Morning report

Penile
Fracture
SKDI : 3B
ICD 10 : S39.840

Aulia Oktariani CLINICAL CLERKSHIP OF SURGERY DEPARTMENT

FACULTY OF MEDICINE, UNIVERSITY OF RIAU
1908436686
ARIFIN ACHMAD GENERAL HOSPITAL
2019
 PATIENT IDENTITY

Name : Mr. SR
Medical Record : 01029165
Date of Birth : 4th June 1977 (42 y.o)
Date of Hospital Admission : 17th November 2019
Address : Sei. Guntung, Rengat.
History
Chief Complain

Pain on his penis since 18 hours before came to the hospital.

Primary Survey
AIRWAY AND C-SPINE CONTROL
Objective
Patient could answer questions and speak fluently.
Gurgling (-), snoring (-), stridor (-).

Assessment
Airway clear

Action
(-)
Primary Survey
BREATHING AND VENTILATION
Objective
patient breath spontaneously, no sign of chest wall retraction, symmetrical chest wall
movement, respiratory rate 20 times/min.

Assessment
Ventilation clear

Action
(-)
Primary Survey
CIRCULATION AND HAEMORRHAGE CONTROL
Objective Action
Heart rate: 104 bpm, regular IVFD Ringer Laktat 75 drops/minute micro
Blood pressure 147/85 mmHg drip or 18 drops/minute macro drip
Active bleeding (-)
Warm extremity
Capillary refill time (CRT) <2 sec

Assessment
Shock (-), Circulation  clear
Primary Survey

DISSABILITY
Objective Action
Glasgow coma scale (GCS) 15 (-)
Pupils were isochoric ø 2 mm/2 mm
Direct light reflex (+/+)
Indirect light reflex (+/+)
Lateralization (-)

Assessment
There is no neurological disorders
Primary Survey

EXPOSURE

Objective
T : 36,6 0C

Assessment
Hypotermia (-)

Action
Patient’s body covered to prevent hypothermia.
Secondary Survey
Mechanism of trauma
18 hours before came to the hospital, patient felt very painful after got an accident
on his penis. Patient felt his penis came to swollen and had the discolored into
blue. The accident happened when he had a sexual intercourse close to 18 hours
before with his wife. He gave a clear history of rough sexual intercourse by the
position his wife were on the top and his penis were slip out of vagina. His penile
was turn into the left side and followed a cracking sound. The history with meatal
bleeding, pain during urinate (dysuria), got the discharge from meatus were denied
by the patient. Before came into Arifin Achmad General Hospital, the patient had
came to Kasih Ibu Hospital, Rengat and they gave some examination such as
physical examination and laboratory examination and gave a pain reliever.
AMPLE
Allergy
The patient has no history of allergies
Medication
The patient not use any medicine
Past illness
There is no past illness
Last meal
12 hours before trauma
Event
Mechanism of trauma
Physical Examination
Generalist status :
 Consciousness : Composmentis cooperative
 General circumstances : Moderate illness
 Vital sign:
Weight : 64 kg
BP: 147/85 mmHg
Height : 165 cm
HR : 104 bpm
BMI : 23,5 (normoweight)
RR : 20 x/min
T : 36,6 0C
VAS : 7 (Severe pain)
Physical Examination
Head and neck : within normal limit
Thorax : within normal limit
Abdomen : within normal limit
Extremities : within normal limit
Genitourinary : local state
Localized Status : Urological Status
• Flank Area

Right Left
Trauma sign - -
Inflammation sign - -
Mass - -
Ballotement - -

• Supra pubis
Inspection : lession (-), hematoma (-), inflammation sign (-),
Palpation : mass (-), tenderness (-)
Localized Status : Urological Status
1. Penis
Size of penile: edema and look bigger
Position : deviated to the left
Preputium : circumcised
Trauma : lession (+) colored blue, hematoma (+)
Inflammation : swollen (+)
Mass : (-)
MUE : normal position
Pain : (+)
Localized Status : Urological Status
2. Skrotum
Trauma sign : lesion (-), laceration (-), hematom (-)
Inflammation sign : rubor (-), swelling (-), pain (-), discharge (-)
Mass : tumor (-), cyst (-)

3. Testis
Right Left
Availability + +
Size Normal Normal
Consistention Firm Firm
Tenderness - -
Translumination - -
Localized Status : Urological Status
4. Rectal Toucher
• External anal sphincter contraction : (+)
• Bulbocavernous reflex: (+)
• Prostat :
- interlobaris sulcus : (+)
- consistency : firm
- symmetric lobule (+)
- upper pole (-)
- pain : (-)
- nodul : (-)
Working Diagnose
Penile Fracture
Workup
• Complete blood count
• Homeostate
Complete blood count
(19-11-2019)
• Hb : 13.2 g/dL
• Ht : 38.5 %
• RBC : 4.54 x 106 /uL
• WBC : 8.380 /uL
• PT : 13.4 s
• APTT : 29.1 s
• INR : 0.94
Plan of Treatment
• Non Pharmacologic
1. IVFD Ringer Laktat 75 drops/minute micro drip or 18 drops/minute macro drip
2. Consult to Urologist!

• Pharmacologic
1. Ketorolac inj. 2 x 30 mg.
2. Omeprazole inj. 2 x 80 mg.
Pre
operative
Intra
operative
Post
operative
Final Diagnose
Penile fracture
Literature Review
Definition
• Disruption of the tunica albuginea with rupture of the corpus cavernosum
due to the trauma when erect penis.

• This is commonly occur during vigorous sexual intercourse, masturbation, and

any conditions that can cause blunt trauma to the penis.
Anatomy
of Penis
Anatomy
of Penis
Pathophysiology
• Tunica albuginea has the function to protect inside of the penis from
external trauma that can cause damage. In the condition of flaxid (not erect),
this layer is thick and does not risk to break.

• When the erect penile, the tunica albuginea is considerably thinner (<0.25
mm) than the corpora cavernosa (approximately 2 mm) and this can cause a
trauma.
Signs and Symptoms
o Acute pain
o Immediate loss of erection
o History of a snapping or cracking sound
o Ecchymosis, penile swelling and penile angulation toward the
side opposite to the injury (Aubergine sign)
o Haematuria or dysuria indicates subsequent urethral injury
Diagnose
Anamnesis

1. History with felt after immediate loss of erection.

2. History of a snapping or cracking sound.
3. Haematuria or dysuria indicates subsequent urethral
injury.
Diagnose
Physical Examination

1. Focal tenderness
2. Eggplant deformity : swelling and discoloration of the penis and penile deviation
in the contralateral side of the injury.
3. Rolling sign : palpation on the part of the hematoma that affirm and mobile.
4. Swelling on the supra pubis, scrotum and perineum.
5. Meatal bleeding with an injury to the urethra.
Diagnose
Workup

imaging
1. USG
2. MRI
3. Cavernosonography
4. Retrograde urethrography

Laboratory
5. Complete blood count
6. Urinalysis
7. Electrolytes
Differential Diagnose
1. Rupture of suspensorium ligament
2. Rupture of urethra
3. Subcutan hematoma caused by blunt trauma
Treatment
• An emergency case of urology, thus need a surgical intervention.

• Principles of surgical intervention :

1) To Evacuate of hematoma,
2) Debridement
3) To identification of place of injury, repair of a defect on tunica albuginea
4) Vascular repair
Treatment
• Non Pharmacologic
1) Cold compresses
2) Operative

• Pharmacological
1) Analgesic
2) Anti inflammatory medication
Complications
Peyronie’s disease
Erectile dysfunction
Permanent penis angulation
THANK
YOU!