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Question

Difficulty: HardUrologic Surgery

A 29-year-old man presents to the emergency department with acute, agonizing pain in his groin. He reports that 2 hours ago, during vigorous sexual intercourse, he heard a distinct "snapping" sound, which was immediately followed by a loss of erection and rapid swelling of his penis. He states that he has felt a strong urge to urinate since the event but has been unable to pass any urine. Vital signs are within normal limits. Physical examination reveals a markedly swollen, ecchymotic penis that is severely deviated to the right. The scrotum is unremarkable, but there is a visible drop of fresh blood at the external urethral meatus. Which of the following is the most appropriate next step in the management of this patient?

  1. Retrograde urethrographyAnswer
  2. B
    Emergent surgical exploration of the corpora cavernosa
  3. C
    Insertion of a 16-French urethral catheter
  4. D
    Color Doppler ultrasonography of the penis
  5. E
    Placement of a percutaneous suprapubic cystostomy

Answer

Retrograde urethrography
This patient's presentation of a snapping sound during intercourse followed by rapid detumescence, pain, and an ecchymotic, swollen, deviated penis (the "eggplant" deformity) is pathognomonic for a penile fracture. This condition involves the traumatic rupture of the tunica albuginea of the corpus cavernosum. While the definitive treatment for an isolated penile fracture is emergent surgical exploration and repair, this patient has signs highly concerning for a concomitant urethral injury: an inability to void and blood at the urethral meatus. Concomitant urethral injuries occur in up to 20% of penile fractures. When a urethral injury is suspected, a retrograde urethrogram (RUG) is the mandatory next step to evaluate the integrity of the urethra before any blind catheterization or surgical intervention is attempted.

Step-by-Step Solution

1
Analyze the mechanism of injury and physical exam findings.
The patient has a classic "eggplant" deformity, snapping sound, and rapid detumescence, establishing a clinical diagnosis of penile fracture (rupture of the tunica albuginea).
Recognizing the primary injury dictates the general treatment algorithm (surgical emergency).
2
Identify complicating clinical signs.
The presence of blood at the urethral meatus and an inability to void indicate a high probability of a concomitant urethral injury (occurring in up to 20% of penile fractures).
Complicating factors alter the standard management pathway and introduce absolute procedural contraindications.
3
Determine the appropriate diagnostic sequence based on the complicating signs.
Because a urethral injury is strongly suspected, a retrograde urethrogram must be performed to evaluate the urethral integrity before any blind catheterization or definitive surgical exploration is attempted.
Failing to image the urethra can lead to exacerbation of a partial tear or an unprepared surgical team during cavernosal repair.

Key Concept

In patients with a penile fracture who exhibit signs of concomitant urethral injury (e.g., blood at the meatus, gross hematuria, urinary retention), a retrograde urethrogram is the mandatory next step prior to surgical exploration.
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Topics

Urologic Surgery

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