND METHODS
RESULTS
CONCLUSION
To report a series of penile fractures, describing preoperative evaluation, surgical repair, and long-term outcomes. Medical records from Northwestern Memorial Hospital and Oregon Health & Science University from 2002 to 2011 were reviewed. Clinical presentation, preoperative evaluation, time from injury, mechanism and site of injury, and presence of urethral injury were assessed. Outcomes including erectile dysfunction, penile curvature, and voiding symptoms were evaluated using International Prostate Symptom Score and International Index of Erectile Function scores. Twenty-nine patients with 30 separate episodes of penile fractures presenting to the emergency room were identified. Mean patient age was 43 9.6 years. The time from presentation to the initiation of surgery was 5.5 4.4 hours. Mechanism of injury was intercourse in 26 of 30 fractures with the remaining attributed to masturbation or “rolling over.” Immediate surgical repair was offered to all patients. Twenty-seven patients underwent surgery. Urethral injury was noted in 5 of the 27. The site of fracture was at the proximal shaft in 11, mid shaft in 12, and distal shaft in 4 patients. The mean follow-up period was 14.3 15.8 weeks. Nine patients reported new mild erectile dysfunction or penile curvature. One patient reported new irritative voiding symptoms. The most common mechanism of penile fracture was from sexual intercourse, and frequent concomitant urethral injuries were observed. The frequency of concomitant urethral injury was higher than in previous studies. Although we observed high incidence of erectile dysfunction or penile curvature with early surgical repair, we retain it as the favored approach. UROLOGY 84: 1117e1121, 2014. 2014 Elsevier Inc.
P
enile fracture is a rare urologic emergency in Western societies, with 1043 hospital admissions in the United States from 2006 to 2007.1 Because of the dramatic nature of the injury, many patients present rapidly to the emergency department and are offered immediate surgical repair. Surgery is typically done through either a degloving incision or a midline ventral incision. Occasionally, most often because of embarrassment by the injury or the mechanism, the patient may present in a delayed fashion, or refuse surgical intervention altogether.2 Diagnosis is typically made based on
Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: The study was supported by the the sponsors at Havana Day Dreamers Foundation and SIU Urology Endowment Fund, as well as the SMSNA Research Fellowship. From the Department of Urology, Oregon Health & Science University, Portland, OR; the Division of Urology, Department of Surgery, NorthShore University Health, Glenview, IL; the Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Urology, Brigham and Woman’s Hospital, Boston, MA; and the Division of Urology, Southern Illinois University of Medicine, Springfield, IL Address correspondence to: Jason C. Hedges, M.D., Ph.D., Department of Urology, Oregon Health & Science University, 3303 SW Bond Avenue, CH10U, Portland, OR 97239. E-mail: [email protected] Submitted: February 14, 2014, accepted (with revisions): July 18, 2014
ª 2014 Elsevier Inc. All Rights Reserved
history and clinical examination. In rare cases when the diagnosis is in doubt, patients are evaluated with various imaging techniques, including magnetic resonance imaging (MRI), ultrasonography, cavernosography, or urethrography.2 Because of the practice of Taqaandan (Kurdish for “to click”), the prevalence of penile fracture in the Middle East and northern Africa is greater than in the rest of the world.3 Most large studies on the treatments and outcomes of penile fracture have been reported from this part of the world and represent the aforementioned mechanism of injury. In the United States, the mechanism of injury is more commonly related to sexual intercourse or “faux pas du coit”, which occurs when the penis inadvertently dislodges from the vagina and is forcefully struck on the perineum or pubic bone.4 There are few studies with limited study size published from Western populations where the predominant mechanism of injury is related to trauma during sexual intercourse. We report the largest US study examining postoperative outcomes of penile fracture repair, as well as injury patterns and practice patterns regarding preoperative imaging and surgical technique. http://dx.doi.org/10.1016/j.urology.2014.07.034 0090-4295/14
1117
Table 1. Patient and injury characteristics Patient Characteristics (30 Injuries) Age, y, mean SD F/U, wk, mean SD Mechanism of injury, n (%) Intercourse Self-Injury Other Time to presentation, h, mean SD Time to surgery, h, mean SD Repair, n (%) Surgical Conservative Incision, n (%) Degloving Directed incision Location of injury, n (%) Proximal Mid Distal Urethral injury
43.2 9.6 14.3 15.8 26 (86) 2 (7) 2 (7) 13.9 14.6 5.5 4.4 27 (90) 3 (10) 23 (85) 4 (15) 11 12 4 5
(40.7) (44.4) (13) (18)
F/U, follow-up; SD, standard deviation.
