Emergency Duty Report

UROLOGY TEAM C
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME
J.N 27YRS, Male Traumatic penile - Conservative Stable on B2
injury Management
- Antibiotics and
analgesia

B.A.B 16YRS, Male ISCHAEMIC -Resuscitation with - Discharged from

PRIAPISM SEC. hydration urology and to
NEWLY DIAGNOSED -Broad spectrum review in 2 weeks at
SICKLE CELL DISEASE antibiotics OPD
(SS) -Analgesia
?ACUTE CHEST -Glanocavernous
SYNDROME shunt
-SC Clexane 40mg
dly
-To hemotransfuse
- Hematology review
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME
T.O 26YRS, Male -Post RTA hematuria -Conservative - To review at OPD
-Fracture of Management in 2 weeks
tibia/fibula -Orthopaedic team
to continue
management

Y.S 53YRS, Male -Fournier’s gangrene -Resuscitation with Stable on b2

-perianal fistula maintenance
-systemic hydration
hypertension -debridement
-Broad spectrum
antibiotics
-Analgesia
-sitz bath
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME
M.K.D 84yrs, Male LUTO sec. Suprapubic Died
Metastatic Prostate catetherisation
Ca with bilateral Iv antibiotics
hydronephrosis with Cardiothoracic
CKD review
-malignant pleural Renal consult
effusion
-moderate aneamia
A.G 62 yrs, Male Acute Urinary Suprapubic Discharged home
retension sec. BPH catetherization and to review at
R/O Prostate Ca Antibiotics and OPD in 2 weeks
analgesia
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME
R.Y 33YRS, Male Priapism sec. herbal Hydration and - Stable on B2
medication analgesia
Declined surgical
Intervention
R.A 21yrs, Male Post glanocavernous Analgesia Discharge home
shunt FF ? High flow Antibiotics To review in 2 wee
priapism sec. penile at OPD
trauma
R/O Ischemic
Priapism
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME

E.A 73yrs, male Acute urinary -3 way catether with Stable at yellow
retention sec. continuous bladder
Suspected bladder irrigation
Ca with hematuria -antibiotics and
analgesia
-Resuscitation with
maintenance
hydration
-to do
abdominopelvic
USG

A.G.A 26 yrs, Male Right nephrolithiasis Analgesia Stable on B2

Antibiotics
Low dose
abdominopelvic CT
scan
Resuscitation with
maintenance
hydration
NAME AGE / SEX DIAGNOSIS MANAGEMENT OUTCOME

C.A 18yrs, Male Post glanocavernous Resuscitation with Stable at Yellow

shunt FF ischemic maintenance
Priapisim in a hydration
known SCDx (SC) Antibiotics and
analgesia
Tab bicalutamide
50mg daily

