Posts filed under Urology

Penile Injuries

Written by: Jacob Stelter, MD (NUEM ‘19) Edited by: Kimberly Iwaki, MD (NUEM ‘18) Expert commentary by: D. Mark Courtney, MD, MCSI

Case

A 54 year old male with no significant past medical history presents to the ED around 11pm with the chief complaint of “swollen penis.” He appears notably distressed on initial assessment and complains of penile swelling and pain. Per the history, the patient states that he was having sexual intercourse with his wife, with her on top of him, when he felt a sudden “popping” sensation in his penis followed by swelling, detumescence and pain. Vitals are stable and exam is notable for an enlarged, swollen, ecchymotic, mildly angulated and deformed penis. Diagnosis?

Penile fracture. Yes, penises (or penes) can fracture. The penis can sustain multiple different forms of injury, including fracture, direct trauma, burns and strangulation. It is both dramatic and problematic and requires emergent evaluation. Three of these injuries will be discussed here – penile fracture, zipper injury and penile strangulation.

Penile Fractures

Anatomy and Pathophysiology

The penis consists of two corpora cavernosa on the dorsal aspect of the penis and one corpus spongiosum on the ventral portion of the penis, all wrapped in a tough fascial layer call the tunica albuginea (1). Penile fractures typically involve an injury to the tunica albuginea that becomes significantly thinner and more stretched during an erection (2). Usually, this involves the tunica albuginea of one of the corpus cavernosum, which can also become injured or lacerated (2, 3). The most common mechanism for penile fracture in the United States is during vigorous vaginal sexual intercourse when the erect penis is misdirected into the female pubic bone (2). This most often occurs with the female-on-top or “cowgirl” positions (2). In the Middle East, the most common practice that leads to penile fracture is “taghaandan” or “to click or snap when forcibly pushing the erect penis down to achieve detumescence” (4). In fact, one study conducted in Iran determined that 69% of penile fractures were related to this mechanism (4).

Figure 1: Normal Penile Anatomy (1) — **Figure 1:** Normal Penile Anatomy (1)

Presentation

The clinical presentation of a penile fracture is typically a “popping” sensation or sound, followed by significant pain, swelling and detumescence of the penis, often with notable ecchymosis, swelling and deformity on exam (3). Clinically, this is referred to as the “eggplant deformity” (5). The “rolling sign” refers to the physical exam maneuver that identifies where the corporal fracture is located by rolling the penis and palpating a firm, immobile swelling that represents the hematoma overlying the fracture (5). Most often, this is a clinical diagnosis with little utility for imaging studies. However, if the diagnosis is unclear, ultrasound or MRI can be used to diagnose injuries to the underlying fascia or corpora cavernosa (6).

Figure 2: Penile fracture — **Figure 2:** Penile fracture

Treatment

From an emergency department (ED) management perspective, if a penile fracture is suspected, an emergent urology consultation is indicated. Up to 38% of penile fractures can involve urethral injuries and, while they may present with hematuria and difficulty urinating, these signs are not reliable in ruling out a urethral tear (2). As a result, a retrograde urethrogram (RUG) or cystoscopy should be performed prior to Foley catheter placement (2). This is important, as acute urinary retention in the setting of a penile fracture is an emergency indication for Foley placement and an urologist may not be readily available to assist with this. Symptom control in the ED should include ice packs to reduce swelling, pain control and Foley placement as indicated (5). Current urological treatment guidelines recommend immediate surgical repair which includes hematoma evacuation, examination of the urethra, and repair of the corporal fracture and any tears in the surrounding fascia (5,2). If promptly repaired, within 36 hours, most patients have minimal residual effects after sustaining a penile fracture (3).

Zipper Injury

Zipper injuries involving the penis are another injury that can be encountered by the emergency physician. Most often, this occurs in children and is more common in uncircumcised males (1). Using a lubricant to attempt to separate the entrapped penis can be successful and is noninvasive (1). In fact, a recent study showed that the use of mineral oil to free a simulated entrapped penis was nearly 100% successful (7). If unsuccessful, using a wire cutter can help to cut the middle portion of the zipper that connects the two halves to help separate the zipper from the entrapped foreskin (1). Additionally, the zipper can be grasped above and below the entrapment to separate the teeth to free the penis (1). This can be painful, so using local or regional anesthesia is recommended (1).

