AJR 2004; 183:1085-1089
© American Roentgen Ray Society
Nonpenetrating Penile Traumas: Sonographic and Doppler Features
Michele Bertolotto1 and
Roberto Pozzi Mucelli1
1 Both authors: Department of Radiology, University of Trieste, Ospedale di
Cattinara, Strada di Fiume 449, Trieste 34149, Italy.
Received November 3, 2003;
accepted after revision January 21, 2004.
Address correspondence to M. Bertolotto.
Introduction
Injury to the penis may result from penetrating and blunt trauma or from
acute bending of the erect shaft. Subcutaneous or intracorporeal hematomas may
result or, more important, tunical disruption and urethral lesions may occur.
Different penile injuries may follow traumas to the flaccid or erect penis
because the possibility to bend, the degree of motility, and the position of
the organ are essentially different.
Sonography is the preferred imaging technique for evaluating patients with
penile trauma because it can accurately depict the normal anatomy and
delineate the nature and extent of injury. Other imaging techniques are rarely
required. Penile vasculature can be fully evaluated using Doppler
techniques.
The aim of this pictorial essay is to present the sonographic features of
penile injuries resulting from nonpenetrating traumas to the erect and to the
flaccid penis.
Nonpenetrating Traumas to the Erect Penis
Most traumas to the erect penis result from sudden bending during sexual
foreplay, intercourse, or masturbation. The main role of sonography in these
patients is to exclude albugineal tears because extratunical and cavernous
hematomas can be treated conservatively, but surgery is required when rupture
of the tunica albuginea cannot be excluded. Immediate surgical repair of an
albugineal tear markedly reduces the risk of posttraumatic curvature, lowers
the incidence of erectile dysfunction, and allows earlier resumption of sexual
activity [1].
Penile Fracture
Diagnosis of albugineal rupture is usually made from a characteristic
history of severe pain with a cracking or popping sound during acute bending
of the erect penis, followed by immediate detumescence, penile swelling, and
deformity.
Albugineal rupture is associated with urethral injury in 10–20% of
cases [1]. Penile hematoma is
confined to the shaft when the Buck's fascia is intact; otherwise, it is
contained only by the Colles' fascia, resulting in scrotal and perineal
ecchymosis with a characteristic butterfly pattern. Imaging is used to confirm
the diagnosis in patients with atypical clinical presentations or with severe
local pain or swelling that prohibits a thorough physical examination
[1–3].
Sonography can detect the exact site of the tear
(Fig. 1) as an interruption of
the thin echogenic line of the tunica albuginea
[2,
3] and show evidence of
associated hematoma. Small albugineal ruptures may be identified on color
Doppler sonography by squeezing the penile shaft and producing a blood flush
from the cavernosal bodies through the lesion. Associated urethral injuries
may be difficult to detect. Evaluation of the urethra with sonography can help
identify interruption of the urethral wall, but retrograde urethrography may
be needed [1]. In the absence
of external penetrating traumas, an indirect sign of urethral injury is the
presence of air in the cavernosal bodies (Figs.
2A and
2B).
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Fig. 1. —35-year-old man with penile fracture. Patient experienced
acute pain and sudden detumescence after hearing cracking sound during sexual
intercourse. Sagittal sonogram of injured corpus cavernosum shows albugineal
tear (arrow) as interruption of thin echogenic line of tunica
albuginea (arrowheads). Extraalbugineal hematoma (asterisk)
is also visible.
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Fig. 2A. —26-year-old man with penile fracture. During intercourse with
woman on top, penis slipped out of vagina and thrust against partner's
perineum. Patient experienced pain, loss of rigidity, and hematuria. Sagittal
sonogram at distal portion of right corpus cavernosum shows small albugineal
tear (arrow) as interruption of thin echogenic line of tunica
albuginea (arrowheads).
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Fig. 2B. —26-year-old man with penile fracture. During intercourse with
woman on top, penis slipped out of vagina and thrust against partner's
perineum. Patient experienced pain, loss of rigidity, and hematuria.
Transverse sonogram at level of albugineal tear shows presence of air
spreading from urethral lumen to corpus spongiosum (curved arrow) and
right corpus cavernosum (straight arrow).
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Traumatic Avulsion of the Dorsal Penile Vessels
These injuries can mimic penile fracture
[4,
5], but deformation and
immediate detumescence do not occur because the tunica albuginea is intact.
Rupture of small venous collaterals is more common than injury to the main
branches and usually manifests only with penile swelling and ecchymosis. In
patients with rupture of the deep dorsal vessels below an intact Buck's
fascia, the hematoma is confined to the shaft, but a "butterfly"
hematoma develops if the Buck's fascia is injured or avulsion of the
superficial dorsal vein occurs (Figs.
3A,
3B,
3C, and
3D).
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Fig. 3A. —21-year-old man with posttraumatic arteriovenous fistula
between superficial dorsal vein and dorsal artery. Patient experienced pain
and penile swelling during intercourse without loss of rigidity. Penile,
scrotal, and perineal ecchymosis developed with butterfly pattern. Transverse
sonogram of ventral aspect of penis shows extratunical hematoma spreading in
space between tunica albuginea (arrowheads) and Buck's fascia
(arrows). Hematoma spreads also in tissues surrounding superficial
dorsal vein (asterisk), which is dilated, suggesting rupture of
Buck's fascia.
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Fig. 3B. —21-year-old man with posttraumatic arteriovenous fistula
between superficial dorsal vein and dorsal artery. Patient experienced pain
and penile swelling during intercourse without loss of rigidity. Penile,
scrotal, and perineal ecchymosis developed with butterfly pattern. Oblique
color Doppler sonograms of dorsal artery (B) and superficial dorsal
vein (C) indicate high-velocity flows, suggesting posttraumatic
arteriovenous communication.
