Corpus Cavernosum-Spongiosum Fistula After Blunt Pelvic Trauma: Successful Resolution with Digoxin

Abstract

Traumatic urethrocavernous communications may develop as an acute or late complication after blunt penile trauma, usually associated with penile fracture.l.2 In approximately a third of penile fractures an associated urethral injury results in urethrocorporeal communication. Urethrocavernous fistula as a late sequela of penile or perineal trauma without penile fracture has rarely been reported. Successful treatment depends on fistula size. Small fistulas appear to resolve with conservative management, while larger fistulas may require surgical repair. We report a case in which a urethrocavernous fistula secondary to blunt penile trauma with no associated penile fracture was successfully treated with oral digoxin therapy. CASE REPORT A 17-year-old man received a direct blow to the penis and pelvis with a soccer ball. Several days after the injury he noticed bleeding from the urethra only during erections. He was not sexually active and spontaneous erections were normal before the injury. The fistula did not heal spontaneously. Hematuria persisted despite oral antibiotic therapy given anecdotally due to the possibility of lower urinary tract infection and oral phenylpropanolamine given with the intention of suppressing nocturnal erections. Retrograde urethrography and cystoscopy were performed 6 weeks after the injury with the patient under general anesthesia. Urethrography showed no abnormalities and cystoscopy demonstrated a small area thought to be the source of bleeding in the bulbous urethra along the right side. This site was fulgurated with the Bugbee electrode but bleeding with erections persisted. Penile color duplex ultrasonography after injection of 20 pg. prostaglandin El revealed normal arterial flow and no fistulous process. Dynamic infusion cavernosography showed a small fistula between the corpus cavernosum and spongiosum (see figure). Digoxin therapy (0.25 mg. daily) was begun orally based on recent evidence that this drug may be associated with impotence by inhibiting va~orelaxation.~ Digoxin and serum electrolyte levels were monitored weekly. Bleeding resolved after digoxin levels became therapeutic (0.77 pg./l., therapeutic range 0.5 to 2.0). After 8 weeks of therapy bleeding ceased and repeat dynamic infusion cavernosography revealed a healed fistula. Digoxin was discontinued and there have been no further episodes of bleeding. The patient reports normal spontaneous erections. DISCUSSION Our case and that of Motiwalaz involved a urethrocavernous fistula of the penile urethra secondary to blunt penile trauma without a concomitant penile fracture. This finding is unusual. Urethrocavernous fistula as a late sequela of penile or perineal trauma without penile fracture has rarely been reported. Such fistulas are usually associated with a penile fracture. The hallmark diagnostic sign is gross hematuria with erection and diagnosis is made on retrograde urethrog