Figure 3: Zipper median bar bisection (1) — **Figure 3:** Zipper median bar bisection (1)

Penile Strangulation

Penile strangulation injuries are seen occasionally in the ED. Most often, this results from self-application of rings to the base of the penis and often including the scrotum in an attempt to prolong erections or enhance sexual pleasure. Multiple case reports have been published, detailing various objects used as cock rings and methods to remove them. Being unable to remove the constricting ring is a medical emergency as it can cause a prolonged erection and can lead to ischemia and eventual necrosis of the penis (8). There are five published grades of injury resulting from penile strangulation (9):

Grade I: Penile edema with no urethral or skin injury
Grade II: Skin injury with constriction of the corpus spongiosum with penile edema and decreased sensation
Grade III: Injury to both the skin and urethra without urethral fistula
Grade IV: Urethral fistula formation due to division of the corpus spongiosum
Grade V: Penile necrosis or amputation of the distal segment

Multiple different tools can be used to remove these rings, including ring cutters found in most emergency departments, dental drills or pliers (8). Care must be taken to protect the skin of the penis underneath the ring and this can be done by using a tongue depressor or other protective guard. If it is difficult to get anything underneath the constricting band, blood can be drained from the corpora cavernosa in a manner similar to draining a priapism (8). If this is unsuccessful, an emergent urology consult is indicated to avoid permanent penile damage (8).

Take Home Points

Penile fractures are one of the most common injuries of the penis and are often sustained by vigorous sexual intercourse. ED management of penile fractures includes pain control, swelling reduction with ice, Foley placement once a urethral injury is ruled out and emergent urology consult for operative intervention.
Zipper injuries occur most frequently in young, uncircumcised males. Mineral oil is the best way to try to free a zipper-trapped penis. If unsuccessful, try bisection of the median bar of the zipper.
Penile strangulation occurs by the self-placement of constricting rings and can end up causing penile necrosis or amputation if the constricting object is not promptly removed.

Expert Commentary

One of the more difficult aspects of management of these injuries is reassurance and anxiolysis to the patient and perhaps their partner or parent in the case of a child with a zipper injury. There is often a morbid curiosity on the part of members of the treatment team including other physicians and nurses. For the sake of maintaining a calm patient who trusts in you as you approach the penis with a tool that looks like and may have come from the hospital mechanical maintenance room, try to avoid spectacle and treat the patient with dignity and respect and perhaps a bit of a benzodiazepine. This will make them feel more comfortable and make your job easier.

Additionally, don’t trust the history. There are many reasons patients may not be forthright about the events leading up to and causing a penile fracture. In my experience half of the patients I have taken care of have denied onset while having intercourse despite later revealing the truth. Point is….if it looks like a penile fracture, it almost certainly is, regardless of the history that may be unclear or inconsistent with your suspicion.

Finally, the seriousness of implications of untreated penile injuries at times needs to be impressed upon patients, family members, and treating physicians. Sometimes these patients arrive intoxicated and wanting to leave. This presents the usual difficulties in determining medical decision making capacity and preventing harm. Though the above Blog post notes most have a good outcome with repair, un-repaired penile fractures have a high incidence of subsequent deformity and erectile dysfunction.

