A 34-year-old man comes to the emergency department due to severe, sudden-onset pain in his penis. During sexual intercourse 2 hours ago, he heard a cracking sound followed by pain and rapid loss of erection. When attempting to urinate, the pain is aggravated, and the patient is unable to pass urine. Physical examination shows a swollen and ecchymotic penis. Following adequate analgesia, which of the following is the best next step in management of this patient?

Question

A 34-year-old man comes to the emergency department due to severe, sudden-onset pain in his penis.  During sexual intercourse 2 hours ago, he heard a cracking sound followed by pain and rapid loss of erection.  When attempting to urinate, the pain is aggravated, and the patient is unable to pass urine.  Physical examination shows a swollen and ecchymotic penis.  Following adequate analgesia, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d929_92ad_bc81_f15a7ca46f63_MD0003_00 This patient has a classic presentation of penile fracture (PF), a urologic emergency most commonly caused by blunt trauma (eg, sexual intercourse) to the erect penis. PF results from rupture of the fibrous tunica albuginea that envelopes the corpus cavernosum. At the moment of rupture, patients often hear a snapping sound and experience sudden-onset pain. Afterward, as blood exits the engorged corpus cavernosum, patients experience rapid penile detumescence and formation of a penile shaft hematoma (eg, swelling, ecchymosis). Diagnosis of PF is usually clinical, and urgent surgical repair of the tunica albuginea is the mainstay of treatment. However, because concomitant urethral injury occurs in approximately 20% of PF cases (due to the close proximity of the corpus spongiosum), the following findings warrant investigation with retrograde urethrography (or urethroscopy) prior to surgery: Blood at the meatus Hematuria Dysuria Urinary retention If urethral injury is confirmed by urethrography, then the urethra should also undergo repair at the time of surgery. (Choice A) Medical management of PF (eg, cold compresses, pressure dressings, penile splinting) was previously routine, but it has overwhelmingly been replaced by surgery due to the much higher rate of long-term complications (eg, erectile dysfunction, painful erections) with nonoperative management. (Choice B) Color Doppler ultrasonography is sometimes used in the evaluation of testicular torsion, which would present with sudden-onset testicular pain and a high-riding testis on examination (due to fixation of the testis to the tunica vaginalis). (Choice C) CT scan is recommended in the evaluation of patients with blunt genitourinary trauma who have suspected renal injury, which would be unlikely with PF. (Choice D) In some cases of urethral injury (typically posterior urethral injuries associated with pelvic fracture), a suprapubic catheter is required to decompress the bladder until the urethra can be repaired. However, PF causes isolated anterior urethral injury that is more commonly managed with urgent urethral repair and intraoperative urethral catheter placement (for bladder drainage as well as postoperative protection of the repair). Educational objective: Penile fracture is most commonly caused by blunt trauma (eg, sexual intercourse) to an erect penis. Although penile fracture is a urologic emergency that requires urgent operative repair, patients with evidence of urethral injury (eg, blood at the meatus, dysuria, urinary retention) should undergo retrograde urethrography prior to surgery. References: Fracture with urethral injury: evaluation by retrograde urethrogram. (http://www.ncbi.nlm.nih.gov/pubmed/29123449) Penile fracture: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/26953932) Management of penile fracture. (http://www.ncbi.nlm.nih.gov/pubmed/31194931)

A 34-Year-Old Man Comes to the Emergency Department Due to Severe