CASE REPORT Isolated Urethral Rupture Related To Sexual Intercourse in Male and Lit- erature Review Hung-Chieh Chiu,1 Chao-Hsiang Chang,1,2 Po-Fan Hsieh1* INTRODUCTION Penile fracture is defined as blunt trauma resulting in a tear of tunica albuginea surrounding the corpus caverno-sum and rapidly expanding hematoma during erection.(1) Concomitant penile fracture with urethral rupture has been reported from 10% to 20% in all penile fracture cases.(2) However, isolated urethral injury during sexual inter courseis extremely rare. In females, intercourse-related urethral injury might occur after rape, sexual abuse, Mül- lerian anomalies, or intraurethral intercourse.(3) Among males, only 5 cases have been described in the literature. (4-6) We report a patient suffering from penile trauma during sexual intercourse and urethral rupture without penile fracture as demonstrated on surgical exploration. CASE REPORT A 51-year-old heterosexual married male had penile trauma while attempting to penetrate his partner’s vagina in the missionary position. Sharp penile shaft pain developed suddenly, followed by detumescence and penile swelling. He also suffered from gross hematuria, difficulty in urination and weak stream thereafter. Initially, he did 1 Department of Urology, China Medical University Hospital, Taichung, Taiwan. 2 School of Medicine, China Medical University, Taichung, Taiwan. *Correspondence: Department of Urology, China Medical University Hospital, No. 2, Yu-Der Rd, Taichung, Taiwan. Tel: +886 4 22052121, ext 4439. Fax: +886 4 22052121, ext 6399. E-mail: phdoublem@yahoo.com.tw. Received February 2015 & Accepted November 2015 Figure 1. Ecchymosis, extended from penis to scrotum and perineum without penile deformity. Figure 2. Contrast medium extravasation at proximal penile urethra in retrograde urethrography. Vol 12 No 06 November-December 2015 2462 not take the symptoms seriously. Because of progres- sive penile shaft pain, he visited the outpatient urology clinic 3 days later. Physical examination showed flaccid and mildly swell- ing penis, as well as ecchymosis on penis, scrotum and perineum. There was some bloody discharge over ure- thral meatus. No penile deformity was observed (Fig- ure 1). Under the suspicion of penile fracture with concomitant urethral rupture, he was subjected to retrograde ure- thrography with subsequent surgical exploration. Con- trast medium extravasation at proximal penile urethra was demonstrated and flexible urethroscopy showed a urethral tear over the penobulbous junction (Figures 2 and 3). A subcoronal circumferential incision with penile de- gloving was made but there was no tunica albuginea injury surrounding the corpus cavernosum nor perituni- cal hematoma. We identified the rupture of the urethra over the penobulbous junction (Figure 4). The wound edge debridement was done and the length of rupture was measured as 1 cm. The circumferential defect in- volved up to five-sixths of the urethra. Primary anas- tomosis with 5-0 Vicryl was done, and the patient was discharged with 16 French Foley catheter on the next day. Foley catheter was removed 3 weeks later and urethral stricture was noted during follow-up. He kept regular sounding for urethral stricture in the first 4 months and then he had no more voiding difficulty. Uroflowmetry revealed fair urinary maximum flow rate (20.3 mL/s) with acceptable residual urine amount (59 mL) in the fourth month follow-up. There was no fistula for mat- ion. International Prostate Symptom Score (IPSS) was 3 (1 score in intermittency, 1 score in frequency and 1 score in weak stream), International Index of Erectile Function (IIEF) was 25 in the sixth month follow-up. DISCUSSION The classic presentation of penile fracture is a crack- ing or snap sound , followed by sharp pain, detumes- cence, penile swelling, deformation and ecchymosis.(7) Furthermore, if bloody discharge over urethral meatus or difficulty in urination occurs, concomitant urethral injury should be taken into consideration.(8) The frequency of combined penile fracture and urethral injury is variable, ranging from 0% to 3% in Asia to 20~30% in Europe and the United States.(7,8) It is be- lieved that greater force results in greater injury, and bilateral corporal injury with concomitant urethral inju- ry is more often seen compared with unilateral corporal injury. The site of urethral injury is usually the same Table. Summary of reports of isolated male urethral injury. Study Year Patient Number Site of Injury Position Mohapatra et al.3 1990 3 Fossa navicularis Reverse position De Mendonça et al.4 2009 1 Fossa navicularis Reverse position Patel et al.5 2010 1 Penobulbous junction Missionary position Present case 2015 1 Penobulbous junction Missionary position Urethral Rupture due to Sexual Intercourse-Chiu et al. Figure 3. Urethroscopy showed urethral rupture over proximal urethra. Figure 4. Proximal penile urethral injury was detected and repaired. Case Report 2463 level as corporal injury.(8,10) Isolated urethral injury without penile fracture during coitus is extremely rare. Based on the literature, only five male patients have been reported. Mohapatra and colleagues described 3 cases of fossa navicularis inju- ry on the reverse position.(4) Mendonça and colleagues reported 1 case of fossa navicularis injury on the re- verse position.(5) Patel and colleagues reported an iso- lated urethral injury over the penobulbous junction in missionary position (Table).(6) In the present case, the injury was over penobulbous junction while the patient adopted the missionary position. To the best of our knowledge, this is the sixth case of isolated male ure- thral injury in the literature. From an anatomical aspect, the hypothesis is that corpus spongiosum is overlain by the rigid tunica albuginea of the corpus caverno- sa except for the glans and bulb of the penis. At the penile base, the corpus cavernosa diverts beneath the pubis and has inserted placement into the bilateral pu- bic ramus, leaving the bulb of the penis unsupported and vulnerable. On the other hand, in the missionary position, the penis is relatively dorsiflexed with more ventral force encountered; therefore, the proximal pe- nile and bulbous urethra along with the adjacent corpus spongiosum might be injured by this ventral force, re- sulting in isolated urethral rupture. For partial urethral injury, diverting cystostomy or urethral catheterization has been described in some reports.(11) But the recent lit- erature advocates surgical treatment for penile fracture and/or urethral injury as soon as possible as this appears related to fewer complications and better outcomes.(8,12) In our case, although urethral stricture was identified in the post-operative first 4 months, there was no erectile dysfunction or fistula formation. CONCLUSIONS Physicians should remain alert to urethral injury when patients present with gross hematuria or voiding dif- ficulty after sexual intercourse, even though there is no typical feature of penile fracture. The main stream treatment for penile fracture with concomitant urethral injury or isolated urethral injury is early surgical explo- ration and repair. CONFLICT OF INTEREST None declared. REFERENCES 1. Mydlo JH, Hayyeri M, Macchia RJ. Urethrography and cavernosography imaging in a small series of penile fractures: a comparison with surgical findings. Urology. 1998;51:616-9. 2. Bertero EB, Campos RSM, Mattos Jr D. Penile fracture with urethral injury. Braz J Urol. 2000;26:295-7. 3. Zargham M, Abbasi H, Alizadeh F, et al. Intra urethral intercourse: a report of two cases. Urol J. 2014;11:1343-6. 4. Mohapatra TP, Kumar S. Reverse coitus: mechanism of urethral injury in male partner. J Urol. 1990;144:1467-8. 5. De Mendonca RR, Bicudo M C, Sakuramoto PK, Bezerra C A, PompeoA C, Wroclawski ER. Isolated anterior urethral trauma in man after coitus: a case report. Einstein. 2009; 7(4 Pt 1):503-5. 6. Patel A, Kotkin L. Isolated urethral injury after coitus-related penile trauma. 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