D. Mark Courtney, MD, MSCI

Associate Professor

Department of Emergency Medicine

Northwestern University

How to Cite this Post

[Peer-Reviewed, Web Publication] Stelter J, Iwaki K. (2019, Dec 2). Penile Injuries. [NUEM Blog. Expert Commentary by Courtney DM]. Retrieved from http://www.nuemblog.com/blog/penile-injuries

References

Dubin J, Davis JE. Penile emergencies. Emerg Med Clin N Am 2011;29:485-499.
Chang AJ, Brandes SB. Advances in diagnosis and management of genital injuries. Urol Clin N Am 2013;40:427-438.
Cooper BL, Beres KP. Penile Fracture. J Emerg Med 2017;52(2):238-239.
Zargooshi, J. Penile fracture in Kermanshah, Iran: Report of 172 cases. J Urol 2000;164:364-366.
Jack GS, et al. Current treatment options for penile fractures. Rev in Urol 2004;6(3):114-120.
Bertolotto M, et al. Penile trauma. Chapter 125 in Abdominal Imaging. 2013. Pp. 1937-1946.
Oquist M, et al. Comparative analysis of five methods of emergency zipper release by experienced versus novice clinicians 2016;68(45):S116.
Chapman JD. A case of penile strangulation secondary to deliberate placement of a wedding band. J Clin Urol 2016;9(2):131-132.
Agarwal AA, et al. Penile strangulation due to plastic bottle neck: A surgical emergency. BMJ Case Rep 2014:1-2.

Priapism: The ED-Focused Approach

Written by: Aaron Quarles, MD (EM Resident Physician, PGY-3, NUEM), Emmanuel Ogele, MS4, Northwestern University Feinberg School of Medicine ; Edited by: Meghan Quigley, MD (NEUM 2017 Graduate); Expert Commentary by: Nelson Bennett, Jr., MD

The Case

An otherwise healthy 36 year old man presents to the emergency department late on a Saturday night. You enter the exam room to find a man who appears anxious and cannot seem to get comfortable. He immediately informs you that he is in the adult film industry and they were doing a shoot earlier in the day. He states that he took Viagra, but was unable to achieve an erection as rapidly as needed. So he injected an intracavernosal prostaglandin E1 with rapid and resolute effect.

Despite the popular refrain to “seek immediate medical help for erections lasting more than 4 hours,” your patient waited until hour 9 before presenting. He was thorough, however, in his attempt to detumesce; employing such strategies as repeated masturbation, warm baths, alcohol, and even cocaine (the latter two may actually cause priapism!).

Physical exam revealed an extremely firm, fully erect penis that was painful to touch. The glans was soft and not discolored. At this point, all the patient can say is, “Please doc, you have to help me.”

A Bit About Priapism

Priapism is most commonly defined as an erection lasting longer than 4 hours and is unrelated to sexual stimulation. Between 2006 and 2009, somewhere between 5 and 8 visits per 100,000 male subjects to the emergency department (ED) in the United States were due to priapism. In adult males, erectile dysfunction drugs are the usual culprit, accounting for up to 25% of presentations. There is also a notable increase in incidence during the summer months and in patients with sickle cell disease, leukemia, pelvic tumors, & trauma [1,2,3].

What is the pathophysiology behind this condition?

Ischemic priapism occurs secondary to obstruction of venous outflow. The nitric oxide-phosphodiesterase-5 (NO-PDE5) pathway has been implicated in the pathogenesis of ischemic priapism. Dysregulation of this pathway leads to failure to control vasodilation, which in turn leads to prolonged arterial inflow and subsequent obstruction of venous outflow. This causes prolonged erection and ischemia in the penis [3,4].

Non ischemic priapism is not caused by obstruction but rather is due to extravasation of blood into the corpus cavernosum from an arterial fistula. This is less common than the ischemic variant and often happens in the setting of trauma to the perineum (think bicycle seats and other straddle injuries).

A third type of priapism, known as stuttering priapism, represents unwanted intermittent erections usually lasting 3 hours and confined mostly to the sickle cell population. Given its veno-occlusive pathophysiology, stuttering priapism is akin to a self-limited ischemic priapism. These patients are sometimes managed with self-injection of sympathomimetic agents.

How can I distinguish between the types of priapism and why is it important to do so?

It is important to distinguish ischemic from non-ischemic priapism because ischemic priapism is a urologic emergency. This is the first step in management. In ischemic priapism, microscopic changes begin to occur at 4 hours of persistent erection and irreversible fibrotic damage occurs after 24 hours. 90% of cases lasting over 24 hours develop erectile dysfunction with severe impairment in sexual function, which is why early intervention along with counseling the patient on likely outcomes is critical.

