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Goldman C, Shaw N, du Plessis D, Myers JB, van der Merwe A, Venkatesan K. Gunshot wounds to the penis and scrotum: a narrative review of management in civilian and military settings. Transl Androl Urol 2021; 10:2596-2608. [PMID: 34295746 PMCID: PMC8261456 DOI: 10.21037/tau-20-1175] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/08/2020] [Indexed: 11/29/2022] Open
Abstract
Gunshot wounds (GSW) to the penis and scrotum are present in two thirds of all genitourinary (GU) trauma, with a growing proportion of blast injuries in the military setting. Depending on the energy of the projectile, the injury patterns present differently for military and civilian GSWs. In this review, we sought to provide a detailed overview of GSWs to the external genitalia, from mechanisms to management. We examine how ballistic injury impacts tissues, as well as the types of injuries that occur, and how to assess these injuries to the external genitalia. If there is concern for injury to the deep structures of the penis or scrotum, operative exploration and repair is warranted. Relevant history and physical examination, role of imaging, and choice of conservative or surgical treatment options in the civilian and military setting are discussed, as well as guidelines for management set forth by the American Urological Association (AUA) and European Association of Urology (EAU).
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Affiliation(s)
- Charlotte Goldman
- Georgetown University School of Medicine, Department of Urology, Washington, DC, USA
| | - Nathan Shaw
- Georgetown University School of Medicine, Department of Urology, Washington, DC, USA
| | - Danelo du Plessis
- Division of Urology, Department of Surgical Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Andre van der Merwe
- Division of Urology, Department of Surgical Sciences, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
| | - Krishnan Venkatesan
- Georgetown University School of Medicine, Department of Urology, Washington, DC, USA.,MedStar Washington Hospital Center, Department of Urology, Washington, DC, USA
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Abstract
This article reviews the anatomy and magnetic resonance imaging (MRI) appearance of the penis. The recommended technique for MRI of the penis is outlined, with discussion of the benefits and drawbacks to imaging the penis after artificial erection. Common penile pathologies are reviewed, with a summary of their clinical features, MRI appearance, and treatment. The ability to demonstrate the erectile bodies and vasculature helps to evaluate vascular pathologies such as priapism, Mondor disease, and cavernosal thrombosis. MRI is also a useful tool to assess for traumatic abnormalities of the penis, with the depiction of soft tissue anatomy and fascial layers allowing for evaluation of penile fracture and penile contusion. Malignant disease of the penis is also reviewed, including squamous cell carcinoma, urethral carcinoma, metastases, and rare neoplasms. Staging of these neoplasms is addressed, with discussion of how MRI can be used to assess the extent of tumor involvement. MRI also clearly demonstrates the tunica albuginea, which allows for evaluation of Peyronie's disease.
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Ma M, Yu B, Qin F, Yuan J. Current approaches to the diagnosis of vascular erectile dysfunction. Transl Androl Urol 2020; 9:709-721. [PMID: 32420178 PMCID: PMC7215019 DOI: 10.21037/tau.2020.03.10] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Vascular erectile dysfunction (ED) is closely related to cardiovascular events, and early diagnosis of vascular ED may be helpful to predict the occurrence of cardiovascular events and improve prognosis. At present, there are many approaches to diagnose ED, but each method has its advantages and limitations. This study retrospectively reviewed all available literature focusing on the diagnosis of vascular ED through a systematic PubMed and EMBASE search. According to the different application scenarios, the main methods for the diagnosis of vascular ED are divided into four categories. Intra-cavernous injection of vasoactive drugs is the earliest method used in the diagnosis of vascular ED and is a basic test. For the diagnosis of arterial ED, color duplex Doppler ultrasound, selective penile angiography, magnetic resonance imaging, and computed tomography are more commonly used. While for the diagnosis of venous ED, shear wave elastography, dynamic infusion cavernosometry and cavernosography are more accurate. Endo-peripheral arterial tonometry (PAT) has also been used to detect vascular endothelial function. Although various existing examinations are widely used for the evaluation of vascular ED, they still have some shortcomings, such as invasiveness, contingency, high false positive (negative) rate. New methods of long-term dynamic detection are needed.