PATIENTS AND METHODS After approval from the internal review boards, we reviewed medical records of patients with penile fracture treated at Northwestern Memorial Hospital and Oregon Health & Science University from 2002 to 2011. Clinical presentation, preoperative evaluation, time from injury, mechanism and site of injury, and the presence of urethral injury were assessed. Postoperative outcomes including erectile dysfunction (ED), penile curvature, and voiding symptoms were evaluated using history and physical examination. At the discretion of the provider, select patients completed the International Prostate Symptom Score and International Index of Erectile Function Erectile Function Domain scores at the time of their follow-up. Medical records were analyzed to determine diagnoses relevant to either voiding dysfunction or ED. SAS Software, version 9.2 (SAS Institute Inc., Cary NC) was used to calculate mean scores; further statistical analysis was done using the Student t test.
RESULTS We identified 29 patients who presented with 30 distinct injuries during the study period (Table 1). Patient age ranged from 19 to 59 years (mean 43.2 9.6 years). The injury was caused by sexual intercourse in 26 of the injuries. Two were sustained during masturbation, 1 rolling over in bed, and 1 during “routine stretching.” The average time from injury to presentation was 25.4 hours; however, after excluding a single patient who presented over a week after the injury, the average time was 13.9 14.6 hours. We considered this patient as an outlier. All patients reported a detumescence and subsequent swelling or deformity of the penis. All patients except 2 presented with pain. Four had blood at the urethral meatus. All except 3 were able to void spontaneously. These 3 underwent surgery and subsequent catheterization, and only 1 was found to have a urethral injury. All patients were evaluated primarily with history and physical examination. Radiographic examinations were 1118
not performed routinely and were usually done before urologic consultation; 1 patient underwent an ultrasonography examination, 1 had an MRI, 1 had a retrograde urethrography, and 1 had a cystoscopy in the emergency department before operative intervention. In all other patients, the diagnosis was made clinically. Twenty-seven of the 30 injuries were treated with immediate surgery. The time from presentation to the initiation of surgery ranged from 2.0 to 19.0 hours (mean 5.5 4.4 hours). Of the 27 injuries treated surgically, we used a degloving incision for 23 patients and a direct longitudinal incision to the point of maximal swelling and ecchymosis for 4 patients. In all cases, the hematoma beneath the Buck fascia was evacuated and the cavernosal injury was identified and repaired. A concomitant circumcision was performed in 1 patient who underwent a degloving incision, which was done for patient preference. One case was a proximal injury and required a perineal incision to access the tear in the tunica albuginea. There were 11 proximal injuries (40.7%), 12 midshaft injuries (44.4%), and 4 distal injuries (14.8%). All corpus cavernosal injuries were unilateral. Urethral injury was assessed in all patients using cystoscopy and urethrography. There was an associated urethral injury in 5 cases (18% of explored patients), 4 of which were partial disruptions and 1 was complete disruption. Interestingly, one of these urethral injuries was found in a patient who underwent a preoperative ultrasonography which did not show any injury. All cases were repaired in a similar fashion using 4-0 or 5-0 Maxon (Covidien) for most of the corpus cavernosal tears and Vicryl (Ethicon) was used in a single layer for the urethral repairs. Postoperatively, a catheter was placed in all cases and was removed within 24 hours when there was no urethral injury present. In patients with a urethral injury, the catheter was left in place for 17-45 days according to surgeon preference. In 1 injury, postoperative urethrography showed persistent extravasation of contrast at 2 weeks; therefore, the catheter was replaced for another 4 weeks, at which time follow-up urethrography was negative. We did not perform pericatheter urethrography. Another had urinary retention after catheter removal and required a suprapubic tube for several weeks, which was then removed and he was able to void spontaneously without problems. All patients were discharged home by postoperative day 1. No patient who was treated conservatively was admitted to the hospital. No routine prophylactic antibiotics or erection inhibitors were given postoperatively. Follow-up ranged from 0 to 60 weeks, with a mean of 14.3 15.8 weeks (Table 2). Although no preoperative questionnaires were administered to patients, postoperative questionnaires were collected in most cases. One patient complained of new-onset voiding symptoms (International Prostate Symptom Score 22) at his last follow-up visit. Including the patients who did not undergo surgery, erectile function was queried in 24 patients. Seven of 24 patients (29.2%) reported new ED UROLOGY 84 (5), 2014
Table 2. Results available at last follow-up Outcomes of Injuries Erectile dysfunction, n (%) Surgical repair Degloving incision, n (%) Directed incision, n (%) Conservative, n (%) Curvature, n (%) Surgical repair Degloving incision, n (%) Directed incision, n (%) Conservative, n (%) IIEF EF domain (N ¼ 24), mean SD IPSS (N ¼ 24), mean SD
7/24 (29.2) 4/20 2/2 1/2 5/24
(20) (100) (50) (20.8)
3/20 (15) 2/2 (100) 0/2 (0) 26.8 3.7 3.6 4.7
IIEF, International Index of Erectile Function; IPSS, International Prostate Symptom Score; other abbreviations as in Table 1. Percentages based on number of patients with follow-up and data available for the variable. Numbers were based on numbers of injuries, not number of patients.