R.A 26 YRS, male Hemoperitoneum Surgical intervention stable

sec. trauma by GSTC
Traumatic urethral Urethral
catheterisation catetherization
INDEX CASE
Name : Joseph Nsiah
Age : 27yrs
Sex: Male
Religion: Christian
Referral from a county hospital (Anhwia
Nkwanta)
PC=Penile swelling - 2/7
HPC=Client with no known chronic illness who was in his usual state of
health until he noticed a sudden swelling of the penis 2 days after sexual
intercourse where he experienced a sudden brief pain of 7/10 when he hit
his penis against the perineum of the lady in a doggy style position during
one of the strokes. There was no popping sound or sudden loss of
erection but he decided to stop the act on his own. He didn’t experience
any further pains or swelling afterwards so he went about his daily routine
until he noticed a suddenly his penis was swollen in an attempt to urinate
2 days after whilst running a business errand. He quickly reported to a
peripheral facility where he was referred here for further management.
• Odq: hematuria-, no penile discharge, lower abdominal pains-, able to
void, post trauma erection+
• Drughx: no medications or herbal conconction was taken, no drug
allergies, IV paracetamol, IV amoxiclav
• Pmhx: nil of note
• Fhx: nil of note
• Shx: manages a provision shop, alcohol-, smoking-, single with 2
children, lives at Manso, NHIS-,
• O/E=YOUNG MALE,NOT IN RESPIRATORY DISTRESS,J-,P-,WELL
HYDRATED
• CVS=S1+S2 MO
• BP-111/64MMHG,HR-60BPM
• R/S=A/E IS ADEQUATE SYMMETRICAL,BS,NO ADDED,SPO2-98% ON RA
• ABD=FULL,SOFT,NON-TENDER
• CNS=GCS-15/15
• SL: swollen, deformed shaft of penis, no differential warmth, not
tender-, no bloody discharge from urethral meatus
IMPRESSION:
Traumatic penile injury with superficial vascular compromise
R/O: penile fracture with laceration of tunica albuginea
PLAN
To do CBC,RFT, USG of the penis
IV analgesia and antibiotics
Resuscitation and maintenance IVF
Patient counselled on condition
To keep NPO
• Diagnosis
Traumatic penile injury with hematoma from
1. isolated fracture of corpus spongiosum
2. Superficial vascular tear
PLAN
Continue iv antibiotics and analgesia
Monitor for progressive increase in size
To repeat USG of penis
Continue hydration and regular diet
To pass a silicon urethral catether
Transout to B2
TRAUMATIC PENILE INJURIES
Traumatic penile injuries are diverse with penile fracture being the
most common one. It is defined as the disruption of the tunica
albuginea with the disruption of corpus cavernosum.
Vascular penile injuries are another cause of penile trauma which may
resemble true penile fracture but without the tunical tear. They include
• rupture of the penile superficial dorsal vein
• deep dorsal vein
• dorsal artery
• non-specific dartos bleeding.
• These acute penile emergencies necessitate urgent medical attention
and in most cases prompt interference. Dorsal vein injury is the most
frequent entity which presents with sudden onset of hematoma and
swelling mimicking penile fracture.
• There is less information or data about traumatic penile injuries due
to majority of the cases not reporting to the health facilities. Penile
injuries are uncommon because of the well-protected location on the
body and a high degree of genital mobility
Anatomy of penis
• Anatomically, the major penile vasculature consists of the superficial and deep
dorsal veins and the dorsal artery of the penis, lying out of the tunica albuginea. The
deep artery of the penis is in the middle of the corpora cavernosa and is covered by
the tunica albuginea. The deep dorsal penile vein and deep dorsal artey are present
underneath the Buck's fascia while superficial dorsal vein rests outside the fascia.
• The ecchymosis due to superficial dorsal vein rupture can spread through the
subcutaneous tissue of the scrotum and perineum. On the contrary, the hematoma
due to deep dorsal vein rupture and penile fracture is confined to the space
beneath Buck's fascia and thus remains within the penile shaft as long as Buck's
fascia remains intact.
• If ecchymosis involves scrotum, perineum or pubic area, a diagnosis of either true
penile fracture with tearing of Buck's fascia or of false penile fracture with
superficial dorsal vein rupture can be considered.
• Rupture of the deep dorsal vein is almost difficult to differentiate from that of
cavernous bodies, except for the absence of an initial snap and sometimes of pain.
Common sex postions that lead to traumatic penile injury:
• Doggy style
• Cow girl / reverse cowgirl
• Missionary / man on top

We do not observe differences between the severity of the PF between the

‘doggy style’ and ‘man-on-top’ (P=0.9595), but the ‘doggy style’ had more
severity of PF when compared with ‘woman-on-top’ (P=0.0396). The ‘man-
on-top’ and ‘doggy style’ positions showed more associations with bilateral
fractures of the corpus cavernosum and urethral lesions. (Barros, R., Schulze,
L., Ornellas, A. et al. Relationship between sexual position and severity of
penile fracture. Int J Impot Res 29, 207–209 (2017). https://
doi.org/10.1038/ijir.2017.24 )
• Penile fracture is readily diagnosed by thorough history and physical
examination. A history of vigorous sexual intercourse or penile
bending during masturbation together with a snapping sound, rapid
detumescence and penile discoloration is characteristic in such cases.
• Examination usually reveals swollen, ecchymotic, tender and
deviated penis. Sometimes, the tunical defect can be palpable.
• Vascular penile injuries are less common causes of acute penis which
may mimic penile fracture.
• They occur predominantly during intercourse, less commonly when
turning or falling on the bed with the penis erected, or during
masturbation.
• The patients present with hematoma, swelling and gradual
detumescence. Although false penile injuries are clinically similar to
true penile fracture, they usually could be differentiated by the lack
of the snap penile sound, absence of tunical defect, gradual
detumescence and post-traumatic new erection.
• Diverse radiological methods such as cavernosography, ultrasonography and
magnetic resonance imaging (MRI) have been utilized to diagnose and assess penile
fracture.
• However, an ideal radiographic imaging is lacking until now. The sensitivity and
specificity of these techniques are significantly different and none has proven to be
the reliable diagnostic investigation and definitely differentiate false from true
penile fracture.
• Penile ultrasound is operator dependent investigation and may give false negative
results due to small albuginea disruptions or the presence of clots at the fracture’
site.
• Caversonography carries the risk of infection, priapism and contrast
hypersensitivity in addition to its false negative results.
• MRI has the advantages of mutiplanar capacity and high soft tissue resolution,
making it the most precise imaging tool in cases of penile fracture. However, MRI
cannot be used as a routine diagnostic mean in cases of suspected penile fracture
as it is costly, time exhausting and not always available.
• Surgical management is aimed at evacuation of the hematoma, identification
or exclusion of the tunica injury and ligation of any injured vessels.
• A degloving circumferential subcoronal incision provides good cosmetic
results and exploratory advantage with exposure of the entire tunica
bilaterally and the urethra.
• The evacuation of the hematoma in false penile fractures might prevent
possible future complications.
• Among surgically treated patients with penile fracture, those undergoing
repair within 8 h of injury had significantly better long-term results than did
those having surgery delayed 36 h after the occurrence of insult.
• Unlike true penile fracture, time is not a prognostic factor for patients with
pseudo-penile fracture.
• Conservative treatment of true penile fracture injuries may result in
complications in up to 29% of cases.

