Traumatic intracorporal septal avulsion resulting in cavernous veno-occlusive dysfunction

Abstract

A 44-y-old man was evaluated for ED 4 months after an untreated penile fracture. During the initial incident, the patient felt a ‘snap’ during intromission, followed by pain, detumescence, bruising of the penile shaft, and blood at his urethral meatus. He reported penile rigidity as 5/10, with a ‘bulge’ on the dorsum of the shaft during maximal rigidity. His ED did not improve with sildenafil citrate. He denied penile curvature or pain. Physical examination revealed dorsal mid-shaft thickening of the corporal bodies without a discrete plaque of the tunica albuginea. Urinalysis and retrograde urethrogram were normal. During penile duplex doppler ultrasound with intracavernosal injection of PGE-1, he obtained 50% rigidity after self-stimulation and we made the following measurements on the right and left sides, respectively: peak systolic velocity 32.4 and 53.5 cm/s; end diastolic velocity 8.0 and 11.4 cm/s; resistive index 0.68 and 0.71. With erection, a 3 cm ballotable area on the dorsal shaft appeared. Ultrasound of this region demonstrated absence of the septal insertion into the dorsal tunica albuginea (Figure 1). Figure 1a demonstrates the normal appearance of the intracorporal septum as it inserts into the dorsal tunica in the proximal penile shaft. Dynamic infusion cavernosometry and cavernosography with injection of papaverine demonstrated a flow-to-maintain rate greater than 140 ml/min with outflow of contrast to the deep dorsal vein. We began penile reconstruction by degloving the penis, elevating the dorsal vein, and ligating it at the proximal shaft. Artificial erection demonstrated a dorsal bulge of the tunica albuginea (Figure 2a) that was incised longitudinally, confirming a 3.5 cm avulsion of septum from the dorsal tunica. We used 4.0 Maxon sutures to imbricate the dorsal tunica albuginea with reattachment to the septum. Artificial erection verified absence of the dorsal bulge and straightness of the penis without narrowing (Figure 2b). After 1 month, the patient resumed intercourse. After 1 y, he continues to have rigid erections, sufficient for intercourse, and equivalent to his baseline.