Replacement of Both Tunica and Urethra by Inner Prepucial Flap in a Neglected, Old Case of Fracture of the Penis

Abstract

The present case is a rare complication of fractured penis involving the tunica leading to a large fibrous plaque and stricture urethra because of involvement of corpus spongiosum in the plaque. The fibrous plaque in the tunica was excised and distal urethra involved in plaque was resected. An inner preputial flap was divided into 2 and used successfully to cover the resultant tunica defect and for urethral replacement with good results. KEYWOrDs: Penile fracture, Peyronie's, urethral stricture cOrrEsPONDENcE: Dr. Amilal Bhat, C-15 Sadul Ganj, Bikaner (Rajasthan), India 334003 (amilalbhat@rediffmail.com, bhatamilal@ gmail.com) cItAtION: UroToday Int J. 2013 December;6(6):art 77. http://dx.doi.org/10.3834/uij.1944-5784.2013.12.12 UroToday International Journal® ©2013 Digital Science Press, Inc. UIJ / Vol 6 / Iss 6 / December / http://dx.doi.org/10.3834/uij.1944-5784.2013.12.12 http://www.urotodayinternationaljournal.com ISSN 1944-5792 (print), ISSN 1944-5784 (online) of penile bending during sexual intercourse followed by a loss of penile erection and swelling of the penile shaft, pain, and bleeding via the urethra. Bleeding via the urethra continued for 3 consecutive nights during nocturnal tumescence. He did not come to the hospital because of shyness. The pain disappeared in about 10 days but the swelling of penile shaft persisted with loss of erection. The patient gradually developed a thin stream and ultimately started passing urine in drops. Examination revealed a swelling of 5 cm x 4 cm on the right side of the distal shaft involving the urethra (Figure 1a). The urethrogram showed almost complete loss of lumen (Figure 2) in the distal 5 centimetres of the urethra. Ultrasonography (USG) showed a large echogenic area in the distal penile shaft on the right side (Figure 2). Penile degloving was done after circumferential circumcoronal incision. The plaque, which was starting from mid penis to the corona, was identified and dissected (Figure 1b, Figure 1c, Figure 1d). The plaque was excised, including the involved urethra, resulting in a gap in the tunica of about 4 cm x 3.5 cm and urethral loss of 4 cm (figure 1d). An inner prepucial flap was raised and divided into 2 (figure 1e, Figure 1f). One flap was used to cover the defect in tunica (Figure 1g) and another was used for distal urethral replacement by tubularizing the flap over a catheter (Figure 1i, Figure 1j, Figure 1k). Pressure dressing was done after applying skin sutures. INtrODuctION Fracture of the penis is not so uncommon but involvement of the urethra in fracture of the penis is rare, and the treatment of choice is immediate surgical exploration. Untreated or conservatively treated patients heal with fibrous plaque formation with or without calcification, and such patients present with chordee, painful erections, and painful coitus or impotence. If a small segment of the urethra is involved, the resultant stricture is amenable to visual internal urethrotomy. But sometimes both the corpora and urethra are involved in a large segment of fibrous plaque, leading to a large segmental loss of the urethra. Such cases are very rare and pose problems in management. We managed 1 case of old penile fracture with large fibrous plaque involving both the tunica and distal urethra. The objective of the case report is to highlight this rare complication of fracture of the penis and difficulty in its management. PAtIENts AND MEtHODs A 42-year-old male presented with a history of poor urinary stream, impotence, and swelling in the distal half of the penis for 6 months after penile trauma. The patient gave a history UIJUroToday International Journal® ©2013 Digital Science Press, Inc. UIJ / Vol 6 / Iss 6 / December / http://dx.doi.org/10.3834/uij.1944-5784.2013.12.12 http://www.urotodayinternationaljournal.com ISSN 1944-5792 (print), ISSN 1944-5784 (online) urethrography to be unnecessary [3]. After excision of the plaque, provided the defect is small and the fibrosis isn’t deep, resuturing the tunica albuginea is a reasonable alternative. If resection of the fibrous tissue produces a big gap in the tunica rEsuLts Postoperative progress was uneventful and the patient voided in a good stream after removal of the catheter at 2 weeks. The patient reported good penile erection and sexual intercourse at 3 months, but his urinary stream was thin. The Urethrogram revealed a normal distal urethra but proximal bulbar urethral stricture (Figure 3). Visual internal urethrotomy was done for the stricture 4 months after surgery. The patient reported having sexual intercourse and voiding well when last seen at 18 months of follow-up .