Is a physical exam necessary for patient presenting with priapism?

Although presentation is usually self-evident, a fast, focused physical examination of the genitals, perineum and abdomen are warranted. Ischemic priapism will usually present with a painful, tender and a fully rigid phallus. Non-ischemic is usually less rigid and less painful. Abdominal and perineal inspection are helpful to rule out any other traumatic injuries.

Management in the ED

Ischemic Priapism

Once the diagnosis of ischemic priapism has been made, intervention is required to prevent long term dysfunction. Underlying conditions such as sickle cell, should be considered and treated as appropriate (hydration, O2 etc), but they should not delay treatment of priapism. A general approach to management of ischemic priapism is demonstrated below:

Analgesia → Systemic Vasodilators → Direct Vasoconstrictor → Aspiration/Irrigation → Urologic surgery

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Provide oral or parenteral analgesia as appropriate. You may consider systemic vasodilators such as terbutaline (Roberts and Hedges recommends 0.25 to 0.5 mg subQ q15minutes; or 5mg PO once). However, the AUA guidelines suggest no indication for oral systemic vasodilators given limited efficacy. And let’s be honest, the next steps provide significantly more bang for your buck.

Both the European and American Urological Associations recommend cavernosal aspiration and intracavernosal sympathomimetic injection as the treatment of choice. When sympathomimetic injection was added to aspiration and irrigation there was a significant associated increase in resolving priapism [7].

But first, provide local anesthesia. A dorsal penile nerve block can be achieved using a 27-gauge needle and 1% lidocaine (without epinephrine). Raise a skin wheal at the 10 and 2 o’clock positions of the penis as close to the base as possible. Inject through the wheals in a medial direction, being careful to avoid cavernous artery injury. Alternatively a subcutaneous ring block over the dorsal aspect of the penis is effective. Or simply anesthetize the skin on either side of the mid penile shaft where you anticipate entering for aspiration. Be careful to avoid superficial veins.

Next, sterilely attach a 19 or 21 gauge butterfly needle to a syringe or tubing irrigation system of your choice (a useful video demonstrating a convenient way to set up aspiration and irrigation tubing by Dr. Larry Melick ).

Direct the butterfly needle into the now anesthetized 10 or 2 o’clock position of your choice and begin to aspirate. Advance carefully until you get return of dark venous blood. The corpora communicate, so in most cases, only one side needs to be aspirated. If one side isn’t working, try the other. After about 30-60 cc’s of blood are removed, if priapism persists, irrigation with 10-20 ml aliquots of saline or a diluted phenylephrine solution may be attempted. Continue with this approach until the dark venous blood becomes bright red or until flaccidity is achieved.

Alternatively, direct injections of phenylephrine diluted to a concentration of 100-500 mcg/mL dosed in 1 mL injections can be performed every 3-5 minutes. Treatment failure is considered after one hour of these injections. Patients should be placed on a cardiac monitor while administering these medications given the risk of systemic effects (severe hypertension, dysrhythmia). Proceed with caution in those patients with such underlying conditions.

If these methods fail, urgent urological consultation is required for possible placement of a corpus cavernosum-spongiosum shunt.

Pearl: Phenylephrine is less capable of binding its receptor in acidotic conditions. Thus in patients presenting with 2-3 days of sustained erection, although one should try Phenylephrine as first line, keep in mind this patient will most likely need surgery and should be moved to the OR faster.

Pearl: For patients with a positive history of sickle cell disease, ischemic priapism is managed in the same way it is when caused by other etiologies. In addition, narcotic analgesia, IV hydration, supplemental oxygen, and alkalization is indicated.

Non – ischemic Priapism

Non-ischemic priapism is not an emergency. Management consists of observation with the expectation that it will resolve spontaneously.

