ÖZKAN ONUK, Nusret Can ÇİLESİZ, Arif ÖZKAN, Aydın İsmet HAZAR, Burak ARSLAN, Cem Tuğrul GEZMİŞ, Memduh AYDIN

Penil fraktür ve neden olduğu üretral yaralanmaya yaklaşımımız; 10 yıllık cerrahi deneyim

AMAÇ: Penil fraktür, tunika albugineadaki ayrışma sonucu korpus kavernozumda oluşan rüptürdür. Penil fraktür genellikle şiddetli cinsel ilişki sonrası görülür. Penil fraktür olan hastaların yaklaşık olarak %10-20'sinde üretral yaralanma mevcuttur. Görüntüleme yöntemlerinden penil doppler USG (ultrasonografi), pelvik MRG (manyetik rezonans görüntüleme) ve üretranın değerlendirilmesi için retrograd üretrografi yapılabilir. Biz bu çalışmada, penil fraktürle gelen hastalarda klinik yaklaşımımızı ve özellikle üretral yaralanmalı penil fraktürlerin tanı ve tedavisinde nelere dikkat edilmesi gerektiğini sunmayı amaçladık.GEREÇ ve YÖNTEM: Kliniğimizde Ekim 2006-Mayıs 2015 tarihleri arasında penil fraktür tanısı ile tedavi edilen 71 hastanın verileri geriye dönük incelendi. Dört hastada el ile penisin bükülmesi sonucu, kalan 67 hastada (%94) ise cinsel ilişki sırasında ortaya çıkmıştır. Üretra yaralanması olan 12 (%17) hastanın hepsi cinsel ilişki sırasında olmuştur. Kesin tanı için bütün hastalara penil USG ve ayrıca measında kan olanlara retrograd üretrografi yapıldı. Hastaların hepsinde cerrahi onarım yapıldı. Tunikanın ve üretranın onarımı için 2/0 ve 4/0 emilebilir sütürler (polyglikolikasit) kullanıldı.BULGULAR: Postoperatif 3. ve 6. ayda yapılan değerlendirmede 6 hastada (%8) cinsel ilişkiye girmeye engel olmayan hafif eğrilik tespit edildi. Hastaların ortalama IIEF skoru 24,7 (16-30) olarak bulundu. Sadece 1 hastada orta derecede erektil disfonksiyon görüldü. Bu hastanın penil Doppler USG'sinde hafif derecede arteryel yetmezlik tespit edildi. Cerrahi sonrasında 6 hastada (%8) iki ay süren ağrılı ereksiyon görüldü. 2 hastada (%3) ele gelen plak mevcuttu. Hastaların 3 ünde hafif derece AÜSS saptandı. Bu hastaların ort. Qmax: 27,7 idi ve rezidüel idrar miktarı normal bulundu.SONUÇ: Penil fraktür genellikle cinsel birleşmeye bağlı oluşan acil ürolojik bir durumdur ve kısa süre içinde cerrahi onarım yapılması uzun dönem komlikasyonlarını önemli ölçüde azaltmaktadır. Penil fraktürü hastaları üretra yaralanması açısından iyi değerlendirilmelidir. Bilateral korpus kavernozum hasarı olan, external meada kan görülen ve makroskopik hematürisi olanlarda preoperatif retrograd üretrografi çekilerek üretral yaralanma araştırılmalıdır

Our approach to the penile fracture and urethral injury caused; ten years of surgical experience

OBJECTIVE: Penile fracture is a rupture in corpus cavernosum resulting from dissociation in tunica albugine. Penile fracture usually occurs after severe sexual intercourse. About 10–20% of patients with penile fracture have urethral injury. Imaging methods include penile Doppler ultrasound (USG), pelvic MRI (magnetic resonance imaging), and retrograde urethrography for urethral evaluation. In this study, we aimed to present our clinical approach to patients with penile fracture and especially what should be considered in the diagnosis and treatment of urethral injured penile fractures.MATERIAL and METHODS: We retrospectively reviewed the data of 71 patients treated with penile fracture diagnosis between October 2006May 2015. Four patients developed during manual penile flexion, the remaining 67 patients (94%) developed during sexual intercourse. Twelve (17%) patients with urethral injury were all during sexual intercourse. For definite diagnosis, all patients had penile USG, and retrograde urethrography was performed for urethrorrhagia. Surgical repair was performed in all patients. Absorbable 2/0 and 4/0 sutures (polyglycolic acid) were used for the repair of tunica and urethra.RESULTS: Six patients (8%) reported mild curvature that did not interfere with sexual intercourse. The mean IIEF score of the patients was found to be 24.7 (24–30). Only 1 patient had moderate erectile dysfunction. Mild degree of arterial insufficiency was detected in penile Doppler USG of this patient. Six patients (8%) had a painful erection for two months after surgery. There were plaques in 2 patients (3%). Mild LUTS was detected in 3 patients. Mean Qmax was 27.7; Residual urine was monitored physiologically.CONCLUSION: As a result, penile fracture is usually an urgent urological condition due to sexual intercourse. Early surgical repair significantly reduces long term complications. Penile fracture patients should be evaluated well for urethral injury. Urethral injury should be investigated by performing preoperative retrograde urethrography in patients with bilateral corpus cavernosum damage, urethrorrhagia, and macroscopic hematuria

