FRACTURE PENIS (penile fracture)

FRACTURE online pharmacy (penile fracture)

 

Saturday night, Mbah Dukun Bagong's neighbour made conversation with mbah dukun Bagong, he asked can the penis get injury like fracture and if it can happened, what the treatment. Mbah Dukun explained fully convincing

DEFINITIONS

Fracture penis is a rupture of one or both corpora cavernosum of the penis with or without corpus spongiosum as blunt trauma in the erect penis.  This is common in sexual  hard, masturbation, or deflect the force an erect penis

.

During coitus, normal size of thickness of the tunica albuginea is 2 mm be thinned to 0.25 mm.  forcibly bending penis is very possible occurrence of rupture.  Both corpora cavernosum rupture can occur, can also rupture the corpus spongiosum which is wrapped around the urethra corpus, if this happens to make urethral rupture.



EPIDEMIOLOGY

Fracture penis is a rare urological emergency, first reported in 1924, a total of 183 reports have been published with 1331 cases since 1935 until 2001.  Over the past 8 years (1987-1995) 12 incidents of Fracture penis have been reported.  And in the years 1982-2002 have been reported 56 patients with Fracture penis.

In the year 1986-1987 reported a surgical repair in 8 cases of Fracture penis.  Malik et al in his research found the average age in 11 patients with Fracture penis is at the age of 19-56 years.  In Western countries the most common cause is sexual intercourse, whereas in the Middle East and Mediterranean countries the most common cause is masturbation.



ETIOLOGY

The most common cause fracture of the penis is trauma during coitus, other causes are masturbation, nocturnal penis manipulation did not realize or to reduce the erection, penis erection knock down with a blunt object, or penis is caught in tight pants.  Most (75%) occurred on one side, 25% on both sides, and 10% of them involving the urethra.

Generally, patients complain of Fracture penis due to coitus with a partner on top position astride the body of the penis.  When coitus penis out of the vagina and when will put back the penis hit the pubis or perineum.  All patients reported a typical crack sound ("Cracking sound") followed by loss of erection, severe pain, penis edema and discolored, and deformed penis.



PATHOPHYSIOLOGY

At the time of erection arterial blood flow to the penis, causing the corpus cavernosum and spongiosum enlarged longitudinal and transverse direction so that the penis becomes hard and its mobility is reduced, the tunica albuginea is thinner than 2 mm reach 0.5 - 0.25 mm, so easily torn if there is trauma.  The penis will swell, hematoma, pain, and bent in the opposite direction from the side of the fracture.  Hematoma is usually confined to Buck's fascia, if Buck's fascia hematoma can get involved then get to the scrotum, perineum anterior, and lower abdominal wall.



DIAGNOSIS

a.Anamnesis

Generally, patients complain of Fracture penis due to coitus with a partner on top position astride the body of the penis.  When coitus penis out of the vagina and when will put back the penis hit the pubis or perineum.  Patients hear the sound of a typical crack (cracking sound) is followed by an ever-greater pain increases, the pain spread to the lower abdomen when driven.  Patients also complained of pain during urination.

Patients complain of sudden penis swelling and increasingly expanding.  followed by loss of erection, severe pain, penis edema and discolored, and deformed penis ..



b. Physical Examination

On physical examination found penis hematoma, penis deviation, penis swelling significantly.  ecchymosis penis can occur if the buck's fascia is not intact, visible ecchymosis formation of butterfly-pattern if the fascia COLLES not intact.

The penis looks swollen and bruised.  If Buck's fascia rupture then bruises will extend to the lower abdominal wall, into the perineum and scrotum.  Pain will be felt on palpation in the area tearing of tunica albuginea.  If the urethra is damaged it will be followed by the discharge of blood through the urethra or meatus occurred hematuria microscopic.  Can also occur gross haematuria, painful urination, and urinary retention.

Sometimes patients present with a history of pain during intercourse, and swelling of the penis, but when checking on the tunica albuginea remained intact, in this case caused by hematoma due to rupture of the dorsal penis vein that required handling of simple ligation of venous rupture.

c. Additional Examination

If there is blood in the urine or if the patient complained of pain or difficulty urinating, do retrograde uretrogram to see the rupture urethra.  Agrawal et al.  (1991) recommends urethrography in all cases of Fracture penis.

Cavernosography is used intracorporeal injection of contrast to see a fracture, ultrasound is used to confirm the diagnosis is uncertain.  Magnetic resonance imaging (MRI) can accurately demonstrate the location of rupture, but this is just a very complex way to investigate a condition in which the diagnosis is generally obvious from anamensa (sounds cracked, detumesence sudden, and pain during intercourse) and clinical examination  (swelling and bruising of the penis).

