Isolated penile corporeal cavernosal injury accompanying pelvic fracture after motor vehicle accident

Abstract

Pelvic fracture is a common cause of traumatic injury of the bladder and posterior urethra; however, isolated corporal injury is rare. We present a case of pelvic fracture associated with proximal injury of the penile corpora cavernosa sparing the urethra and bladder, together with a literature review of erectile dysfunction post–pelvic fracture.

Pelvic fracture is a common cause of posterior urethral distraction injury, accompanying about 3% to 7.1% of pelvic fractures.¹ Penile corpus cavernosus injury (penile fracture) usually occurs with sudden bend of the erected penile shaft during sexual intercourse. Penile fracture requires surgical exploration and repair of the corporeal defect.² A few case reports have reported a proximal corporeal tear, with sparing of the penile shaft, associated with sexual intercourse.^3–6 We report a rare case of proximal corporal cavernosal injury associated with pelvic fracture with sparing of the urethra.

CASE DESCRIPTION

A 35-year-old morbidly obese man (body mass index, 53.9 kg/m²) presented to the emergency room with multiple injuries after a motor vehicle collision. Examination revealed marked scrotal swelling and an indwelling urethral catheter that was previously inserted draining clear urine. The patient suffered pulmonary contusions, mesenteric contusions, a femur fracture, a complex pelvic fracture with wide diastasis of pubic symphysis (Figure 1a), and a comminuted H-shaped fracture of the sacrum and coccyx.

Figure 1.

(a) X-ray showing wide diastasis of symphysis pubis with external fixation. (b) CT showing left corporeal cavernosal injury at the initial presentation. (c) Follow-up CT showing corporeal cavernosal defect with related hematoma.

Computed tomography (CT) of the pelvis revealed hematoma at the left bladder base and marked scrotal swelling. Scrotal ultrasound showed normal testes with scrotal wall hematoma. Complementary CT cystogram revealed an intact bladder with left pelvic wall hematoma with the greatest density along the left base of the penis and inferior aspect of the left pubic ramus. Left corporeal cavernosal injury was suspected based on the CT scan (Figure 1b). Conservative management of the suspected corporeal injury was the chosen approach due to the associated multiple injuries and the patient’s biplanar fixation of pelvis fractures.

Follow-up CT of the pelvis after 1 week revealed interval significant increased size of the left perineal hematoma, measuring about 16 × 21 cm, with evident disruption of the left corpus cavernosa (Figure 1c). At that time, the patient had high-grade fever with leukocytosis. The collection was successfully drained percutaneously with empirical parenteral antibiotics given. The patient showed rapid clinical improvement, and follow-up CT showed resolution of collection. No organism was isolated from the aspirated fluid culture. At 4-month follow-up, the patient had erectile dysfunction despite use of phosphodiesterase inhibitor. He declined any erectile problems before the accident.

DISCUSSION

Pelvic fracture is a common cause of morbidity in a urology practice. Posterior urethral injury and bladder injury are seen in 3% to 7.1% and 2.5% of pelvic fractures, respectively. Pubic ramus fracture, ischial ramus fracture, wide separation of symphysis pubis, and complex fractures pose a higher risk for associated urethral and bladder injury.^1,7,8

Chen et al studied erectile dysfunction after pelvic fracture and its correlation with associated ischiocavernosus muscle injury.⁷ They showed that the incidence of erectile dysfunction after pelvic fracture was 27.3%, which was irreversible in 60% of patients. Injury of the ischiocavernosus muscle, especially bilateral injury, was associated with a higher risk of erectile dysfunction.

The incidence of erectile dysfunction after pelvic fracture is highly variable in different studies. Some studies reported an incidence of 5% to 20% with pelvic fracture alone, whereas the incidence in cases with associated urethral injury increased to 42% to 62%. The risk of erectile dysfunction increases with sacroiliac fracture, wide pubic diastasis, urethral injury with long urethral gap, or prostatic displacement. Penile rehabilitation therapy using an oral phosphodiesterase-5-inhibitor has a proposed influence on improving erectile function and quality of life in these patients.^8,9

Corpus cavernosal rupture is classically seen in the erect penis with penile fracture. A few cases reported proximal deep penile fracture with tear at the penile root. To the best of our knowledge, injury of the penile corpus cavernosum with pelvic fracture has not been previously reported. No specific recommendation for management of such injury could be found. Considering the multiple associated injuries and complex pelvic fracture, the decision was to treat the injury conservatively.

In conclusion, injury of the corpus cavernosum and ischiocavernosus muscle should be considered as a potential source of perineal and pelvic hematoma–associated pelvic fracture even in the absence of an associated urethral injury. Immediate repair should be considered if the patient’s clinical situation allows it to preserve erectile function. Appropriate assessment of erectile function and an early start of penile rehabilitation therapy using phosphodiesterase-5-inhibitor should be encouraged.