A 28-year-old man comes to the emergency department due to severe penile pain and swelling… — USMLE Step 2 CK

A $28$ -year-old man comes to the emergency department due to severe penile pain and swelling. $1$ hour ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound followed immediately by a loss of erection and severe pain. He has not attempted to void since the incident. His temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $128/82\text{ mm Hg}$ , and pulse is $92/\text{min}$ . Physical examination shows a significantly swollen and ecchymotic penis that is deviated to the right side. The scrotum is normal. There is a small drop of blood visible at the urethral meatus. Which of the following is the most appropriate next step in management?

Retrograde urethrographyAnswer
B
Immediate surgical repair of the tunica albuginea
C
Insertion of a transurethral Foley catheter
D
Computed tomography scan of the pelvis without contrast
E
Color Doppler ultrasonography of the penis

Answer

Retrograde urethrography

This patient's presentation of a 'snapping' sound during vigorous intercourse, followed by immediate detumescence, severe pain, swelling, and deviation of the penis, is highly characteristic of a penile fracture. A penile fracture is defined as the traumatic rupture of the tunica albuginea surrounding the corpora cavernosa. The standard of care for an isolated penile fracture without urethral involvement is immediate surgical exploration and repair of the tunica albuginea to prevent long-term complications such as erectile dysfunction and penile curvature. However, approximately

10\%

20\%

of penile fractures are associated with a concomitant urethral injury (typically involving the corpus spongiosum). Clinical signs of a urethral injury include blood at the urethral meatus, gross hematuria, inability to void, and dysuria. When any of these signs are present, the integrity of the urethra must be evaluated with retrograde urethrography prior to surgery. This imaging modality will identify the presence and extent of the urethral tear, guiding the surgeon to repair both the tunica albuginea and the urethra simultaneously.

Step-by-Step Solution

Analyze the patient's history and physical examination findings.

The patient describes a 'snapping' sound during intercourse followed by pain, detumescence, and an ecchymotic, deviated penis.

These findings are the classic presentation of a penile fracture, which involves the rupture of the tunica albuginea.

Evaluate for signs of associated injuries.

A small drop of blood is visible at the urethral meatus.

Blood at the meatus, gross hematuria, or inability to void strongly suggests a concomitant anterior urethral injury, which occurs in up to

20\%

of penile fractures.

Determine the appropriate diagnostic or therapeutic sequence based on the suspected injuries.

Retrograde urethrography is the indicated next step.

Before proceeding to surgical repair of the tunica albuginea or attempting catheterization, the integrity of the urethra must be definitively evaluated to prevent exacerbating a partial tear.

Key Concept

Patients with a penile fracture and signs of urethral injury (e.g., blood at the meatus, gross hematuria, dysuria, or urinary retention) require retrograde urethrography prior to surgical repair to evaluate the integrity of the urethra.

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