Isolated anterior urethral trauma in man after coitus: a case report

case report
Isolated anterior urethral trauma in man after coitus:
a case report
Trauma isolado de uretra anterior masculina após coito: relato de caso
Rafaela Rosalba de Mendonça1, Maria Claudia Bicudo2, Paulo Kouiti Sakuramoto3, Carlos Alberto Bezerra4,
Antonio Carlos Lima Pompeo5, Eric Roger Wroclawski6†
Abstract
Penile fracture with or without urethral injury after coitus presents with
severe pain and immediate penile detumescence accompanied by a
cracking sound. Hematuria or voiding difficulty are common findings
and suggest associated urethral injury. The objective of this report is
to describe an unusual complication of coital trauma diagnosed based
on clinical findings. The isolated urethral injury is rare but is one of the
causes of male coital trauma and may be suspected when patients
present urethral bleeding.
Keywords: Urethra/injuries; Coitus; Case reports
RESUMO
Fratura de pênis com ou sem lesão de uretra é a principal lesão
ocorrida durante o ato sexual e se apresenta com dor intensa, rápido
intumescimento e estalido. Hematúria ou dificuldade miccional são
sintomas incomuns, que sugerem lesão de uretra associada. O
objetivo do trabalho foi relatar essa rara complicação de lesão isolada
de uretra durante o intercurso sexual cujo diagnóstico se acha
baseado em achados clínicos. A lesão isolada de uretra, embora rara,
pode ocorrer durante o intercurso sexual e deve ser suspeitada na
presença de uretrorragia.
Descritores: Uretra/lesões; Coito; Relatos de casos
INTRODUCTION
Penile fracture with or without urethral injury is the most
common lesion that occurs during sexual intercourse.
It is presented with a snapping sound associated with
severe pain and rapid detumescence(1,2).
Gross hematuria or difficulty when voiding are
uncommon symptoms but, if present, suggest associated
urethral injury. On inspection, the penis is tender,
swollen and bruised(3). Penis deviation away from the
injury side can also be observed(4). Penile fracture is
defined as rupture of the corpus cavernosum due to
blunt trauma to the erect penis and diagnosis is usually
made based on clinical findings(3,4).
Urethral injury is associated with penile fracture in 2
to 20% of cases(3) and it is usually partial, but complete
rupture has been reported(5).
Retrograde urethrography should be performed if
urinalysis reveals blood, or when signs or symptoms of
urethral injury are present. However, urethrography
is not 100% sensitive and some false negative results
may be observed. Other imaging examinations can be
ordered but must not replace clinical assessment and
exploration(6).
If diagnosis of penile fracture is uncertain,
cavernosography and ultrasound may be required(4,7).
Magnetic resonance imaging (MRI) can give excellent
images of the penile injury, but difficulty in performing
MRI should not delay treatment(8).
Isolated urethral injury is very rare and might occur
with absence of a snapping sound, sharp pain and
detumescence(9).
CASE REPORT
A 23-year-old man was referred to hospital following a
penile injury sustained five hours before. He described
1
Resident at Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
2
Preceptor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
3
Head of the General Urology Group of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
4
Post-doctorate degree; Lecturer of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
5
Adjunct and Regent professor of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
6†
In memoriam; Post-doctorate degree; Full professor of the Department of Urology of Faculdade de Medicina do ABC – FMABC, Santo André (SP), Brazil.
Corresponding author: Rafaela Rosalba de Mendonça – Avenida Príncipe de Gales, 821 – Anexo II – Sacadura Cabral – CEP 09060-650 – Santo André (SP), Brasil – Tel.: 11 3705-1074 – e-mail:
[email protected]
Received on: June 3, 2009 – Accepted on: Oct 15, 2009
einstein. 2009; 7(4 Pt 1):503-5
504
Mendonça RR, Bicudo MC, Sakuramoto PK, Bezerra CA, Pompeo ACL, Wroclavski ER
Figure 2. Retrograde urethrography with contrast leakage in penile urethra
Figure 1. Upon physical examination, urethral bleeding and flacid penis can be
observed, with no edema or hematoma
having sexual intercourse in the reverse position (female
superior position) when, on attempting penetration, his
penis bent sharply against his partner’s thigh and he
noticed urethral bleeding and hematuria. There was no
cracking sound or penile pain, swelling or immediate
detumescence. On examination, the patient had not
tender or swollen penis (Figure 1). His bladder was
impalpable and urethral bleeding observed. Palpation of
the penis was painless. Urethrography showed a partial
anterior urethra injury in the medial portion of the penis
(Figure 2). The ultrasound showed small hematoma of
the corpus spongiosum around the urethral injury and
absence of hematoma of corpus cavernosum. The patient
was treated with vesical catheter 16 Fr for 10 days, and
was discharged after 48 hours, with advice to refrain
from sexual activity for 6 weeks. A new urethrography
showed absence of contrast leakage and normal urethra
without stricture.
DISCUSSION
Male coital injuries are often caused by unusual sexual
practices or positions, such as female superior position
(reverse). During sexual intercourse, urethral injury
einstein. 2009; 7(4 Pt 1):503-5
can occur since the urethra is on the ventral side of the
penis, which is between the male hard erection of the
corpora and the pubic symphysis or perineum of the
woman(9).
Mohapatra reported three cases of isolated urethral
injury during reverse coitus and all patients complained
of severe pain, urethral bleeding and immediate
detumescence. All lesions occurred in the fossa
navicularis, and bleeding stopped with manual penis
pressure. Although rare, isolated urethral injury is one
of the causes of male coital trauma, which may present
without the typical features of penile fracture(9).
Cheng et al. reported the case of a 29-year-old
man who was presented with a three-year history
of hematospermia and post-coital gross hematuria.
An isolated urethral injury with active bleeding was
detected during urethroscopy, and the patient was
treated with transurethral fulguration. The authors
recommend urethroscopy when the penis is tumescent
as a useful diagnostic modality for male coital trauma.
Transurethral fulguration, short-term oral estrogen
and abstinence are adequate treatment for this unique
coital-related injury. The posterior urethra, as well as
the fossa navicularis, are possibly vulnerable sites(10).
CONCLUSION
The diagnosis of penile fracture is based on clinical
findings. Isolated urethral injury is rare, but is one of
the causes of male coital trauma and may be suspected
when the patient presents with urethral bleeding.
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