(International Index of Erectile Function Erectile Function Domain score 26.8 3.7). Twenty-two patients “who underwent surgical repair” were asked about postoperative erectile function. Six of 22 patients (27.2%) reported new ED. Among the 2 patients who underwent a longitudinal direct incision, who were asked about erectile function, both reported ED. One of these men had 2 separate injuries about 6 months apart, both of which were repaired using this type of incision. He reports ongoing ED. The other patient has significant ventral penile curvature after a ventral incision. Average followup for these 2 patients was 34 weeks. Among the 23 patients who underwent a degloving incision, 20 were asked about erectile function at the time of follow-up, which averaged 16.2 weeks. Four of 20 patients (20%) reported new ED. Mild new penile curvature, which was defined as any curvature noticeable to the patient, was found in both patients who underwent a ventral incision and in 3 of 20 patients who underwent a degloving incision and were asked about erectile function. Three patients were treated nonoperatively. These patients presented significantly later, an average time of 139 hours after injury (range, 10-360 192 hours). The reason for nonsurgical management was patient refusal in one instance and resolution of symptoms in another patient. The third patient presented with a hematoma approximately 15 days after injury. The hematoma was drained with resolution of symptoms. Follow-up for these patients was short, averaging less than a week; however, 1 patient who was queried about erectile function at 2 weeks of follow-up reported mild penile curvature (
RESULTS
CONCLUSION
To report a series of penile fractures, describing preoperative evaluation, surgical repair, and long-term outcomes. Medical records from Northwestern Memorial Hospital and Oregon Health & Science University from 2002 to 2011 were reviewed. Clinical presentation, preoperative evaluation, time from injury, mechanism and site of injury, and presence of urethral injury were assessed. Outcomes including erectile dysfunction, penile curvature, and voiding symptoms were evaluated using International Prostate Symptom Score and International Index of Erectile Function scores. Twenty-nine patients with 30 separate episodes of penile fractures presenting to the emergency room were identified. Mean patient age was 43 9.6 years. The time from presentation to the initiation of surgery was 5.5 4.4 hours. Mechanism of injury was intercourse in 26 of 30 fractures with the remaining attributed to masturbation or “rolling over.” Immediate surgical repair was offered to all patients. Twenty-seven patients underwent surgery. Urethral injury was noted in 5 of the 27. The site of fracture was at the proximal shaft in 11, mid shaft in 12, and distal shaft in 4 patients. The mean follow-up period was 14.3 15.8 weeks. Nine patients reported new mild erectile dysfunction or penile curvature. One patient reported new irritative voiding symptoms. The most common mechanism of penile fracture was from sexual intercourse, and frequent concomitant urethral injuries were observed. The frequency of concomitant urethral injury was higher than in previous studies. Although we observed high incidence of erectile dysfunction or penile curvature with early surgical repair, we retain it as the favored approach. UROLOGY 84: 1117e1121, 2014. 2014 Elsevier Inc.