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Fig. 3C. —21-year-old man with posttraumatic arteriovenous fistula
between superficial dorsal vein and dorsal artery. Patient experienced pain
and penile swelling during intercourse without loss of rigidity. Penile,
scrotal, and perineal ecchymosis developed with butterfly pattern. Oblique
color Doppler sonograms of dorsal artery (B) and superficial dorsal
vein (C) indicate high-velocity flows, suggesting posttraumatic
arteriovenous communication.
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Fig. 3D. —21-year-old man with posttraumatic arteriovenous fistula
between superficial dorsal vein and dorsal artery. Patient experienced pain
and penile swelling during intercourse without loss of rigidity. Penile,
scrotal, and perineal ecchymosis developed with butterfly pattern. Oblique
sonogram shows 3D rendering of arteriovenous fistula between superficial
dorsal vein (asterisk) and dorsal artery (arrows).
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In general, torn veins collapse and are not visible directly on sonography.
If an arterial lesion is present, a posttraumatic arteriovenous fistula with
increased venous pressure and dilatation of the injured vessel may result.
Doppler sonography reveals low-resistance high-velocity arterial flows and
turbulent high-velocity venous flows (Figs.
3A,
3B,
3C, and
3D).
Injury to the Suspensory Ligament
This lesion can occur when the erect penis is forcibly displaced toward the
feet. The shaft remains unstable; it does not assume the normal position
during erection and tends to slip out of the vagina
[6]. Diagnosis of rupture of
the suspensory ligament is made by history and by palpation of a gap between
the base of the shaft of the penis and the symphysis pubis
[6]. An abnormal angle is noted
during erection. Imaging does not usually provide additional information.
Sonography can document the gap between the pubis and the penile shaft and
associated hematomas of the soft tissues
(Fig. 4).
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Fig. 4. —33-year-old man with rupture of suspensory ligament. Patient
experienced pain 2 days before, after partner's fall during standing
intercourse. Sonogram shows small hematoma of soft tissues (asterisk)
in gap between corpora cavernosa (CC) and pubis (P).
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Blunt Traumas to the Flaccid Penis
Most blunt traumas to the flaccid penis result in extratunical or
cavernosal hematomas with an intact tunica albuginea. Rupture of the
cavernosal arteries is rare and presents clinically with high-flow priapism.
Color Doppler sonograms can delineate the hematoma to confirm the integrity of
the tunica albuginea and to examine the penile vessels.
Extraalbugineal and Cavernosal Hematomas
Direct traumas to the genitalia may result in blood extravasation within
the subepithelial connective tissue or in the space between the Colles' fascia
and Buck's fascia (Fig. 5).
Cavernosal hematomas are often bilateral; they result from injury to the
cavernosal tissue when the base of the penile shaft is crushed against the
pelvic bones (Fig. 6).
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Fig. 5. —60-year-old man with extraalbugineal hematoma after direct
blunt trauma to flaccid penis. Patient fell overboard during powerboat race
and developed scrotal, perineal, and penile ecchymosis with butterfly
configuration. Axial sonogram obtained with probe on dorsal aspect of penis
shows hematoma between Buck's fascia (arrowhead) and Colles' fascia
(arrow).
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Fig. 6. —28-year-old man with cavernosal hematoma after indirect blunt
trauma to flaccid penis. Patient crushed base of penile shaft against gasoline
tank of his motorcycle during collision. Axial sonogram obtained with probe on
ventral aspect shows hematoma (asterisk) in right corpus
cavernosum.
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High-Flow Priapism
Patients with rupture of one or both cavernosal arteries and formation of
an arterial–lacunar fistula into the cavernous tissue develop a partial
erection that is not acutely painful
[7,
8]. Venous outflow is
maintained, preventing complete erection, stasis, and hypoxia. The patients
are able to increase penile rigidity with sexual stimulation. In patients with
high-flow priapism, color Doppler sonography is currently considered the
imaging technique of choice [8]
because it is sensitive, noninvasive, and widely available. Gray-scale
sonography depicts cavernosal tissue laceration as a hypoechoic region within
the echogenic corpus cavernosum. In this area, color Doppler sonography shows
a characteristic arterial color blush consistent with extravasation of blood
from the lacerated artery. Doppler interrogation of the fistula displays
turbulent high-velocity flows (Figs.
7A,
7B, and
7C).
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Fig. 7A. —27-year-old man with high-flow priapism. Patient crushed base
of penile shaft against gasoline tank of his motorcycle during collision.
Transverse sonograms of penis obtained with probe on ventral aspect show
anechoic region within left corpus cavernosum (asterisk, A)
with characteristic color blush that is consistent with extravasation of blood
from lacerated cavernosal artery (B).
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Fig. 7B. —27-year-old man with high-flow priapism. Patient crushed base
of penile shaft against gasoline tank of his motorcycle during collision.
Transverse sonograms of penis obtained with probe on ventral aspect show
anechoic region within left corpus cavernosum (asterisk, A)
with characteristic color blush that is consistent with extravasation of blood
from lacerated cavernosal artery (B).
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Fig. 7C. —27-year-old man with high-flow priapism. Patient crushed base
of penile shaft against gasoline tank of his motorcycle during collision.
Doppler sonogram of fistula shows turbulent high-velocity flows.
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Conclusion
Digital equipment and new broadband high-frequency probes have improved the
quality of sonography. Penile imaging has gained many benefits from the
introduction of these new technologies; in patients with penile traumas, an
excellent depiction of the tunica albuginea is obtained with better
identification of tears and other damage. Side, location, and anatomic
relationships of fluid collections can be readily identified, and increased
color Doppler sensitivity allows full evaluation of the penile vasculature and
its changes.
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Introduction
Nonpenetrating Traumas to the...
