PENILE CRURAL INJURY DUE TO PERINEAL

PENETRATING TRAUMA: A CASE REPORT

Turgay Akgül, Erim Ersoy, Osman Polat, Tolga Karakan, and Cankon Germiyanoğlu
Department of Second Urology Clinic, Ministry of Health Ankara Training and
Research Hospital, Ankara, Turkey.

Perineal traumas are rarely seen in males, and can affect the anterior urethra and corpus caver-
nosum of the penis. In this paper, we report the case of a 14-year-old boy admitted to the emer-
gency room with a pencil entering the perineum. We performed perineal exploration and
observed that the urethra was totally intact, and that the pencil had entered into the right penile
cavernosal structure.

Key Words: anterior urethra, corpus cavernosum, perineal trauma, urethra

(Kaohsiung J Med Sci 2008;24:422–4)

Perineal traumas are seen rarely in emergency condi-
tions and can be blunt or penetrating. In a male patient
with perineal injury, the probability of developing an
anterior urethral injury is greater than that of devel-
oping a posterior urethral injury [1]. Here, we report
the case of a male patient who suffered penetrating
injury due to a pencil, as a result of a friend’s joke,
without any urethral injury.
CASE PRESENTATION
A 14-year-old boy presented to the emergency room
with a foreign object stuck in his perineal region. On
physical examination, we observed 2 cm of red pencil
protruding from the central line of the perineum
through the skin (Figure 1A). There was no active
bleeding in the perineal region, and no scrotal or per-
ineal hematoma was observed. Suspicious clinical
signs suggestive of urethral injury, such as blood at the
meatus, gross hematuria and urinary retention, were
Received: Oct 12, 2007 Accepted: Dec 7, 2007
Address correspondence and reprint requests to:
Dr Turgay Akgül, 11.Sokak 18/4 Bahçelievler,
Ankara, Turkey.
E-mail: turgayakgul@gmail.com
absent. From his history, it was understood that his
condition was the result of a friend’s joke. The patient
had sat on the pencil, which was held by a friend.
Digital rectal examination revealed that the pencil had
no involvement with the rectum. Serum biochemical
and hemoglobulin parameters were within the normal
ranges. To exclude a probable urethral trauma, retro-
grade urethrography was performed. There was no
radiocontrast agent extravasation, and the urethra
was completely intact (Figure 1B).
The patient was prepared for perineal exploration
under general anesthesia. Perineal incision was per-
formed and anatomical planes were opened. The ure-
thra was found and separated from the neighboring
tissues. After dissecting the tissues, it was observed
that the pencil had invaded the right penile crus and
entered into the right corpus cavernosum (Figure 2A).
There was no defect in the neighboring vascular struc-
tures. The foreign object was taken out and measured
to be nearly 4 cm in length (Figure 2B). After removing
the pencil, active hemorrhage began from the caver-
nosal structures. The defective cavernosal structure
was repaired with 2/0 polyglactin, and the anatomical
planes were closed.
The patient was examined at 3 and 8 weeks after
the operation. During these examinations, we did not
observe or palpate any pathological formations on the
penis. Erectile function was also evaluated 8 weeks

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Perineal penetrating trauma by pencil

A B

Figure 1. (A) A pencil entering the perineum. (B) Retrograde urethrography.

A B

Figure 2. (A) View of the pencil entering the right corpus cavernosum. (B) The pencil was nearly 4 cm long.

after operation, and we observed that the straightening
of the penis during erection was absolutely normal.
DISCUSSION
Urethral trauma should be considered in patients
with perineal trauma [2]. Before an attempt at trans-
urethral catheterization, retrograde urethrography is
indicated in all cases [3]. The extravasation of con-
trast material supports a diagnosis of urethral trauma.
When a patient presents acutely after injury, one
should obtain a history of the mechanism of injury,
and of the post-injury voiding pattern. Suspicious clin-
ical signs include blood at the meatus, gross hema-
turia, perineal hematoma, urinary retention and frank
urethral extrusion through the skin [4].
Anterior urethral injuries usually occur during
urethral procedures. Blunt traumas, such as straddle
injuries, and penetrating traumas, such as gunshot or
stab wounds, can also be seen. Acute bleeding from
the urethra is the principal sign of acute anterior ure-
thral injury [5]. If there is partial dismemberment
of the urethra, and Buck’s fascia is intact, then extrav-
asation is confined within the fascia, but if the rupture
is through Buck’s fascia, then a hematoma may devel-
op in the perineum. There is usually urinary retention
and bladder distension.
Penetrating injuries to the penis have associated
injuries in up to 83% of patients. Those with associ-
ated urethral injury usually present with blood at the
urethral meatus and inability to void; the absence of
these signs does not exclude urethral injury. Active
bleeding, hematoma, and a defect in the fibers of the

Kaohsiung J Med Sci August 2008 • Vol 24 • No 8 423


T. Akgül, E. Ersoy, O. Polat, et al
tunica albuginea are all characteristic of penile frac-
tures and penetrating injuries to the corpus caver-
nosum. Urethral injury, which occurs in 25–40% of
penetrating injuries to the penis, should be excluded
in all cases [6].
Preservation of potency is a significant long-term
concern in patients who have sustained a penetrating
injury to the penis. Evaluation of potency rates after
injury is usually difficult because of difficulty with
follow-up in these patients. However, as we know
from the literature, excellent functional results may
be obtained after penetrating trauma to the penis [7].
Our patient was in the early age of adolescence and
thus naturally we had concerns about his potency.
Fortunately, the straightening of the penis was ob-
served to be normal during erection 8 weeks after the
surgery. Nevertheless, the patient will be followed-up
for possible long-term potency failure.
To the best of our knowledge, this is the first
report of a patient with a penetrating perineal injury
and corpus cavernosum injury without anterior ure-
thral injury. In penetrating perineal traumas, such as
our case, clinicians should consider a probable urethral
injury. However, we should also be alert to probable
424
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injury of cavernosal structures in male patients with
penetrating perineal trauma.
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