Archives of Medicine and Health Sciences

CASE REPORT
Year
: 2013  |  Volume : 1  |  Issue : 1  |  Page : 54--56

Magnetic Resonance Imaging: An accurate diagnostic tool in the precise localization of penile fracture


Mujeeb M Rahiman1, T Manasa1, Devadasa Acharya Koteshwara2,  
1 Department of Urology, Yenepoya University, Mangalore, Karnataka, India
2 Department of Radiology, Yenepoya University, Mangalore, Karnataka, India

Correspondence Address:
Mujeeb M Rahiman
Department of Urology, Yenepoya University, Mangalore - 575 018, Karnataka
India

Abstract

An 18-year-old male presented with history and clinical findings suggestive of penile fracture. An MRI demonstrated disruption of the tunica albuginea and corpora cavernosa on the left dorso-lateral aspect, mid-shaft of penis with adjacent hematoma, and subcutaneous edema. At surgery, imaging findings were found to be accurate, and the penis was successfully repaired with minimal postoperative morbidity.



How to cite this article:
Rahiman MM, Manasa T, Koteshwara DA. Magnetic Resonance Imaging: An accurate diagnostic tool in the precise localization of penile fracture.Arch Med Health Sci 2013;1:54-56


How to cite this URL:
Rahiman MM, Manasa T, Koteshwara DA. Magnetic Resonance Imaging: An accurate diagnostic tool in the precise localization of penile fracture. Arch Med Health Sci [serial online] 2013 [cited 2021 Oct 20 ];1:54-56
Available from: https://www.amhsjournal.org/text.asp?2013/1/1/54/113572


Full Text

 Case Report



An 18-year-old male presented to our hospital with pain and asymmetric penile swelling following forceful lateral bending of the erect penis. There was no associated voiding difficulty or hematuria. On physical examination, the patient had a grossly deformed penis with swelling and deviation to the right [Figure 1].{Figure 1}

Ultrasound scan demonstrated a hypoechoic collection, approximately measuring 3.5 × 2.2 cm in the left lateral aspect of the penis, with evidence of subcutaneous edema. No definite tunica albugineal defect could be made out.

Magnetic Resonance (MR) imaging examination was performed with a 0.4 T unit MR imaging scanner (Hitachi, Aperto, and Tokyo, Japan). Fast spin-echo T1- and T2-weighted axial, sagittal, and coronal images were obtained. In addition, axial Short STIR (Short tau inversion recovery) sequences were studied. MR imaging parameters for T1-weighted images were; Time of Repetition (TR), 285 ms and Time of Echo (TE), 13 ms, and for T2-weighted images; TR, 3616 ms, TE, 100 ms. Section thickness was 6 mm with 1 mm interslice gap and an acquisition matrix of 256 × 19. An MRI scan of pelvis revealed loss of continuity of tunica albuginea in the left dorso-lateral aspect at the mid-shaft of penis and adjacent heterogenous signal intensity collection approximately measuring 3.5 × 2.2 cm in the left lateral aspect with minimal left corpus cavernosal extension [Figure 2]. There was evidence of subcutaneous edema on the left dorsal aspect. Corpus spongiosum, right corpus cavernosal, urethra, and dorsal vessels appeared normal.{Figure 2}

At surgery, a circumferential subcoronal incision was made, with penile degloving. Hematoma was seen in the subcutaneous plane extending into the tunica albuginea and underlying corpora cavernosum. On evacuation of the hematoma, disruption of the left dorsolateral tunica albuginea was noted at the mid-shaft of the penis with extension to the corpus cavernosum [Figure 3].{Figure 3}

The defect was repaired with interruputed 3-0 Vicrylsutures [Figure 4]. Artificial erection was performed at the end of the procedure.{Figure 4}

 Discussion



Penile fracture is defined as the rupture of the tunica albuginea of the corpus cavernosum caused by blunt trauma to the erect penis. Typically, the patient reports a snap or cracking sound accompanied by immediate pain and rapid detumescence followed immediately by the development of swelling and angulation. [1] Potential co-existing injuries include those to the penile urethra, corpus spongiosum, or dorsal vein of the penis. [2]

