European Society of Multimodality imaging of penile ... Penile emergencies M BERTOLOTTO.pdf ·...

AT

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18

European Society of Urogenital Radiology

2nd ESUR Teaching Course Multimodality Imaging Approach to Scrotal and Penile Pathologies

Penis - Section IX- Multimodality Imaging of Penile Pathology

Multimodality imaging of penile emergencies

Michele Bertolotto

Dept Radiology - University of Trieste (IT)

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Essentially clinical diagnosis?

Surgical management in all cases?

Imaging not indicated?

“Awareness of mode of trauma and clinical

features is all that required for diagnosis

and no more investigation is desirable.

Surgical exploration is ideal for its

management”

PENILE EMERGENCIES

Non-penetrating penile traumas

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o Do not require surgery, provided that a firm preoperative

diagnosis of intact tunica albuginea is reached

o Surgical exploration in equivocal cases

o Imaging (US, MRI) identify laceration of

the tunica albuginea


Last update: March 2018

PENILE EMERGENCIES

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Urologists’ expertise in US is often inadequate

for evaluation of penile traumas

Radiologists often are not able to provide

satisfactory and clinically targeted information

PENILE EMERGENCIES


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Flaccid or erect

Different injuries depending on firmness, mobility, deformability, and position differences

o Penile fracture

o Intracavernosal haematoma

o Isolated septal haematoma

o Extra-albugineal haematoma

o High-flow priapism

Imaging: differential diagnosis between surgical

and non-surgical lesions


PENILE EMERGENCIES

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Surgical emergency, if unrepaired, it may lead

to deformity and erectile dysfunction

Forceful bending of the erect penis

Cracking sensation and severe pain

followed by rapid detumescence

Eggplant deformity of the penis

Penile fracture

PENILE EMERGENCIES

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Imaging: differential diagnosis between

surgical and non-surgical injuries

In expert hands US as potential to detect interruption of the tunica albuginea

o High-end equipment, high-frequency broadband probes

MRI has much higher contrast resolution

o Better and easier evaluation of albugineal disruption

o More panoramic than US

PENILE EMERGENCIES

Penile fracture

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Impractical in the acute setting (especially if requested outside the normal working hours)

Often US is the only available imaging modality

*

CC * CC

Non-penetrating penile traumas - MRI

PENILE EMERGENCIES

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Penile fracture

PENILE EMERGENCIES

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Penile fracture – limitations of US

A 44yo patient experienced severe pain after accidental bending of the penis during

intercourse followed by rapid detumescence and bleeding from the urethra when he

was abroad spending his holidays. He was able to void. Eggplant deformity of the

penis rapidly developed. He presented to the emergency room of the local hospital

where he was advises to present in an hospital with dedicated expertise in this field.

He presented to our hospital 4 days after the trauma

Fracture of the penis with injury of the urethra were obvious clinically. US was requested in emergency to have a more panoramic view of the extension of the trauma before operation

PENILE EMERGENCIES

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A 4 days after the trauma the haematomas are largerly organized, and the contrast

resolution between the blood collections and the erectile bodies is markedly reduced

Diagnosis: o Ventral rupture of the right corpus cavernosus o Urethral injury not identified, but clinically obvious

PENILE EMERGENCIES

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A 4 days after the trauma the haematomas are largerly organized, and the contrast

resolution between the blood collections and the erectile bodies is markedly reduced

Diagnosis: o Ventral rupture of the right corpus cavernosus o Urethral injury not identified, but clinically obvious

At surgery: rupture of the left corpus cavernosum as well!

PENILE EMERGENCIES

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Penile fracture – associated vascular injuries

PENILE EMERGENCIES

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Difficult to identify at US

Retrograde urethrography can be done

Flexible cystoscopy is recommended above

retrograde urethrography in penile fracture with

associated suspected urethral injury


Penile fracture – Urethral injuries

Flexible cystoscopy can be performed under

anaesthesia during exploration/repair

PENILE EMERGENCIES

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*

Penile fracture – associated urethral injuries

PENILE EMERGENCIES

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Early Early 1 wk

Cavernosal haematomas

PENILE EMERGENCIES

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Recently identified trauma to the erect penis

Peyronie’s disease with septum

involvement is a predisposing factor

Can result in septal fibrosis with penile deformity

Brant WO, J Urol 2007

Isolated septal haematoma

PENILE EMERGENCIES

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Isolated septal haematoma & Peyronie’s disease

PENILE EMERGENCIES

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1

2 3

1- Skin 2- Colles’ fascia

3- Buck’s fascia

Extra-albugineal haematomas

PENILE EMERGENCIES

Below the Buck’s fascia Above the Buck’s fascia

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To confirm location

To assess the integrity of

the tunica albuginea

Extra-albugineal haematomas -US

Below the Buck’s fascia Above the Buck’s fascia

1

2 3

1- Skin 2- Colles’ fascia

3- Buck’s fascia

PENILE EMERGENCIES

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Extra-albugineal haematomas -MRI

To confirm location

To assess the integrity of the tunica albuginea

PENILE EMERGENCIES

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Ischemic (low-flow or veno-occlusive)

Stuttering High-flow

Partial (acute segmental thrombosis)

“Malignant”

Colour Doppler US: differentiate ischemic from

arterial priapism as an alternative or adjunct to

blood gas analysis (LE:2b)