In general, in the case of Fracture penis is not needed investigation, but in cases where the etiology and physical examination are not balanced, and uretrogram cavernosogram can be done.



TREATMENT and THERAPY

a) conservative

First, the management of Fracture penis with the use of conservative penis splint, cold compress, analgesic drugs, NSAIDs and absent from sexual intercourse for 6-8 weeks . This therapy slowly changed since 1986, 80% of patients following surgery Fracture penis

Jallu et.al reported 4 cases of Fracture penis that did well with conservative treatment of Oxyphenbutazone 3 x 200 mg and diazepam 10 mg orally 3 times daily for 2-3 weeks.  But many authors who advocate immediate exploration to take action.  Conservative management is indicated only for patients who are unable to receive anesthesia, no surgical facilities and surgical team, the reluctance of patients to surgery and a history of penis trauma but normal on physical examination found no abnormalities .

Operative therapy is better than conservative therapy.  In several studies have reported 10-41% of patients experienced complications with conservative management.  Other researchers reported conservative therapy provides 25-53% of complications.  Complications may include blood clot, curvatura abnormal on the penis, infection, penis abscess, persistent extravasation of urine, pain on erection and erectile dysfunction.  No postoperative complications occurred and generally does not affect sexual activity in the future.  Length of stay in hospital about 14 days compared with operative treatment - average 6.6 days.

b) Operative

Surgery is the primary choice in Fracture penis haematoma with severe clinically.

The principle of surgery consisted of open hand fractures in the tunica albuginea, evacuation of haematoma, and closing the tunica damaged.  The location of fracture can be opened by degloving the penis through an incision around the sulcus circumcision subcoronal.

As an alternative, a incisi can be made directly over the defect, with the assumption that the degree of swelling is not too big.  if there is a urethral trauma, degloving generally allow exposure to repair the urethra.  An alternative is a midline incision of the distal midline raphe scrotum to the penis along the shaft.

  Incision with degloving incision to expose both corpora cavernosum so that if any other unexpected bilateral trauma can be fixed easily.

Preoperative catheter placement remains controversial, there is suggesting as a routine action after the physical examination there was no sign - a sign of urethral injury.  Installation of the catheter facilitate intraoperative dissection without injuring the urethra and prevent postoperative wound contamination.

Exploration action with circumscibbing degloving incision and exposure of the corpus cavernosum and corpus spongiosum, followed by hematoma evacuation, and identification of tears to the tunica albuginea.  Tear in a 3-0 Vicryl suture with interruptus, leather stitched with "chromic catgut" in interuptus 3-0.

All patients treated for 5 days in good condition.  Follow-up to 6 weeks, there was no deformity of the penis, the penis can be erect with straight without pain and coitus can be done well.



 COMPLICATIONS

In several studies have reported 10-41% of patients experienced complications with conservative management.  Other researchers reported conservative therapy provides 25-53% of complications.  Complications may include blood clot, curvatura abnormal on the penis, infection, penis abscess, persistent extravasation of urine, pain on erection and erectile dysfunction.  No postoperative complications occurred and generally does not affect sexual activity in the future.



  Prognosis

Patients who were treated with conservative at high risk of complications.  No postoperative complications occurred and generally does not affect sexual activity in the future

ALK INHIBITORS FOR A SUBSET OF LUNG ADENOCARCINOMA

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January 15, 2010 (Coronado, California) —Targeted therapies, which include monoclonal antibodies and small-molecule inhibitors, are altering the treatment of cancer. A new therapy — ALK inhibitors — might soon be added to the list.

Oncogenic rearrangements of the anaplastic lymphoma kinase (ALK) gene have recently been described in nonsmall-cell lung cancer (NSCLC). Promising results from a phase 1 study, presented here at the American Association for Cancer Research-International Association for the Study of Lung Cancer Joint Conference on Molecular Origins of Lung Cancer: Prospects for Personalized Prevention and Therapy, indicate that ALK represents a new therapeutic target in this molecularly defined subset of NSCLC.

PF02341066, an oral ALK cheap cialis being developed by Pfizer, has demonstrated efficacy in ALK-positive patients. Thus far, 31 NSCLC patients with the ALK rearrangement have been enrolled in the study, and a response has been observed in 65% of this cohort.

"There are at least 12 easily identifiable oncogenes now for which there are new therapeutic agents," said Paul A. Bunn Jr., MD, professor of medicine and James Dudley chair in cancer research at the University of Colorado, Denver. "ALK is an oncogene and, in lung cancer, is activated not by mutation but by fusion with another gene."