PDF

___

1. Zargooshi J. Sexual function and tunica albuginea wound healing following penile fracture: An 18-year follow-up study of 352 patients from Kermanshah, Iran. J Sex Med 2009;6:1141–50. doi: 10.1111/j.1743-6109.2008.01117.x
2. Al-Shaiji TF, Amann J, Brock GB. Fractured penis: Diagnosis and management. J Sex Med 2009;6:3231–40. doi: 10.1111/j.1743- 6109.2009.01593.x
3. Koifman L, Barros R, Júnior RA, Cavalcanti AG, Favorito LA. Penile fracture: Diagnosis, treatment and outcomes of 150 patients. Urology 2010;76:1488–92. doi: 10.1016/j.urology.2010.05.043
4. Acikgoz A, Gokce E, Asci R, Buyukalpelli R, Yilmaz AF, Sarikaya S. Relationship between penile fracture and Peyronie’s disease: A prospective study. Int J Impot Res 2011;23:165–72. doi: 10.1038/
5. Majzoub AA, Canguven O, Raidh TA. Alteration in the etiology of penile fracture in the Middle East and Central Asia regions in the last decade; a literature review. Urol Ann 2015;7:284–8. doi: 10.4103/0974-7796.157973
6. McAninch JW, Santucci RA. Genitourinary trauma. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds. Campbell’s Urology 8th edition, Vol 4, Chapter 105. Philadelphia, PA. WB Saunders; 2002. p.3707–44.
7. Tsang T, Demby AM. Penile fracture with urethral injury. J Urol 1992;147:466–8.
8. Maubon AJ, Roux JO, Faix A, et al. Penile fracture: MRI demonstration of a urethral tear associated with a rupture of the corpus cavernosum. Eur Radiol 1998;8:469–70. doi: 10.1007/ s003300050416
9. Yapanoglu T, Aksoy Y, Adanur S, Kabadayi B, Ozturk G, Ozbey I. Seventeen years’ experience of penile fracture: Conservative vs. surgical treatment. J Sex Med 2009;6:2058–63. doi: 10.1111/j.1743-6109.2009.01296.x
10. Zargooshi J. Sexual function and tunica albuginea wound healing following penile fracture: An 18-year follow-up study of 352 patients from Kermanshah, Iran. J Sex Med 2009;6:1141–50. doi: 10.1111/j.1743-6109.2008.01117.x
11. Fetter TR, Gartman E. Traumatic rupture of penis. Case report. Am J Surg 1936;32:371–2.
12. Lynch TH, Martínez-Piñeiro L, Plas E, Serafetinides E, Türkeri L, Santucci RA, et al. EAU guidelines on urological trauma. Eur Urol 2005;47:1–15. doi: 10.1016/j.eururo.2004.07.028
13. Malis J, Zur K. Der fractura penis. Arch Klin Chir 1924;129:651.
14. Agarwal MM, Singh SK, Sharma DK, Ranjan P, Kumar S, Chandramohan V, et al. Fracture of the penis: a radiological or clinical diagnosis? A case series and literature review. Can J Urol 2009;16:4568–75.
15. Jack GS, Garraway I, Reznichek R, Rajfer J. Current treatment options for penile fractures. Rev Urol 2004;6:114–20.
16. Muentener M, Suter S, Hauri D, Sulser T. Long-term experience with surgical and conservative treatment of penile fracture. J Urol 2004;172:576–9. doi: 10.1097/01.ju.0000131594.99785.1c
17. Gamal WM, Osman MM, Hammady A, Aldahshoury MZ, Hussein MM, Saleem M. Penile fracture: long-term results of surgical and conservative management. J Trauma 2011;71:491–3.
18. Mydlo JH. Surgeon experience with penile fracture. J Urol 2001;166:526–8.
19. Mahapatra RS, Kundu AK, Pal DK. Penile Fracture: Our Experience in a Tertiary Care Hospital. World J Mens Health 2015;33:95–102.
20. Karadeniz T, Topsakal M, Ariman A, Erton H, Basak D. Penile fracture: differential diagnosis, management and outcome. Br J Urol 1996;77:279–81.
21. el-Sherif AE, Dauleh M, Allowneh N, Vijayan P. Management of fracture of the penis in Qatar. Br J Urol 1991;68:622–5.
22. 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.
23. Nane I, Tefekli A, Armagan A, Sanli O, Kadioglu A. Penile vascular abnormalities observed long-term after surgical repair of penile fractures. Int J Urol 2004;11:316–20. doi: 10.1111/j.1442- 2042.2004.00794.x
24. Phillips EA, Esposito AJ, Munarriz R. Acute penile trauma and associated morbidity: 9-year experience at a tertiary care center. Andrology 2015;3:632–6. doi: 10.1111/andr.12043
25. Ahmadnia H, Younesi Rostami M, Kamalati A, Imani MM. Penile fracture and its treatment: is retrograde urethrograghy necessary for management of penile fracture? Chin J Traumatol 2014;17:338– 40.
26. Kiliçarslan H, Gökçe G, Kaya K, Ayan S, Gültekin YE. Surgical treatment of penil fractures. Ulus Travma Acil Cerrahi Derg 2003;9:54–6.
27. Ugwu BT. Penile fracture in a developing environment. J West Afr Coll Surg 2014;4:x-xi.
28. Koifman L, Cavalcanti AG, Manes CH, R Filho D, Favorito LA. Penile fracture: experience in 56 cases. Int Braz J Urol 2003;29:35– 9