P
enile fracture is a rare urologic emergency in Western societies, with 1043 hospital admissions in the United States from 2006 to 2007.1 Because of the dramatic nature of the injury, many patients present rapidly to the emergency department and are offered immediate surgical repair. Surgery is typically done through either a degloving incision or a midline ventral incision. Occasionally, most often because of embarrassment by the injury or the mechanism, the patient may present in a delayed fashion, or refuse surgical intervention altogether.2 Diagnosis is typically made based on
Financial Disclosure: The authors declare that they have no relevant financial interests. Funding Support: The study was supported by the the sponsors at Havana Day Dreamers Foundation and SIU Urology Endowment Fund, as well as the SMSNA Research Fellowship. From the Department of Urology, Oregon Health & Science University, Portland, OR; the Division of Urology, Department of Surgery, NorthShore University Health, Glenview, IL; the Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, IL; the Department of Urology, Brigham and Woman’s Hospital, Boston, MA; and the Division of Urology, Southern Illinois University of Medicine, Springfield, IL Address correspondence to: Jason C. Hedges, M.D., Ph.D., Department of Urology, Oregon Health & Science University, 3303 SW Bond Avenue, CH10U, Portland, OR 97239. E-mail: [email protected] Submitted: February 14, 2014, accepted (with revisions): July 18, 2014
ª 2014 Elsevier Inc. All Rights Reserved
history and clinical examination. In rare cases when the diagnosis is in doubt, patients are evaluated with various imaging techniques, including magnetic resonance imaging (MRI), ultrasonography, cavernosography, or urethrography.2 Because of the practice of Taqaandan (Kurdish for “to click”), the prevalence of penile fracture in the Middle East and northern Africa is greater than in the rest of the world.3 Most large studies on the treatments and outcomes of penile fracture have been reported from this part of the world and represent the aforementioned mechanism of injury. In the United States, the mechanism of injury is more commonly related to sexual intercourse or “faux pas du coit”, which occurs when the penis inadvertently dislodges from the vagina and is forcefully struck on the perineum or pubic bone.4 There are few studies with limited study size published from Western populations where the predominant mechanism of injury is related to trauma during sexual intercourse. We report the largest US study examining postoperative outcomes of penile fracture repair, as well as injury patterns and practice patterns regarding preoperative imaging and surgical technique. http://dx.doi.org/10.1016/j.urology.2014.07.034 0090-4295/14
1117
Table 1. Patient and injury characteristics Patient Characteristics (30 Injuries) Age, y, mean SD F/U, wk, mean SD Mechanism of injury, n (%) Intercourse Self-Injury Other Time to presentation, h, mean SD Time to surgery, h, mean SD Repair, n (%) Surgical Conservative Incision, n (%) Degloving Directed incision Location of injury, n (%) Proximal Mid Distal Urethral injury
43.2 9.6 14.3 15.8 26 (86) 2 (7) 2 (7) 13.9 14.6 5.5 4.4 27 (90) 3 (10) 23 (85) 4 (15) 11 12 4 5
(40.7) (44.4) (13) (18)
F/U, follow-up; SD, standard deviation.
PATIENTS AND METHODS After approval from the internal review boards, we reviewed medical records of patients with penile fracture treated at Northwestern Memorial Hospital and Oregon Health & Science University from 2002 to 2011. Clinical presentation, preoperative evaluation, time from injury, mechanism and site of injury, and the presence of urethral injury were assessed. Postoperative outcomes including erectile dysfunction (ED), penile curvature, and voiding symptoms were evaluated using history and physical examination. At the discretion of the provider, select patients completed the International Prostate Symptom Score and International Index of Erectile Function Erectile Function Domain scores at the time of their follow-up. Medical records were analyzed to determine diagnoses relevant to either voiding dysfunction or ED. SAS Software, version 9.2 (SAS Institute Inc., Cary NC) was used to calculate mean scores; further statistical analysis was done using the Student t test.
