INTRODUCTION

Traumatic occlusion of the penile artery is a rare but clinically significant condition that can lead to erectile dysfunction by reducing blood flow to the corpora cavernosa [1]. Such vascular injuries are most often associated with blunt pelvic trauma, pelvic fractures, or direct impact to the perineal region [2]. Contrast-enhanced multidetector computed tomography (MDCT) plays a key role in evaluating patients with pelvic trauma, providing visualization of the internal pudendal artery network and the penile artery [3,4]. In this case report, we describe a penile artery occlusion following a motorbike collision with pelvic trauma, resulting in arteriogenic erectile dysfunction.

CASE REPORT

A 34-year-old man was referred to the emergency department after sustaining pelvic trauma in a motorbike collision. He reported pelvic pain, and physical examination revealed scrotal and perineal swelling with a hematoma. Heart rate, respiratory rate, and oxygen saturation on room air were within normal limits. Laboratory tests showed mild anemia, with hemoglobin at 11 g/dL. The patient underwent contrast-enhanced MDCT using a multiphasic protocol, including the arteriographic phase [5]. Volume rendering (Fig. 1, Video S1) and maximum intensity projection (Fig. 2) reconstructions facilitated improved image interpretation. According to the Young and Burgess classification [6], a combined mechanism fracture pattern was identified, with pubic diastasis >25 mm, fracture of the left sacral ala (Fig. 1A), and avulsion of the left ischiatic spine (Fig. 1B). Since the patient was hemodynamically stable and no active contrast extravasation was found on contrast-enhanced MDCT, the World Society of Emergency Surgery (WSES) grade was III. Initial management included pelvic fracture stabilization with a pelvic binder, followed by external surgical fixation.

However, a posttraumatic complete occlusion of the penile artery was detected along the perineal segment of the right internal pudendal artery, immediately distal to the origin of the perineal scrotal artery (Figs. 1, 2). Although opacification of the right bulbar, cavernosal, and dorsal penile arteries was maintained through collateral vessels, there was a notable absence of homolateral bulbar and cavernosal corpora blushes compared to the left side (Figs. 1, 2). In the days following the trauma, the patient developed posttraumatic arteriogenic erectile dysfunction, with an International Index of Erectile Function score of 14. He was promptly referred to a multidisciplinary team at another hospital specializing in this condition, where a therapeutic and rehabilitative program was initiated.

Ethics statement

Informed consent for the publication of the research details and clinical images was obtained from the patient.

DISCUSSION

Pelvic trauma is a well-recognized cause of arteriogenic erectile dysfunction in young patients [7]. Early and accurate diagnosis is critical for determining the severity of vascular compromise and guiding appropriate treatment strategies. The distal internal pudendal artery, penile artery, and proximal cavernosal artery are particularly susceptible to traumatic injury—either hemorrhagic or thrombotic—due to their close anatomical relationship with the ischiopubic ramus along Alcock canal [1].

Motorbike and bicycle accidents are frequently associated with pelvic or perineal impact, often resulting in pudendal artery network involvement. Consequently, preventive measures such as using less traumatic, anatomically designed bicycle seats have been advocated to reduce the risk of vascular injury [1].

The gold standard for imaging pudendal internal artery injuries is digital subtraction angiography [8]. Selective internal pudendal arteriography offers highly detailed visualization of the penile vascular network and facilitates both diagnosis and endovascular treatment of hemorrhagic lesions [9].

Contrast-enhanced MDCT is now regarded as a comprehensive and reliable imaging technique for pelvic trauma, as it enables evaluation of all involved anatomical structures, including blood vessels [2,3]. Contrast-enhanced MDCT provides detailed, non-invasive visualization of both the penile and pelvic arterial networks, allowing detection of vascular occlusions or contrast media extravasation [10]. It may also reveal the absence of homolateral bulbar and cavernosal corpora blushes, an indirect sign of vascular occlusion that underscores the importance of evaluating the internal pudendal artery. Multiplanar reconstructions, maximum intensity projection, and three-dimensional volume rendering techniques enable clinicians to localize and assess the extent of arterial injury with greater precision [11].

Management of traumatic penile artery occlusion depends on the extent of vascular damage. In select cases, conservative treatment with pharmacological therapy may suffice. However, other situations may necessitate interventional procedures, such as placement of dedicated devices or prosthetic implants, or microvascular arterial bypass surgery [1]. Because of the significant impact of penile vascular injuries on sexual function and overall quality of life, a comprehensive, multidisciplinary approach is essential to optimize patient outcomes.

Our report aims to emphasize the role of contrast-enhanced MDCT in the early diagnosis of internal pudendal artery injury following pelvic trauma. This study presents a single case managed in the emergency department, highlighting the need for further case accumulation to expand understanding of this rare condition. A further limitation of our report is the absence of follow-up data and imaging, as the patient was transferred to another hospital with a multidisciplinary team for subsequent imaging studies (such as Doppler ultrasonography) and evaluation of optimal therapeutic strategies.

Notably, there is currently no well-established standard for the timing of erectile function assessment and imaging in the acute posttraumatic setting, particularly given the variability in expertise and resources across emergency hospital networks. To our knowledge, only a few reports in the literature have described contrast-enhanced MDCT findings in cases of acute traumatic penile artery occlusion. In this paper, we underscore the importance of thoroughly evaluating the penile artery and internal pudendal artery network on contrast-enhanced MDCT in pelvic trauma, to promptly identify arterial occlusion and absence of cavernosal blushes, thus ensuring timely referral for erectile dysfunction assessment and treatment.

SUPPLEMENTARY MATERIALS

ARTICLE INFORMATION

Author contributions

Conceptualization: FMR, FP, ST; Investigation: all authors; Methodology: FMR, TDG; Visualization: TDG, FP; Writing–original draft: FMR, TDG, FP; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Volume rendering reconstruction. (A) Pubic diastasis (asterisks) and fracture of the left sacral ala (arrows) are shown. There is a notable absence of right bulbar and cavernosal corpora blushes compared to the left side (arrowhead). (B) Avulsion of the left ischiatic spine (circle) and a complete occlusion of the penile artery (arrowhead) immediately distal to the origin of the perineal scrotal artery (asterisks) are shown. Downstream luminal opacification of the right bulbar artery is preserved (arrow); however, homolateral bulbar and cavernosal corpora blushes are absent compared to the left side (curved arrow).

Fig. 2.

Maximum intensity projection reconstruction demonstrates complete occlusion of the penile artery (arrowhead), opacification of the right bulbar artery (arrow), and absence of homolateral bulbar and cavernosal corpora blushes compared to the left side (curved arrows).

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References

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