Penile Fracture

[txterp98]

Hey guys, I'm an ER doc a year and a half outside of residency. I was wondering if some of the residents/attendings here can give me a little guidance about the proper disposition for a penile fracture. I have 2 different urologists who apparently have different views and as a result, a complaint was lodged. Not that I truly care about the complaint, I'm just wondering what others think and if there's a correct answer. Here's the case.....

20-some year old guy comes into the ER at 0100 after a masturbation induced penile injury. On my exam, bilateral corpora cavernosa are soft and the corpora spongiosum is soft as well. Bright red blood is present at the meatus. He has echymosis at the base of the penis extending 3/4 up the shaft on either side. He can void freely without difficulty. I spoke with the on-call urologist who says a urethrogram isn't indicated. He says to send him home, ice the penis, he can come to the office 8 hrs later. He does this where one of the on-call urologist's partners sees the patient. He is upset the patient wasn't admitted because from what I'm told, the surgery gets exceedingly more complex as time passes.

I was wondering if you guys can help me with a couple of questions....

1) Is a urethrogram indicated for patients like this? If not, when would it be helpful....if he has difficulty voiding? Or maybe if he cannot void and is retaining?

2) When does this patient necessitate surgery? Should the on-call urologist handle this emergently? Does it necessitate admission/surgery in the next 8-10 hours? Can surgery be delayed?

Any advice would be appreciated. I'm still waiting for our local urologists to answer these questions so I can avoid any problems in the future. I was just hoping to gather others' views and insights as well. Thanks for your time.

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[bobbyseal]

Hey guys, I'm an ER doc a year and a half outside of residency. I was wondering if some of the residents/attendings here can give me a little guidance about the proper disposition for a penile fracture. I have 2 different urologists who apparently have different views and as a result, a complaint was lodged. Not that I truly care about the complaint, I'm just wondering what others think and if there's a correct answer. Here's the case.....

20-some year old guy comes into the ER at 0100 after a masturbation induced penile injury. On my exam, bilateral corpora cavernosa are soft and the corpora spongiosum is soft as well. Bright red blood is present at the meatus. He has echymosis at the base of the penis extending 3/4 up the shaft on either side. He can void freely without difficulty. I spoke with the on-call urologist who says a urethrogram isn't indicated. He says to send him home, ice the penis, he can come to the office 8 hrs later. He does this where one of the on-call urologist's partners sees the patient. He is upset the patient wasn't admitted because from what I'm told, the surgery gets exceedingly more complex as time passes.

I was wondering if you guys can help me with a couple of questions....

1) Is a urethrogram indicated for patients like this? If not, when would it be helpful....if he has difficulty voiding? Or maybe if he cannot void and is retaining?

2) When does this patient necessitate surgery? Should the on-call urologist handle this emergently? Does it necessitate admission/surgery in the next 8-10 hours? Can surgery be delayed?

Any advice would be appreciated. I'm still waiting for our local urologists to answer these questions so I can avoid any problems in the future. I was just hoping to gather others' views and insights as well. Thanks for your time.

A urethrogram is probably not needed in this patient. He likely ruptured his corpora extending into the spongiosum. That's a pretty significant injury, but it likely didn't cause a distraction of his urethra. It just led to bleeding out his urethra. You typically need to get a retrograde urethrogram when there's a straddle injury or similar trauma with blood at the meatus.

I think in this case the patient would do best with an immediate surgery. The classic story of a penile fracture is that of an erection and then a crushing force to the penis. A loud pop or snap is heard (that's the corpora breaking). Then they get a rapid detumescence and swelling of the penis.

The proper management would be admission and repair of the corpora in an urgent fashion.

 

[txterp98]

Thanks for the insight, bobbyseal. I truly appreciate the help provided.