Penile ultrasonography, cavernosography, and, recently, magnetic resonance imaging (MRI) have been reported to be helpful in establishing the diagnosis and localizing the site of the tear, particularly in suspicious cases. [3],[4],[5] However, ultrasonography depends on the observers' skill and can miss the site of the tunical tear if it is too small or it is full with a clot that renders it indistinguishable from the surrounding normal tunica albuginea. [3] Cavernosography for the diagnosis of tunical rupture has been opposed for being an invasive procedure with risks of infection, priapism, and allergy to iodides. [3],[4]

An MRI provides better soft-tissue contrast, in addition to achieving high spatial resolution, allowing better definition of images of the male sexual organ, and it can be used to reveal lesions of the corpora cavernosa. [5],[6] The high precision of the method allows differentiating vascular sinusoids of the cavernous body from the tunica albuginea, achieving high diagnostic accuracy. [5],[6] An MR imaging is the diagnostic modality of choice because it precisely demonstrates the presence, location, and extent of the tunical tear, which manifests as discontinuity of the tunica albuginea. [6],[7],[8] An MR imaging also depicts associated injuries to adjacent structures (i.e., corpus spongiosum, urethra). [6] The most commonly reported penile injury is disruption of the right postero-lateral tunica albuginea involving the mid to distal one-third of the penile shaft, adjacent to the corpus cavernosum. [5],[6]

The standard treatment of penile fracture is surgical. [9] In some cases, an MRI may prevent unnecessary surgery if imaging shows only a hematoma rather than a tear of the tunica albuginea. [10]

In our study, the penile ultrasonography demonstrated only a hypoechoic lesion with subcutaneous edema suggestive of hematoma but no fracture. A subsequent MRI scan of pelvis revealed loss of continuity of tunica albuginea in the left dorso-lateral aspect at the mid-shaft of penis and adjacent heterogenous signal intensity collection approximately measuring 3.5 × 2.2 cm in the left lateral aspect with minimal left corpus cavernosal extension and no involvement of adjacent structures. A repeat ultrasonography was performed following MRI for teaching purpose where the radiologist could identify a rent in the tunica albuginea, but could not precisely delineate the extent of fracture. A circumferential subcoronal incision was placed to confirm the findings of MRI and to look for associated injuries to adjacent structures. An MRI in our case was precise in localizing the site and extent of fracture, which was reiterated by our surgical findings. An MRI though expensive, by aiding in directing the incision to the site, avoids unnecessary degloving of the penis and its attendant complications like edema, skin necrosis, and penile curvatures. [10] Most patients recover well after surgical repair, but roughly 10% will have permanent curvature of the penis, and some will experience pain during intercourse. [2]

 Conclusion



An MRI is a promising tool in diagnosis of penile trauma; it precisely demonstrates the presence, location, and extent of the injury and aids in deciding the site of incision for repair, thus minimizing the morbidity associated with the injury, repair. We recommend MRI when an ultrasound fails to reveal the exact site of tear in a suspected penile fracture.

References

1McAninch JW, Santucci RA. Genitourinary trauma. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, ediors. Campbell's Urology. 8 th ed, Vol. 4. Ch. 105. Philadelphia: W B Saunders; 2002.
2El Atat R, Sfaxi M, Benslama MR, Amine D, Ayed M, Mouelli SB, et al. Fracture of the penis: Management and long term results of surgical treatment. Experience in 300 cases. J Trauma 2008;64:121-5.
3Koga S, Saito Y, Arakaki Y, Nakamura N, Matsuoka M, Saita H, et al. Sonography in fracture of the penis. Br J Urol 1993;72:228-9.
4Grosman H, Gray RR, Louis EL, Casey R, Keresteci AG, Elliot DS. The role of corpus cavernosography in acute "fracture" of the penis. Radiology 1982;144:787-8.
5Fedel 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.
6Choi MH, Kim B, Ryu JA, Lee SW, Lee KS. MR imaging of acute penile fracture. Radio Graph 2000;20:1397-405.
7Uder M, Gohl D, Takahashi M, Derouet H, Defreyne L, Kramann B, Schneider G. MRI of penile fracture: Diagnosis and therapeutic follow-up. Eur Radiol 2002;12:113-20.
8De Lucchi R, Rizzo L, Rubino A, Tola E. Magnetic resonance diagnosis of traumatic penile fracture. Radiol Med (Torino) 2004;107:234-40.
9Yapanoglu T, Aksoy Y, Adanur S, Kabadayi B, Ozturk G, Ozbey I. Seventeen years' experience of penile fracture: Conservative vs. surgical treatment. J Sex Med 2009;6:2058-63.
10Abolyosr 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.