奇美醫學中心 外科部 泌尿科
Straddle injury with Penile cavernosal artery pseudoaneurysm
Yu-Che Hsieh, Chia-Cheng Su, Steven K. Huang
Department of Surgery, Division of Urology, Chi Mei Medical Center, Tainan, Taiwan
A 33 years old male patient with chief complaint of perineal injury with scrotum swelling and pain since this morning. He was transferred from other hospital to our ER, Foley was inserted initially without hematuria. Bedside echography showed scrotal hematoma. Physical examination showed no high riding prostate nor rectal trauma. CT showed contrast contrast extravasation at penis corpus cavernosum and corpus sponginosum with bilateral scrotal hematoma, but without pelvic bone fracture. He was admitted thereafter.
However, the range of bruise extended to perineal area with deterioration of pain, corpus cavernosum active bleeding was suspected, we discussed with radiologist for angiography and TAE and informed the patient about sequela of erectile dysfunction after perineal trauma. Angiography showed one large pseudoaneurysm arising from cavernosal artery of left distal internal pudendal artery. Thus, superselective coil embolization was done. We followed scrotal echography, subcutaneous edema and large hematoma at scrotal wall was noted without corpus cavernosum bleeding. Urethrography showed no leakage of contrast material from the urethra. Thus, foley catheter was removed, no hematuria was noted. But dysuria, difficult voiding and urine retention were noted. Silicon Foley was re-inserted. Then, under stable condition, the patient was discharged with Foley catheter indwelling.
At follow-up OPD, scrotal hematoma subsided. Foley was removed and he could void smoothly. No erectile dysfunction was complained.
Among men under the age of 40, pelvic or perineal trauma is the most common cause of erectile dysfunction (ED). Pelvic or perineal trauma often results in arterial injury as the likely mechanism of ED.
In a study of 19 young men who suffered from ED after perineal trauma, cavernosal arterial injury was found in 37%. Therefore, arteriogenic ED is a typical presentation of men who suffer from pelvic or perineal trauma. Cavernosal arterial pseudoaneurysm most commonly results in a high flow priapism (Continuous priapism can lead to corporal fibrosis and erectile dysfunction). The management of post-traumatic, arteriogenic ED with superselective embolization is well described in the literature. Doppler ultrasound has an important role in the management of post-traumatic arteriogenic ED. After embolization of pseudoaneurysms, Doppler US is also used to evaluate the cessation of flow through embolized lesions. Previous studies have estimated preservation of erectile function after angiographic embolization to be 80% at long term follow-up.