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Difficulty: MediumUrologic Surgery

A 28-year-old male is evaluated in the surgical triage area after experiencing sudden, severe genital pain. He reports that approximately two hours ago, during vigorous sexual intercourse, he heard a distinct 'snapping' sound from his groin, which was immediately followed by a rapid loss of erection. Since then, he has noticed progressive swelling and discoloration. His vital signs are within normal limits. Physical examination reveals a markedly edematous and ecchymotic penile shaft that is deviated to the left side. The patient states he was able to urinate normally just prior to arrival, and the urine was clear. There is no blood visible at the urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate surgical exploration and repair of the tunica albugineaAnswer
  2. B
    Retrograde urethrography to evaluate for mucosal disruption
  3. C
    Penile Doppler ultrasonography to assess cavernous blood flow
  4. D
    Application of a pressure dressing, cold compresses, and observation
  5. E
    Administration of broad-spectrum intravenous antibiotics

Answer

Immediate surgical exploration and repair of the tunica albuginea
The correct answer is immediate surgical exploration and repair. This patient presents with a classic penile fracture, which is defined as a traumatic rupture of the tunica albuginea covering one or both corpora cavernosa. It typically occurs when the erect penis is subjected to a bending force, most commonly during vigorous sexual intercourse. The classic presentation involves a snapping or popping sound, abrupt loss of erection, and significant swelling with ecchymosis (often called an 'eggplant deformity'). Because the diagnosis is primarily clinical and the patient has no signs of urethral injury (he is able to void clear urine and has no meatal blood), the most appropriate next step is immediate surgical exploration. Prompt hematoma evacuation and suturing of the tunica albuginea are required to minimize the risk of long-term complications, such as erectile dysfunction and permanent penile curvature.

Step-by-Step Solution

1
Analyze the patient's history of trauma
The patient experienced a sudden snapping sound during vigorous intercourse followed by immediate detumescence.
This specific mechanism of injury is highly characteristic of a traumatic rupture of the corpus cavernosum.
2
Evaluate the physical examination findings
The penile shaft is swollen, ecchymotic, and deviated (eggplant deformity) without signs of urethral injury (no blood at meatus, normal voiding).
These findings confirm the clinical diagnosis of a penile fracture and safely rule out concomitant urethral disruption, which would otherwise require prior imaging.
3
Determine the standard of care for the diagnosed condition
Urgent surgical intervention is indicated.
Prompt surgical repair of the tunica albuginea prevents severe long-term complications such as erectile dysfunction and penile curvature.

Key Concept

A penile fracture (rupture of the tunica albuginea) is a urologic emergency diagnosed clinically based on a history of blunt trauma to an erect penis, immediate detumescence, and an 'eggplant deformity', requiring immediate surgical repair.
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Topics

Urologic Surgery

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