PENILE CRURAL INJURY DUE TO PERINEAL PENETRATING TRAUMA: A CASE REPORT Turgay Akgül, Erim Ersoy, Osman Polat, Tolga Karakan, and Cankon Germiyanog˘lu Department of Second Urology Clinic, Ministry of Health Ankara Training and Research Hospital, Ankara, Turkey.
Perineal traumas are rarely seen in males, and can affect the anterior urethra and corpus cavernosum of the penis. In this paper, we report the case of a 14-year-old boy admitted to the emergency room with a pencil entering the perineum. We performed perineal exploration and observed that the urethra was totally intact, and that the pencil had entered into the right penile cavernosal structure.
Key Words: anterior urethra, corpus cavernosum, perineal trauma, urethra (Kaohsiung J Med Sci 2008;24:422–4)
Perineal traumas are seen rarely in emergency conditions and can be blunt or penetrating. In a male patient with perineal injury, the probability of developing an anterior urethral injury is greater than that of developing a posterior urethral injury [1]. Here, we report the case of a male patient who suffered penetrating injury due to a pencil, as a result of a friend’s joke, without any urethral injury.
CASE PRESENTATION A 14-year-old boy presented to the emergency room with a foreign object stuck in his perineal region. On physical examination, we observed 2 cm of red pencil protruding from the central line of the perineum through the skin (Figure 1A). There was no active bleeding in the perineal region, and no scrotal or perineal hematoma was observed. Suspicious clinical signs suggestive of urethral injury, such as blood at the meatus, gross hematuria and urinary retention, were
Received: Oct 12, 2007 Accepted: Dec 7, 2007 Address correspondence and reprint requests to: Dr Turgay Akgül, 11.Sokak 18/4 Bahçelievler, Ankara, Turkey. E-mail:
[email protected]
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absent. From his history, it was understood that his condition was the result of a friend’s joke. The patient had sat on the pencil, which was held by a friend. Digital rectal examination revealed that the pencil had no involvement with the rectum. Serum biochemical and hemoglobulin parameters were within the normal ranges. To exclude a probable urethral trauma, retrograde urethrography was performed. There was no radiocontrast agent extravasation, and the urethra was completely intact (Figure 1B). The patient was prepared for perineal exploration under general anesthesia. Perineal incision was performed and anatomical planes were opened. The urethra was found and separated from the neighboring tissues. After dissecting the tissues, it was observed that the pencil had invaded the right penile crus and entered into the right corpus cavernosum (Figure 2A). There was no defect in the neighboring vascular structures. The foreign object was taken out and measured to be nearly 4 cm in length (Figure 2B). After removing the pencil, active hemorrhage began from the cavernosal structures. The defective cavernosal structure was repaired with 2/0 polyglactin, and the anatomical planes were closed. The patient was examined at 3 and 8 weeks after the operation. During these examinations, we did not observe or palpate any pathological formations on the penis. Erectile function was also evaluated 8 weeks Kaohsiung J Med Sci August 2008 • Vol 24 • No 8 © 2008 Elsevier. All rights reserved.
Perineal penetrating trauma by pencil A
B
Figure 1. (A) A pencil entering the perineum. (B) Retrograde urethrography. A
B
Figure 2. (A) View of the pencil entering the right corpus cavernosum. (B) The pencil was nearly 4 cm long.
after operation, and we observed that the straightening of the penis during erection was absolutely normal.
DISCUSSION Urethral trauma should be considered in patients with perineal trauma [2]. Before an attempt at transurethral catheterization, retrograde urethrography is indicated in all cases [3]. The extravasation of contrast material supports a diagnosis of urethral trauma. When a patient presents acutely after injury, one should obtain a history of the mechanism of injury, and of the post-injury voiding pattern. Suspicious clinical signs include blood at the meatus, gross hematuria, perineal hematoma, urinary retention and frank urethral extrusion through the skin [4]. Kaohsiung J Med Sci August 2008 • Vol 24 • No 8
Anterior urethral injuries usually occur during urethral procedures. Blunt traumas, such as straddle injuries, and penetrating traumas, such as gunshot or stab wounds, can also be seen. Acute bleeding from the urethra is the principal sign of acute anterior urethral injury [5]. If there is partial dismemberment of the urethra, and Buck’s fascia is intact, then extravasation is confined within the fascia, but if the rupture is through Buck’s fascia, then a hematoma may develop in the perineum. There is usually urinary retention and bladder distension. Penetrating injuries to the penis have associated injuries in up to 83% of patients. Those with associated urethral injury usually present with blood at the urethral meatus and inability to void; the absence of these signs does not exclude urethral injury. Active bleeding, hematoma, and a defect in the fibers of the 423
T. Akgül, E. Ersoy, O. Polat, et al
tunica albuginea are all characteristic of penile fractures and penetrating injuries to the corpus cavernosum. Urethral injury, which occurs in 25–40% of penetrating injuries to the penis, should be excluded in all cases [6]. Preservation of potency is a significant long-term concern in patients who have sustained a penetrating injury to the penis. Evaluation of potency rates after injury is usually difficult because of difficulty with follow-up in these patients. However, as we know from the literature, excellent functional results may be obtained after penetrating trauma to the penis [7]. Our patient was in the early age of adolescence and thus naturally we had concerns about his potency. Fortunately, the straightening of the penis was observed to be normal during erection 8 weeks after the surgery. Nevertheless, the patient will be followed-up for possible long-term potency failure. To the best of our knowledge, this is the first report of a patient with a penetrating perineal injury and corpus cavernosum injury without anterior urethral injury. In penetrating perineal traumas, such as our case, clinicians should consider a probable urethral injury. However, we should also be alert to probable
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injury of cavernosal structures in male patients with penetrating perineal trauma.
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Kiracofe HL, Pfister RR, Peterson NE. Management of non-penetrating distal urethral trauma. J Urol 1975;114: 57–62. Devine CJ Jr, Rudy DC, Horton CE. Anterior urethral injury. Etiology, diagnosis and initial management. Urol Clin North Am 1977;4:125–31. Armenakas NA, McAninch JW. Acute anterior urethral injuries: diagnosis and initial management. In: McAninch JW, ed. Traumatic and Reconstructive Urology. Philadelphia: WB Saunders, 1996:543–50. Park S, McAninch JW. Straddle injuries to the bulbar urethra: management and outcomes in 78 patients. J Urol 2004;171:722–5. Dobrowolski ZF, Weglarz W, Jakubik P, et al. Treatment of posterior and anterior urethral trauma. BJU Int 2002; 89:752–4. Rosenstein DI, Alsikafi NF. Diagnosis and classification of urethral injuries. Urol Clin North Am 2006;33:73–85. Goldman HB, Dmochowski RR, Cox CE. Penetrating trauma to the penis: functional results. J Urol 1996;155: 551–3.
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