 

[MossPoh]

I think additional management of the issue should be a notice to NOT break your penis. That can never be a good day. (Yes, I know there was no useful help with this comment...but reading that kind of made me cringe for a moment)

 

[bobbyseal]

I think additional management of the issue should be a notice to NOT break your penis. That can never be a good day. (Yes, I know there was no useful help with this comment...but reading that kind of made me cringe for a moment)

Yeah, the best defense is certainly prevention. So, when she's on top be careful.

 

[exmike]

Could you elaborate on the HPI please?

 

[TheThroat]

...a broken bone?

Options for repair of the broken bone:
-Just put a splint on it.
-ORIF with miniplates, or, for a long bone injury, perhaps a recon bar.
-If the repair looks to be unfavorable, just put it in traction!

I love the uro board.

 

[toofache32]

...a broken bone?

Options for repair of the broken bone:
-Just put a splint on it.
-ORIF with miniplates, or, for a long bone injury, perhaps a recon bar.
-If the repair looks to be unfavorable, just put it in traction!

You forgot to mention the time-honored external fixator.

 

[-Goose-]

Most painful thread. Ever.

 

[MossPoh]

Most painful thread. Ever.

Yea...whenever the go indepth about what it sounded like. Makes me cringe. Just like the scene in the movie "hard candy" where there is a simulated castration. *shudders*

 

[drivesmecraazee]

Forget about uro man, I will NEVER be able to see guys in such pain, It hurts me just to think about it...how can someone have a penile fracture? is there another cause besides animal/monster masturbation?

 

[MossPoh]

Forget about uro man, I will NEVER be able to see guys in such pain, It hurts me just to think about it...how can someone have a penile fracture? is there another cause besides animal/monster masturbation?

Morning wood man. You get up, faithful morning wood, and then it happens. You trip and fall....straight onto it. SNAP. Picture that.

 

[drivesmecraazee]

Morning wood man. You get up, faithful morning wood, and then it happens. You trip and fall....straight onto it. SNAP. Picture that.

If that happens to a guy, he has the right to call himself the most unlucky guyin the world, he shouldn't be taken to the doctor, try the shaman or something like that beaucse no one can live with that karma.
No seriously...that has to be one of the most painful things that can happen in a guy's life

 

[Richie Truxillo]

I am destined to have a patient like this sometime during my (hopefully uro) residency!

Yeah, the best defense is certainly prevention. So, when she's on top be careful.

Advice duly noted.

 

[drivesmecraazee]

I am destined to have a patient like this sometime during my (hopefully uro) residency!

Advice duly noted.

You decided your residency already! Congrats! Do you have a plan B now or had one before?ROCKS!

I checked your website...NETTER ROCKS!!!

 

[Richie Truxillo]

Have plans B and C of course Always have backup plans. The economy taught me that back in 2001 when Corning stock took a dip and adventure through computer science in the corporate world went down the tubes!

 

[drivesmecraazee]

Have plans B and C of course Always have backup plans. The economy taught me that back in 2001 when Corning stock took a dip and adventure through computer science in the corporate world went down the tubes!

Yeaaah...just in case you don't get the priviledge to see other dudes frank......just kidding, don't get offended

 

[MossPoh]

If that happens to a guy, he has the right to call himself the most unlucky guyin the world, he shouldn't be taken to the doctor, try the shaman or something like that beaucse no one can live with that karma.
No seriously...that has to be one of the most painful things that can happen in a guy's life

I agree. I remember watching "Loveline" with Adam Corolla and Dr. Drew back in the day (mid-90s?) and a guy had that happen. It might not be the most painful, but it is certaintly one of the most traumatic. If you want to watch something that'll make you squirm then check out the movie "Hard Candy". I was sitting next to some random guys in Berlin when I saw that, and we were all extremely uncomfortable with a particular scene. Accidents happen though.....I think I rather have a baseball bat to my knee than that.

 

[drivesmecraazee]

The movie it's not in theaters where I live...just heard about it, what's the movie about and what made you so uncomfortable?