The chromosomal rearrangements that interrupt the ALK gene and fuse it with another gene result in the creation of oncogenic ALK fusion genes. In turn, these enhance cell proliferation and survival.

"In my opinion, this drug should be approved for use worldwide, based on these data," said Dr. Bunn, who was not involved in the study. "But the [US Food and Drug Administration] has deemed that there are not enough data to approve it, so there is now a randomized trial — just starting in the United States — in which patients will be randomized to either the experimental agent or standard chemotherapy."

Dr. Bunn also noted that although PF02341066 appears to induce more responses than standard chemotherapy, it is not curative. Presumably, he surmised, patients will become resistant to it sooner or later.

Right Drug to the Right Patient

ALK is a receptor tyrosine kinase, which is normally expressed in discrete regions of the developing nervous system, and oncogenic rearrangements of ALK on the short arm of chromosome 2 were first described in anaplastic large-cell lymphomas more than 10 years ago, according to the study authors. Subsequently, they have been observed in other malignancies, including diffuse large B-cell lymphomas and malignant histiocytosis, and in several solid tumors, including inflammatory myofibroblastic tumors, squamous cell carcinomas of the esophagus, neuroblastoma and, most recently, in NSCLC.

ALK rearrangements in NSCLC are relatively rare, explained lead author D. Ross Camidge, MD, PhD, clinical director of the Thoracic Oncology Program at the University of Colorado, Denver. In an unselected NSCLC population, ALK gene rearrangements occur with a frequency of 3% to 5%.

Aside from the focus on a specific molecular target, Dr. Camidge explained, this study represents a paradigm shift in the way drugs are moved from the laboratory into human trials.

"When the right targeted agent is appropriately matched with the right target in the right patient, molecular efficacy hypotheses can now be tested effectively within first-in-human phase 1 studies," he told Medscape Oncology. "This can dramatically shorten the drug approval time by focusing on patients who may derive the most benefit from the drug."

ALK gene rearrangements occur almost exclusively in adenocarcinoma, and there doesn't seem to be any variation by ethnicity. But it is almost never seen in squamous cell or other types of lung cancer, said Dr. Camidge. In addition, light exsmokers or never-smokers appear to have significantly higher frequencies of ALK gene rearrangements.

Early Results Promising

Dr. Camidge and colleagues began the phase 1 trial in 2006, and the trial was originally focused on tumors with markers of cMET activation, one of the most common genetically altered tyrosine kinases in human cancers. However, during the dose-escalation phase, it was reported that ALK gene rearrangements also occur in NSCLC. At that time, lung cancer patients with proven ALK-gene-rearranged tumors were recruited into the study.

To date, 31 evaluable heavily pretreated NSCLC patients with ALK rearrangements have been recruited into the study, and they are continuing to enroll patients, explained Dr. Camidge. Within this cohort, there have been 19 partial responses and 1 complete response; patients remain on therapy for a median of 24 weeks.

"We have not yet reached progression-free survival," he said.

The effectiveness of PF02341066 validates oncogenic ALK rearrangements as a therapeutic target in this molecularly defined subset of NSCLC patients, and has allowed for the evaluation of PF02341066 in a randomized phase 3 setting without the need for a separate phase 2 study.

Other companies are working on ALK inhibitors, but they are further behind this one, said Dr. Bunn. "This particular drug inhibits both ALK and MET, and it was the first one developed."

Genetic Testing for Most Adenocarcinomas

Dr. Bunn pointed out that this study demonstrates that research can move quickly, given the right circumstances. "The fusion gene was first reported in lung cancer in 2007 and, in 2009, the benefit in patients was reported," he said. "Sometimes research in cancer is criticized for moving too slowly, but this is an example of something discovered in the laboratory that is benefiting patients 2 years later."

David Carbone, MD, PhD, Harold L. Moses chair in cancer research and director of the Specialized Program of Research Excellence in Lung Cancer at Vanderbilt-Ingram Cancer, in Nashville, Tennessee, emphasized the increasing importance of genetic testing. "From a wider perspective, with the knowledge of these inhibitors, we think that it is clear that most patients with adenocarcinomas of the lung should have genetic testing of their tumors done on a routine basis," he said.

"This is an extremely important point; none of these patients can be identified by clinical parameters — it is the mutations that identify these patients, and more and more of these drugs are going to become available," said Dr. Carbone, who was not involved with this study.

American Association for Cancer Research-International Association for the Study of Lung Cancer (AACR-IASLC) Joint Conference on Molecular Origins of Lung Cancer: Prospects for Personalized Prevention and Therapy: Abstract A24. Presented January 13, 2009.

Benjamin Tang for Men's Health Philippines (January 2011)

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Benjamin Tang for Men's Health Philippines (January 2011)

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