Isolated anterior urethral trauma in man after coitus: a case report
Transcrição
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. REFERENCES 1. Fergany AF, Angermeier KW, Montague DK. Review of Cleveland Clinic experience with penile fracture. Urology. 1999;54(2):352-5. Isolated anterior urethral trauma in man after coitus: a case report 505 2. Karadeniz T, Topsakal M, Ariman A, Erton H, Basak, D. Penile fracture: differential diagnosis, management and outcome. Br J Urol. 1996;77(2): 279-81 7. Beysel M, Tekin A, Gurdal M, Yucebas E, Sengor F. Evaluation and treatment of penile fractures: accuracy of clinical diagnosis and the value of corpus cavernosography. Urology. 2002;60(3):492-6. 3. McEleny K, Ramsden P, Pickard R. Penile fracture. Nat Clin Pract Urol. 2006;3(3):170-4. 8. Abolyosr A, Moneim AE, Abdelatif AM, Abdalla MA, Imam HM. The management of penile fracture based on clinical and magnetic imaging findings. BJU Int. 2005;96(3):373-7. 4. Eke N. Urological complications of coitus. BJU Int. 2002;89(3): 273-7. 5. Heng CT, Brooks AJ. Penile fracture with complete urethral rupture. Asian J Surg. 2003;26(2):126-7. 6. Mydlo, JH. Surgeon experience with penile fracture. J Urol. 2001;166(2): 526-8. 9. Mohapatra TP, Kumar S. Reverse coitus: mechanism of urethral injury in male partner. J Urol. 1990;144(6):1467-8. 10.Cheng YS, Lin JS, Lin YM. Isolated posterior urethral injury: an unusual complication and presentation following male coital trauma. Asian J Androl. 2006;8(3):379-81. einstein. 2009; 7(4 Pt 1):503-5
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