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Affiliation(s)
- Ming Ma
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Botao Yu
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Feng Qin
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jiuhong Yuan
- Andrology Laboratory, West China Hospital, Sichuan University, Chengdu 610041, China.,Department of Urology, West China Hospital, Sichuan University, Chengdu 610041, China
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Parenti GC, Feletti F, Carnevale A, Uccelli L, Giganti M. Imaging of the scrotum: beyond sonography. Insights Imaging 2018; 9:137-148. [PMID: 29450854 PMCID: PMC5893488 DOI: 10.1007/s13244-017-0592-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/18/2017] [Accepted: 12/27/2017] [Indexed: 01/31/2023] Open
Abstract
The aim of this article is to describe the role of second-level imaging techniques after an initial ultrasonography evaluation in the assessment of scrotal diseases. While ultrasonography remains central as the primary imaging modality for the evaluation of pathologic conditions of the scrotum, the role of magnetic resonance imaging continues to evolve: it can actually be valuable as a problem-solving tool when sonographic findings are equivocal or inconclusive. Magnetic resonance imaging of the scrotum may provide accurate detection and characterization of scrotal diseases, well depicting the precise location of scrotal masses (intratesticular or extratesticular) and reliably characterizing benign conditions simulating neoplastic processes, thus preventing unnecessary radical surgery. Advanced magnetic resonance techniques, most of all diffusion weighted imaging and magnetic resonance spectroscopy, play in the meanwhile a more significant role in evaluating scrotal diseases. TEACHING POINTS • Multiparametric ultrasonography usually represents the initial imaging modality for approaching scrotal diseases. • MRI is well established as a problem-solving tool for inconclusive sonographic findings. • Advanced MRI techniques can be successfully applied in scrotal pathology assessment. • MRI is valuable in differentiating benign conditions from neoplastic processes. • CT plays a role in trauma assessment and cancer staging alongside PET/CT.
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Affiliation(s)
- Gian Carlo Parenti
- Department of Diagnostic Imaging of Romagna, Section of Radiology, Ospedale Civile Santa Maria delle Croci, 48100, Ravenna, Italy
| | - Francesco Feletti
- Department of Diagnostic Imaging of Romagna, Section of Radiology, Ospedale Civile Santa Maria delle Croci, 48100, Ravenna, Italy
| | - Aldo Carnevale
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto 35, 44121, Ferrara, Italy.
| | - Licia Uccelli
- Department of Morphology, Surgery and Experimental Medicine, Section of Nuclear Medicine, University of Ferrara, Via Ludovico Ariosto 35, 44121, Ferrara, Italy
| | - Melchiore Giganti
- Department of Morphology, Surgery and Experimental Medicine, Section of Radiology, University of Ferrara, Via Ludovico Ariosto 35, 44121, Ferrara, Italy
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Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current Management of Penile Fracture: An Up-to-Date Systematic Review. Sex Med Rev 2017; 6:253-260. [PMID: 28874325 DOI: 10.1016/j.sxmr.2017.07.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/22/2017] [Accepted: 07/23/2017] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Because of the low incidence of penile fracture, many aspects of the diagnostic process and of the surgical and functional outcomes are rarely reported. AIM To systematically review the current literature on the surgical management of penile fracture, focusing on etiology, diagnosis, functional outcomes, and postoperative complications. METHODS The present review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) declaration standards for systematic reviews. A systematic search for the terms penile fracture, fracture of penis, trauma of penis, rupture of corpora cavernosa, and immediate management of penile fracture was been carried out in the PubMed, EMBASE, Cochrane, SCOPUS, and Science Citation Index databases. MAIN OUTCOME MEASURES Etiology of penile fracture, clinical presentation, types of radiologic investigations and their accuracy, surgical approach, suture material used for tunica repair, timing of surgical exploration, intraoperative findings, surgical complications, and functional outcomes. RESULTS The total number of patients analyzed was 438, and the patients' an average age was 36 years. The most frequent reported cause of penile fracture was sexual intercourse (80% of cases). The most common finding at examination was a penile hematoma (97.5%). Although operator dependent, in experienced hands, ultrasonography was found to be a useful tool in confirming the location of the albuginea tear and identifying the presence of any concomitant urethral injury, helping the surgeon to choose the best surgical approach. Early surgical repair of a penile fracture was found to be a safe procedure, although long-term complications are not uncommon. Tertiary referral centers that managed a larger number of cases seemed to obtain more satisfactory long-term results with a significantly smaller number of complications. CONCLUSION A low incidence of postoperative complications and full satisfactory functional outcomes are reported when early repair is performed in high-volume centers. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current Management of Penile Fracture: An Up-to-Date Systematic Review. Sex Med Rev 2018;6:253-260.