• Erectile Dysfunction,
• Penile curvature
• Abscess
• Debilitating plaques Significantly longer period of hospitalization and
recovery.
conclusion
• Superficial dorsal penile vein injuries are uncommon penile injuries
that simulate true penile fracture.
• Although, few clinical differences exist between these two conditions,
however, due to lack of reliable, fast and practical imaging modality,
surgical exploration is advised to avoid the long-term complications of
missed tunical tears.
• Surgery offers additional advantages as evacuation of hematoma and
repair of possible dorsal penile vessels injury.
References
• 1. Koifman L, Barros R, Júnior RA, Cavalcanti AG, Favorito LA. Penile fracture: Diagnosis, treatment and outcomes of 150 patients. Urology.
2010;76:1488–92. [PubMed] [Google Scholar]
• 2. Polo HE, Garrigós MJ, Ruiz PM, Tendero TP, Marcos SM. Penile hematoma caused by deep dorsal vein rupture during intercourse. Arch Esp Urol.
2000;53:473–5. [PubMed] [Google Scholar]
• 3. Armenakas NA, Hochberg DA, Fracchia JA. Traumatic avulsion of the dorsal penile artery mimicking a penile fracture. J Urol. 2001;166:619. [
PubMed] [Google Scholar]
• 4. Shah DK, Paul EM, Meyersfield SA, Schoor RA. False fracture of the penis. Urology. 2003;61:1259. [PubMed] [Google Scholar]
• 5. Godec CJ, Reiser R, Logush AZ. The erect penis: Injury prone organ. J Trauma. 1988;28:124–6. [PubMed] [Google Scholar]
• 6. Morey AF, Rozanski TA, Wein AJ. Wein: Campbell-Walsh Urology. 9th ed. Ch. 83. Philadelphia, Pa: Saunders Elsevier; 2007. Genital and lower urinary
tract trauma. [Google Scholar]
• 7. Nicolaisen GS, Melamud A, Williams RD, McAninch JW. Rupture of the corpus cavernosum: Surgical management. J Urol. 1983;130:917–9. [PubMed
] [Google Scholar]
• 8. Penson DF, Seftel AD, Krane RJ, Frohrib D, Goldstein I. The hemodynamic pathophysiology of impotence following blunt trauma to the erect penis. J
Urol. 1992;148:1171–80. [PubMed] [Google Scholar]
• 9. Feki W, Derouiche A, Belhaj K, Ouni A, Ben Mouelhi S, Ben Slama MR, et al. False penile fracture: Report of 16 cases. Int J Impot Res. 2007;19:471–3.
[PubMed] [Google Scholar]
• 10. Pereira PA, Fentes PD, Caamaño TV, Parra BM, Parrado VL, González CM. Rupture of the superficial vein of penis: Therapeutic options. Arch Esp
Urol. 2010;63:871–3. [PubMed] [Google Scholar]
• 11. Chung KW. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. Gross Anatomy; pp. 265–7. [Google Scholar]
• 12. Nicely ER, Costabile RA, Moul JW. Rupture of the deep dorsal vein of the penis during sexual intercourse. J Urol. 1992;147:150–2. [PubMed] [
Google Scholar]
• 13. el-Sherif AE, Dauleh M, Allowneh N, Vijayan P. Management of fracture of the penis in Qatar. Br J Urol. 1991;68:622–5. [PubMed] [Google Scholar]
• 14. Tiong JT, Taylor A, England E, Hirsch R. Fracture of the penis: Review with case report. Aust N Z J Surg. 1988;58:428–31. [PubMed] [Google Scholar]
•Thank you