شکستگی آلت با آسیب دوطرفه اجسام غاری قطع کامل مجرا به دنبال اینترکورس مقعدی کیس ریپورت مرور مقاله

Introduction:Penile fracture (PF) is rare urological emergency condition and defined as disruption of the tunica albuginea caused by blunt trauma to erect penis [1]. For the first time, PF was reported by Abul Kasem more than 1000 years ago [1]. the most prevalent complaints of patients are abrupt cracking sound and pain which accompanied by sudden detumescence [2].Also, the common cause of (PF) are variety in western and middle eastern countries. Indeed, In Middle Eastern countries, the most common cause of penile fracture is penile manipula-tion, while in western countries, trauma to the erect penis during vaginal intercourse is re-ported to be the most common [3]. According to previous studies, the incidence of PF is per 175000. Also, unilateral corpus cavernosa injury without urethral involvement is the common pathology of PF, while bilateral corporal tears with frequency of 13.7% are very rare [4].Here we report rare case of PF with bilateral corpus cavernosa tears and complete urethral disruption caused by anal intercourse.Case Report:A 24-year-old heterosexual man who attended to the emergency department with chief complaint of pain in genitalia. He mentioned history of penile trauma at anal intercourse in backward position Due to unexpected movement of his partner. Patient and his partner heard cracking sound, which followed by pain and detumescence. The patient attempt to get an erection again, but he failed to do it. He has no use of any alcohol or narcotics. The pa-tients have no history of penile deviation or curvature or genital trauma in the past.physical examination reveals the evidence of urethral bleeding, but there was no active bleeding (Figure 1). The patient was unable to voiding. There were hematoma and deviation in the middle part of the penile shaft (Figure 1). The portable ultrasonography indicated that bladder was empty. Regarding the diagnosis of PF, The patient was immediately transferred to the operating room. Surgical approach to the penile shaft was made by circumcising incision along the circumcision scar. The skin of the penile shaft was pulled back and mobilized to complete degloving. Bilateral ventral corporeal tears and complete disruption of urethra and corpus spongiosum was found almost at the same level (Figure 2). Left and right corpus cavernosum were repaired with separate 2-0 vicryl suture, and Both sides of urethral defect were debrided. An 18Fr silicone catheter was inserted in bladder and urethra was repaired by end to end anastomosis with interrupted 4-0 vicryl suture (Figure 3).The catheter was removed ten days after surgery. Retrograde urethrography (Figure 4) was done 12 days after surgery that showed no stricture. The patient starts having sexual activity without any dysfunction after four weeks.In 12 months follow–up, the patient has no complaints of lower urinary tract symptoms with normal uroflowmetry. He has normal sexual function too.Discussion: During erection, tunica albuginea thickness is four to eight times thinner than its thickness in the flaccid state. Reduction of tunica albuginea thickness in an erect penis position resulting in PF due to blunt injury [5]. Diagnosis of PF is usually based on the history of trauma to the penis as the well as physical examinations findings. It may be necessary to do more preoperative diagnostic evaluations for some patients with an ambiguous history or examination findings [1]. As seen in our case, retention, gross hematuria, and clot at the meatus should put physician to suspected for urethral injuries.Accompanying urethral injury with the PF is rare condition, and generally, those injuries are partial. Complete disruption of the urethra with bilateral corpus cavernosa rupture is extremely rare, and it was only on 25 reports [4].To the best of our knowledge, anal intercourse as cause of PF with this extent of the injury has not been reported [2]. Urgent surgical approach is generally recommended in PF. However, some other surveys suggest conservative treatment [2].Over time in conservative approach, fibrosis formation process will be done which is associ-ated with higher chance of erectile dysfunction [8]. Furthermore; some complications such as painful erections, infected hematoma, fistulas, penile deviation, and impotence are highly related to conservative management [6]. The immediate surgical approach was recommended even 48 hours after injury [6, 9]. We also believe that PF required emergency surgery, especially in patients with evidence of urethral injury as you seen in our case.Mehmet et al. reported using commonly two surgical approaches for PF; sub-coronal de-gloving incision, and an incision right on the site of suspicious injury on the shaft [8]. We frequently use and advise de-gloving incision on circumcision scar for complicated cases which make wide exposure for the surgeon to repair bilateral tunica albuginea and even urethra, like our case. One of the limitations of our report is that we were not performed retrograde urethrography before surgery which could be helpful.PF by itself is rare, and it is challenging to manage complicated ones. We hope future studies provide more information regarding after surgery like time of onset of intercourse, the need for sexual repression, the role of psychologist and specific protocol for long-term follow-up.Conclusion:The PF usually involves unilateral corpus cavernosa without urethral involvement. We present case of massive injury to bilateral corpus cavernosum and corpus spongiosum with complete rupture of urethra due to anal intercourse, which is extremely rare. It seems that surgical approaches without wasting time as first step in these patients have graet outcome