Pitfall: Injection of sympathomimetics is not recommended as arterial flow will distribute the drug promptly into systemic circulation. In the setting of trauma, other injuries should be managed accordingly. If non – ischemic priapism does not resolve spontaneously, it can be treated by embolization of the fistula in the IR suite [10].

Disposition

Following successful aspiration, observation is recommended. The patient may be sent home with urology follow up.

Pearls and Pitfalls:

A good history can often distinguish between ischemic and nonischemic priapism
Time is functional penis
Providing proper analgesia is critical, dorsal penile nerve block makes you and your patient’s life easier
Intracorporeal injection = intravenous injection (patients should be placed on a monitor when administering vasoactive agents & caution should be taken in severe hypertension, dysrhythmias, etc)
Be mindful that this can be embarrassing and traumatic for patients so care should be taken in addressing the patient as a whole

Expert Commentary

Definition and Etiology

Priapism, a prolonged erection lasting more than 4 hours in the absence of sexual stimulation, is a urologic emergency that can result in ischemia, corporal fibrosis, and erectile dysfunction[15]. The duration of corporal ischemia results in variable reversible and irreversible smooth muscle and endothelial injury with histologic changes seen by 12 hours[16]. After 48 hours of ischemia, there is permanent smooth muscle cell death and erectile dysfunction[16-18]. Incidence of all-cause priapism has been reported between 0.3 per 100,000 person-years up to 2.9 per 100,000 person-years[19].

Although the etiology of priapism is not completely understood, it is believed to be a failure of detumescence[17]. Many disease states have been associated with priapism, including hematologic disorders, malignancy, neurologic disorders, trauma, infection, medications, recreational drugs (see Table 1)[15, 17]. Evaluation should include a complete history, physical exam, CBC with differential, hemoglobin electrophoresis, and urine toxicology screen.

Treatment

For the proper management of priapism, it is important to distinguish between ischemic and non-ischemic subtypes. Ischemic priapism is comparable to a compartment syndrome causing hypoxia of the corpora cavernosa that is typically painful and requires emergent intervention to preserve erectile function. Non-ischemic priapism is a high-flow state that is typically not painful and resolves spontaneously. Non-ischemic priapism is more often associated with trauma. A cavernous blood gas can be performed to differentiate the two. Patients with ischemic priapism will have hypoxia with pH <7.25, pCO2 >60 mmHg, and pO2 >30 mmHg. Blood gas results for patients with non-ischemic priapism will be consistent with normal arterial blood gases. The blood gas on a detumesced penis would be consistent with a mixed venous blood gas.[15]

The practical aspects of priapism treatment deserve special comment. Understand that the patient will be embarrassed, anxious, and in pain. Do everything needed to ensure patient comfort and privacy.

Prior to performing any treatment, obtain informed consent for treatment of priapism.
Place patient on a cardiac and BP monitor.
Administer a dorsal penile nerve block with 1-2% lidocaine using a 25-27G needle.
Insert the needle at the base of the penis at the 10 o’clock position. Advance the needle towards the opposite side of the shaft (2 o’clock). Make sure that you have not entered the corpora by gently aspirated.
Deposit 10 mL of lidocaine into the penile shaft. Note the distention of Buck’s fascia when injecting the lidocaine. Allow approximately 10 minutes for the local anesthesia to reach full effect.
Insert a 16 or 18 gauge needle into the penile shaft and aspirate 20 to 30 mL of blood. Irrigation with a saline solution is not routinely recommended as it rarely results in faster detumescence.
Next, inject 1 mL of a diluted phenylephrine concentration (100-500 mcg/ml). This phenylephrine solution may be injected in 1 mL aliquots - no less than every five minutes
- Pay special attention to the cardiac and BP monitor as phenylephrine may cause reflex bradycardia and hypertension
- There is no upper limit in the amount of phenylephrine that can be injected. However, practically it may take 10 to 15 mL to achieve detumescence or to decide that surgical intervention is needed.
Once the penis is detumesced, it should be wrapped loosely with gauze and non-adhesive dressing (Coban).
The patient should be monitored in the emergency department for at least another hour to ensure continued penile detumescence.