Management of Suspected Penile Fracture with Small Tunica Spongiosa Defect
Proceed directly to surgical exploration and repair, as this patient has a confirmed tunica defect on MRI despite the small size, and surgical intervention provides superior outcomes compared to conservative management. 1
Rationale for Surgical Exploration
The presence of a 7mm tunica spongiosa defect with associated hematoma on MRI, even with normal voiding, warrants surgical intervention. Prompt surgical exploration and repair at the time of presentation is associated with significantly lower rates of erectile dysfunction and penile curvature compared to conservative management. 1 The AUA guidelines emphasize that in patients with equivocal signs and symptoms where imaging is equivocal or diagnosis remains in doubt, surgical exploration should be performed. 2
Key Clinical Considerations:
The normal ultrasound but abnormal MRI indicates MRI's superior sensitivity for detecting tunical defects, particularly smaller injuries that may be missed on ultrasound 2
Normal voiding does not exclude the need for surgery - the primary indication is the documented tunical defect, not urinary symptoms 1
The 7mm defect, though small, represents a true fracture requiring repair to prevent long-term complications including erectile dysfunction, penile curvature, and plaque formation 1, 3
Urethral Evaluation Protocol
Before proceeding to exploration, evaluate for concomitant urethral injury since you have not yet assessed this. 2, 1 The AUA guidelines mandate evaluation for urethral injury in patients with penile fracture who present with blood at the urethral meatus, gross hematuria, or inability to void. 2
Specific Steps:
Perform either retrograde urethrogram (RUG) or urethroscopy - neither method is superior, and the choice depends on equipment availability and timing 2, 1
Urethral injury occurs in 10-22% of penile fracture cases, making this evaluation critical 1
If the patient has any blood at meatus, hematuria, or voiding difficulty, urethral evaluation is mandatory 2, 1
Why NOT Cystoscopy Alone
Cystoscopy evaluates the bladder and is not the appropriate study for urethral injury in penile fracture. The correct urethral evaluation modalities are retrograde urethrogram or urethroscopy (not cystoscopy). 2, 1 Cystoscopy would miss proximal and mid-urethral injuries that commonly occur with penile fracture. 4
Surgical Approach
Once urethral injury is ruled out (or identified for concurrent repair):
Perform surgical exploration through either a circumcision/subcoronal degloving incision or local longitudinal incision based on the known defect location from MRI 3, 5
For isolated tunical defects without urethral involvement, local longitudinal incision is sufficient and associated with less morbidity, minimal influence on blood supply or lymph reflux, and lower complication rates compared to circumferential degloving 5
Repair the tunical tear with absorbable suture (typically 2-0 or 3-0) 1, 3
If urethral injury is found intraoperatively, perform concurrent urethral reconstruction with interrupted absorbable sutures over a Foley catheter 4
Common Pitfalls to Avoid
Do not pursue conservative management - even small defects benefit from surgical repair, with better long-term erectile function and lower complication rates 1, 3
Do not delay surgery - immediate repair provides the best outcomes, though even delayed cases benefit from surgical intervention 1, 3
Do not skip urethral evaluation - missing a concomitant urethral injury (which occurs in up to 22% of cases) leads to significant morbidity 1, 4
Do not rely solely on normal voiding to exclude urethral injury - partial urethral tears may still allow voiding while requiring surgical repair 4, 6