RESULTS We identified 29 patients who presented with 30 distinct injuries during the study period (Table 1). Patient age ranged from 19 to 59 years (mean 43.2 9.6 years). The injury was caused by sexual intercourse in 26 of the injuries. Two were sustained during masturbation, 1 rolling over in bed, and 1 during “routine stretching.” The average time from injury to presentation was 25.4 hours; however, after excluding a single patient who presented over a week after the injury, the average time was 13.9 14.6 hours. We considered this patient as an outlier. All patients reported a detumescence and subsequent swelling or deformity of the penis. All patients except 2 presented with pain. Four had blood at the urethral meatus. All except 3 were able to void spontaneously. These 3 underwent surgery and subsequent catheterization, and only 1 was found to have a urethral injury. All patients were evaluated primarily with history and physical examination. Radiographic examinations were 1118
not performed routinely and were usually done before urologic consultation; 1 patient underwent an ultrasonography examination, 1 had an MRI, 1 had a retrograde urethrography, and 1 had a cystoscopy in the emergency department before operative intervention. In all other patients, the diagnosis was made clinically. Twenty-seven of the 30 injuries were treated with immediate surgery. The time from presentation to the initiation of surgery ranged from 2.0 to 19.0 hours (mean 5.5 4.4 hours). Of the 27 injuries treated surgically, we used a degloving incision for 23 patients and a direct longitudinal incision to the point of maximal swelling and ecchymosis for 4 patients. In all cases, the hematoma beneath the Buck fascia was evacuated and the cavernosal injury was identified and repaired. A concomitant circumcision was performed in 1 patient who underwent a degloving incision, which was done for patient preference. One case was a proximal injury and required a perineal incision to access the tear in the tunica albuginea. There were 11 proximal injuries (40.7%), 12 midshaft injuries (44.4%), and 4 distal injuries (14.8%). All corpus cavernosal injuries were unilateral. Urethral injury was assessed in all patients using cystoscopy and urethrography. There was an associated urethral injury in 5 cases (18% of explored patients), 4 of which were partial disruptions and 1 was complete disruption. Interestingly, one of these urethral injuries was found in a patient who underwent a preoperative ultrasonography which did not show any injury. All cases were repaired in a similar fashion using 4-0 or 5-0 Maxon (Covidien) for most of the corpus cavernosal tears and Vicryl (Ethicon) was used in a single layer for the urethral repairs. Postoperatively, a catheter was placed in all cases and was removed within 24 hours when there was no urethral injury present. In patients with a urethral injury, the catheter was left in place for 17-45 days according to surgeon preference. In 1 injury, postoperative urethrography showed persistent extravasation of contrast at 2 weeks; therefore, the catheter was replaced for another 4 weeks, at which time follow-up urethrography was negative. We did not perform pericatheter urethrography. Another had urinary retention after catheter removal and required a suprapubic tube for several weeks, which was then removed and he was able to void spontaneously without problems. All patients were discharged home by postoperative day 1. No patient who was treated conservatively was admitted to the hospital. No routine prophylactic antibiotics or erection inhibitors were given postoperatively. Follow-up ranged from 0 to 60 weeks, with a mean of 14.3 15.8 weeks (Table 2). Although no preoperative questionnaires were administered to patients, postoperative questionnaires were collected in most cases. One patient complained of new-onset voiding symptoms (International Prostate Symptom Score 22) at his last follow-up visit. Including the patients who did not undergo surgery, erectile function was queried in 24 patients. Seven of 24 patients (29.2%) reported new ED UROLOGY 84 (5), 2014
Table 2. Results available at last follow-up Outcomes of Injuries Erectile dysfunction, n (%) Surgical repair Degloving incision, n (%) Directed incision, n (%) Conservative, n (%) Curvature, n (%) Surgical repair Degloving incision, n (%) Directed incision, n (%) Conservative, n (%) IIEF EF domain (N ¼ 24), mean SD IPSS (N ¼ 24), mean SD
7/24 (29.2) 4/20 2/2 1/2 5/24
(20) (100) (50) (20.8)
3/20 (15) 2/2 (100) 0/2 (0) 26.8 3.7 3.6 4.7
IIEF, International Index of Erectile Function; IPSS, International Prostate Symptom Score; other abbreviations as in Table 1. Percentages based on number of patients with follow-up and data available for the variable. Numbers were based on numbers of injuries, not number of patients.
(International Index of Erectile Function Erectile Function Domain score 26.8 3.7). Twenty-two patients “who underwent surgical repair” were asked about postoperative erectile function. Six of 22 patients (27.2%) reported new ED. Among the 2 patients who underwent a longitudinal direct incision, who were asked about erectile function, both reported ED. One of these men had 2 separate injuries about 6 months apart, both of which were repaired using this type of incision. He reports ongoing ED. The other patient has significant ventral penile curvature after a ventral incision. Average followup for these 2 patients was 34 weeks. Among the 23 patients who underwent a degloving incision, 20 were asked about erectile function at the time of follow-up, which averaged 16.2 weeks. Four of 20 patients (20%) reported new ED. Mild new penile curvature, which was defined as any curvature noticeable to the patient, was found in both patients who underwent a ventral incision and in 3 of 20 patients who underwent a degloving incision and were asked about erectile function. Three patients were treated nonoperatively. These patients presented significantly later, an average time of 139 hours after injury (range, 10-360 192 hours). The reason for nonsurgical management was patient refusal in one instance and resolution of symptoms in another patient. The third patient presented with a hematoma approximately 15 days after injury. The hematoma was drained with resolution of symptoms. Follow-up for these patients was short, averaging less than a week; however, 1 patient who was queried about erectile function at 2 weeks of follow-up reported mild penile curvature (