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Affiliation(s)
- Marco Falcone
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | - Giulio Garaffa
- The Institute of Urology, University College London Hospitals, London, UK
| | - Fabio Castiglione
- The Institute of Urology, University College London Hospitals, London, UK
| | - David J Ralph
- The Institute of Urology, University College London Hospitals, London, UK.
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Saglam E, Tarhan F, Hamarat MB, Can U, Coskun A, Camur E, Sarica K. Efficacy of magnetic resonance imaging for diagnosis of penile fracture: A controlled study. Investig Clin Urol 2017; 58:255-260. [PMID: 28681035 PMCID: PMC5494349 DOI: 10.4111/icu.2017.58.4.255] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/02/2017] [Indexed: 12/03/2022] Open
Abstract
Purpose To evaluate the diagnostic value of magnetic resonance imaging (MRI) in patients with suspected penile fracture. Materials and Methods A total of 122 patients admitted to our inpatient clinic with a suspicion of penile fracture following a recent history of penile trauma and who underwent surgical exploration were included this study. A thorough physical examination, a detailed medical history, description of the trauma, and preoperative International Index of Erectile Function (IIEF) scores were obtained for each patient prior to surgery. Thirty-eight of these patients were evaluated with MRI before the surgical exploration. Intraoperative findings were also recorded. Physical findings and IIEF scores were also recorded at postoperative 6 months. Results The mean age of our patient group was 36.5±12.3 years. Penile fracture was detected in 105 of 122 patients in whom surgical exploration was performed owing to a suspected diagnosis. The mean time interval from penile trauma to hospital admittance was 9.9±15.1 hours. No cavernosal defect was detected in 9 of 84 patients (10.7%) who were not evaluated with MRI prior to surgery. Compared with surgical exploration, MRI findings showed 100% (30 of 30) sensitivity and 87.5% (7 of 8) specificity in the diagnosis of penile fracture. MRI had a high negative predictive value of 100% (7 of 7) and a positive predictive value of 96.7% (30 of 31) with just 1 misdiagnosed patient. Conclusions MRI is a reliable diagnostic tool in the diagnosis of penile fractures. Compared to history and physical findings taken all together, the high sensitivity and specificity of this imaging technique can decrease the number of unnecessary surgical explorations.