MRI: controversial role. Evaluation of viability of the corpora

cavernosa and presence of fibrosis in ischemic priapism

(LE:3), and assessment of malignant priapism

Priapism - Classification

PENILE EMERGENCIES


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≥ 4h: Hypoxia, accumulation of acidic metabolic products

≥ 24h: destruction of the sinusoidal endothelium, exposure

of the basement membrane and thrombocyte adherence

≥ 48h: thrombi in the sinusoidal spaces, smooth muscle

necrosis with fibroblast-like cell transformation

Sanli O, Int J Impot Res 2004

Ul-Hasan M, J Urol 1998 Broderick GA, Int J Impot Res 1994

Juenemann KP, Urol Int 1986

≥ 12h: trabecular interstitial oedema

Ischemic Priapism

PENILE EMERGENCIES

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Clinics

Corporal aspiration of non-oxygenated blood

Imaging usually

not necessary for

the diagnosis

Low-flow priapism - diagnosis

PENILE EMERGENCIES

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Imaging: diagnostic confirmation and prognosis

Cocaine induced priapism lasting since 10 hours

Resolution following corporal aspiration and cavernosal injection

𝛼-adrenergic agonists


PENILE EMERGENCIES

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Imaging: diagnostic confirmation and prognosis


PENILE EMERGENCIES

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Similar to ischaemic priapism (low-flow)

If left untreated, can result in significant penile damage

Sickle cell disease, often idiopathic (LE:3)

Repetitive and painful episodes of prolonged erections

Erections are self-limited, with intervening periods of detumescence

The duration of the erectile episodes is

generally shorter than in ischemic priapism

The frequency and/or duration of the erectile episodes is variable. A single

episode can sometimes progress into a major ischemic priapic episode

Stuttering Priapism (intermittent or recurrent)

PENILE EMERGENCIES

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Stuttering Priapism - Imaging

No specific features (similar to normal erection)

Differentiation from arterial priapism (EAU Guidelines, March 2017)

Findings - color Doppler US

o High velocity (30-40 cm/s or more) flows are commonly found

o Velocities reduce in rigid erection

o End diastolic velocity depens on the degree of penile rigidity

o Echogenicity of the cavernosal bodies is often increased in priapism lasting >10-12h, but can be restored during the follow-up

Likely edema, not fibrosis!

PENILE EMERGENCIES

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Stuttering Priapism - Imaging

Full erection Release of erection

Early after the priapism

episode 1 wk later

PENILE EMERGENCIES

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Perineal blunt trauma producing

cavernosal artery tear

It is not an emergency

Clinics

o Painless, usually incomplete erection

o Increased rigidity with sexual stimulation

Diagnosis

o History, clinics

o Aspiration of oxigenated cavernosal blood

o Colour Doppler US

Pompei, house of Vettii

High-flow Priapism

PENILE EMERGENCIES

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Grey-scale US: identification of the injury

Colour Doppler US: identification of the cavernosal artery tear and feeding vessels, guidance to PW-Doppler interrogation

PW-Doppler: diagnosis confirmation

*

High-flow Priapism

PENILE EMERGENCIES

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Uncommon, usually unilateral, can be bilateral

Idiopathic, or associated to microtraumas o Excessive bicycling, drug abuse, haematological diseases

Presents clinically with a painful lump Involving the

crus of the corpus. Can mimic a tumour

Conservative management with use of

anticoagulation is the treatment of choice

Acute segmental thrombosis

PENILE EMERGENCIES

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T1 T2

T1-fs+Gd

PENILE EMERGENCIES

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T2 T1 T1-fs+Gd T1-FS

Subtraction

T1 T2 T1fs T1fs + Gd Subtraction


PENILE EMERGENCIES

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64yo patient with acute urinary retention and

painless penile induration involving the entire shaft.

«Malignant Priapism»

PENILE EMERGENCIES

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T1 T2 T1+ Gd

Final diagnosis: poorly

differentiated squamous cell

carcinoma with infiltrative

growth pattern likely arising

from the proximal portion of

the penile urethra

«Malignant Priapism»

PENILE EMERGENCIES

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Penile inflammation

(Cutaneous and urethral disease)

Cellulitis, abscess formation, cavernositis

Diagnosis is based on clinics. Imaging indicated in severe

inflammation to evaluate the extension of the disease

US in most of cases, MRI in equivocal cases and

when an underlying mass must be ruled-out

Abscess Cellulitis Cavernositis

PENILE EMERGENCIES

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A 79yo diabetic patient presenting with acute urinary retention and

enlarging, painless swelling of the penis from 3 days. Clinically, the

external urethral orifice was obliterated. 14,000 WBC. The patient denied

trauma. He reported on a small penile lump already present before the

onset of symptoms. MR was performed

Inflammation is present.

Are cavernosal bodies involved?

Is there an underlying tumour?

Penile inflammation

PENILE EMERGENCIES

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T2 T1-fs+Gd

Penile inflammation

PENILE EMERGENCIES

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Thank you

Lorenzo Derchi – Genova (IT)

Pietro Pavlica – Bologna (IT)

Giovanni Serafini – Pietra Ligure (IT)

…with a little help from my friends

PENILE EMERGENCIES

European Society of Multimodality imaging of penile ... Penile emergencies M BERTOLOTTO.pdf ·...

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Transcript of European Society of Multimodality imaging of penile ... Penile emergencies M BERTOLOTTO.pdf ·...