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Affiliation(s)
- Erkin Saglam
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
| | - Fatih Tarhan
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
| | | | - Utku Can
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
| | - Alper Coskun
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
| | - Emre Camur
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
| | - Kemal Sarica
- Dr. Lütfi Kırdar Education and Research Hospital Urology Clinic, Istanbul, Turkey
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De Luca F, Garaffa G, Falcone M, Raheem A, Zacharakis E, Shabbir M, Aljubran A, Muneer A, Holden F, Akers C, Christopher N, Ralph DJ. Functional outcomes following immediate repair of penile fracture: a tertiary referral centre experience with 76 consecutive patients. Scand J Urol 2017; 51:170-175. [DOI: 10.1080/21681805.2017.1280532] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco De Luca
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Giulio Garaffa
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Marco Falcone
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
- Department of Urology, University of Turin, Turin, Italy
| | - Amr Raheem
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
- Department of Andrology, University of Cairo, Cairo, Egypt
| | - Evangelos Zacharakis
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Majed Shabbir
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Abdelkareem Aljubran
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
- Armed Forces Hospital of South Region, Abha, Saudi Arabia
| | - Asif Muneer
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Fiona Holden
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Claire Akers
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - Nim Christopher
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
| | - David J. Ralph
- St Peter’s Andrology Centre and the Institute of Urology, University College London Hospital (UCLH), London, UK
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8
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Xu MX, Zhou Z, Yao HJ, Zhang K, Da J, Zhang M, Wang Z, Lu MJ. Comparison of different approaches to the surgical treatment of penile fractures: quicker return to sexual function with longitudinal incisions. Int J Impot Res 2016; 28:155-9. [PMID: 27193065 DOI: 10.1038/ijir.2016.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 11/24/2015] [Accepted: 01/04/2016] [Indexed: 11/09/2022]
Abstract
The objective of this study was to compare the long-term clinical outcomes from longitudinal incisions and subcoronal circumferential degloving incisions in the surgical treatment of penile fractures. From July 2001 to July 2014, 23 patients were identified with penile fractures. Fourteen patients underwent longitudinal incisions after ultrasound localization; nine patients underwent subcoronal circumferential degloving incisions. Sexual function was evaluated preoperatively and postoperatively using an abridged International Index of Erectile Function (IIEF) questionnaire. The mean (±s.d.) operative time was 19.1 (±3.9) min in the longitudinal incision group and was 45.1 (±6.5) min in the subcoronal circumferential degloving incision group (P<0.05). The mean (±s.d.) times required to recover sexual function were 35.6 (±6.0) days in the longitudinal incision group and 54.0 (±5.8) days in the circumferential incision group (P<0.05). Six months postoperatively, the erectile functions of all cases were comparable to the level preoperatively except three patients. One patient from each group reported symptoms associated with mild ED, but they experienced satisfying sexual orgasms after psychotherapy for 2 months. Another patient's score on the IIEF-5 declined from 25 to 24 points in the circumferential incision group 10 months postoperatively, and this was associated with maintaining an erection after vaginal penetration. In conclusion, the longitudinal incision may allow quicker return to sexual function but not necessarily improved the long-term clinical outcomes. Furthermore, postoperative psychosocial nursing and psychotherapy should receive more attention.
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Affiliation(s)
- M X Xu
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Z Zhou
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - H J Yao
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - K Zhang
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - J Da
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - M Zhang
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Z Wang
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - M J Lu
- Department of Urology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Abstract
Lower genitourinary tract trauma comprises a substantial portion of the trauma burden in the USA. Some key trends and findings are described. Mortality is relatively high in patients with bladder trauma due to associated injuries. Urethral injuries should be suspected in patients presenting with the triad of blood at the urethral meatus, suprapubic fullness indicative of a full bladder, and urinary retention. Urethral injury is common in penetrating penile trauma, and stab wounds to the penis are more likely to involve the urethra than gunshot wounds. Penile fracture is largely a clinical diagnosis and suspicion of fracture requires urgent surgical exploration. Zipper injuries are the most common cause of presentation to the emergency department for penile trauma in adults. Toilet seat injuries are the leading cause of penile pediatric trauma presenting to the emergency department. In the setting of testicular trauma, rates of testicular salvage are excellent when exploration is prompt. Trauma in the form of animal or human bites requires treatment with broad-spectrum antibiotics in addition to repair of the injury. Military trauma has seen an increase in explosive injuries to the lower urinary tracts due to evolution of warfare tactics. Increasing awareness of presentation and context of lower genitourinary tract trauma can reduce delay of diagnosis and morbidity associated with such injuries.
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Affiliation(s)
- David Bayne
- Department of Urology, University of California, San Francisco, CA, USA
| | - Uwais Zaid
- Department of Urology, University of California, San Francisco, CA, USA
| | - Amjad Alwaal
- Department of Urology, University of California, San Francisco, CA, USA
| | - Catherine Harris
- Department of Urology, University of California, San Francisco, CA, USA
| | - Jack McAninch
- Department of Urology, University of California, San Francisco, CA, USA
| | - Benjamin Breyer
- Department of Urology, University of California, San Francisco, CA, USA
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