Utility of contrast enhanced ultrasound (CEUS) in penile trauma
Insights into Imaging volume 14, Article number: 158 (2023)
Penile traumatic injuries are rare with potentially severe consequences, with clinical assessment challenging due to pain and swelling. Ultrasound is the primary imaging modality for assessing the penis. It has a high spatial resolution and rapid availability and is portable. Contrast enhanced ultrasound is an advanced ultrasound technique that adds real-time dynamic vascular imaging safely, increasing diagnostic precision and confidence, allowing for better therapeutic management of traumatic penile injuries. Contrast enhanced ultrasound helps to delineate the extent of a haematoma, distinguishing this from the herniated corpus cavernosum, detecting the point of rupture of the tunica albuginea, showing vascular abnormalities, localising a dislocated penis and determining penile viability. The integrity of the urethra may be assessed with intracavitary contrast enhanced ultrasound. Additionally, contrast enhanced ultrasound allows monitoring of the response to endovascular and surgical treatment. This review aims to detail the anatomy and pathogenesis of penile trauma, to give guidance on optimising the contrast enhanced ultrasound technique and to obtain diagnostic examinations. Illustration of the spectrum of aspects of penile trauma will be complemented with a literature review.
Critical relevance statement Contrast enhanced ultrasound is a safe and efficient imaging modality that allows for highly accurate diagnoses, helping achieve more successful and conservative treatments of penile trauma complications.
• Ultrasound is an accurate and safe imaging test for penile trauma.
• CEUS adds dynamic vascular imaging in real-time increasing diagnostic confidence.
• CEUS can delineate penile haematomas, locate fractures and demonstrate vessel integrity.
• CEUS potentially allows for more conservative treatment of penile trauma complications.
Penile traumatic injuries are rare emergencies with severe life-changing consequences if not managed appropriately. These injuries are often under-reported, as patients may not seek medical care for both ethical and psychological causes . A delay or an erroneous diagnosis could result in ischaemia, infarction, infection, penile atrophy, curvature and consequent infertility .
Clinical evaluation following penile trauma can be challenging due to pain and inflammation. Imaging is the basis for diagnosing traumatic penile trauma, allowing a more accurate assessment of the injuries for a more informed decision on either a surgical or a conservative management approach.
Ultrasound (US) is the primary imaging modality for the evaluation of the penis, as it is superficially located. Ultrasound has many advantages over other imaging techniques: high spatial resolution, affordable, readily available, mobile and can be carried out with no patient preparation . Contrast enhanced ultrasound (CEUS) is an advanced ultrasound technique that provides real-time dynamic vascular imaging without exposure to radiation or the need to administer iodinated contrast. The use of CEUS as an adjunct to conventional US examinations is now well-established with a growing range of clinical indications .
The aim is to review the sonographic anatomy of the penis, the spectrum of sonographic findings when evaluating penile trauma, and the value added by using CEUS.
The penis comprises two corpora cavernosa on the dorsal surface and a ventral corpus spongiosum on the midline. The cavernosal crura insert into the ischial tuberosities. The corpora cavernosa is constituted by venous sinusoids. During an erection, they are filled with blood. The tunica albuginea encloses both corpora cavernosa. The corpus spongiosum wraps the urethra and forms the glans anteriorly, which is also surrounded by its tunica albuginea. The tunica albuginea is the deepest fibrous layer and encompasses each corpus separately. The superficial fascia of Colles and the deeper fascia of Buck encircle the three corpora. The dorsal artery of the penis runs parallel to the dorsal vein and feeds the glans penis and skin. The cavernosal arteries are located in the centre of the corpus cavernosum (one in each corpus), and they are a terminal branch of the internal pudendal artery. They provide arterial flow during erection. The posterior corpus spongiosum and the urethral bulb are supplied by the bulbourethral artery. The venous supply is made by the dorsal veins, which are the deep dorsal vein (deep to the Buck fascia), and the superficial dorsal vein (above Buck’s fascia). The corpora cavernosa blood is drained through small emissary veins, which reach the cavernosal, dorsal and crural veins.
Penile traumas can be broadly classified into blunt and penetrating injuries. The penis, thanks to its consistency, mobility and location, is protected from injury. It is hence prone to injury during erection . The most frequent aetiology in the Western world is an injury during coitus . In Middle Eastern countries, cases of self-harm to stop an erection are not uncommon . Blunt trauma to a non-erect penis causing a penile fracture is extremely rare. However, it is possible to find vascular injuries due to stretching and compression, as well as intra-cavernous and extra-tunical haematomas . Association for the Surgery of Trauma (AAST) injury score aims to classify penile trauma according to its severity (Table 1) .
Sonographic anatomy of the penis 
In the axial view, the two corpora are seen as symmetrical, homogeneous round structures, enclosed by the tunica albuginea, seen as a hyperechoic thin line. The two corpora cavernosa are separated by a septum, which is part of the tunica albuginea. During an erection, the two corpora cavernosa enlarge, and the reflectivity becomes lower. The cavernosal arteries are seen on transverse images as two echogenic dots within the centre of the corpus cavernosum.
Ultrasound evaluation of penile trauma
In the case of acute penile trauma, the US examination may need to be adjusted to facilitate diagnosis and optimise the patient’s well-being . Testicular and penile injuries are commonly associated, so care should be taken in the positioning of the patient to allow for comfortable sonographic exploration of all the structures. When possible, US examination could be performed with the patient supine while holding his penis by its tip on his abdomen. Placing a supporting towel between the patient’s thighs facilitates better comparative images between the testicles by keeping them elevated and parallel . A careful US investigation using sterile gel and transducer covers must be performed in a degloving injury. The B-mode US is conducted conventionally using a linear transducer ranging between 7 and 15 MHz. Penile US should include longitudinal and transverse grey-scale and Doppler colour flow images of the entire penis. If good visualisation of the base of the penis could not be obtained, a transperineal approach with the elevation of the testes could be considered .
Contrast enhanced ultrasound
Doppler ultrasound provides information on blood flow by detecting the relative movement of red blood cells compared to the surrounding tissue. However, its capability is limited in the presence of slow flow, moving structures or low haematocrit. CEUS overcomes these limitations by administering UCAs, which are composed of microbubbles that are larger and more reflective than red blood cells, in a fixed amount that allows for increased sound reflection and a better signal .
Ultrasound contrast agents (UCA) used in CEUS examination, most commonly Lumason/SonoVueTM (Bracco SpA, Milan), are safe and importantly non-nephrotoxic; no patient preparation is needed, and no pre-examination laboratory testing is required. The phospholipid shell is metabolised by the liver, while the sulphur hexafluoride is eliminated through the lungs . Microbubbles can pass through the pulmonary circulation, remaining in circulation and potentially reaching any vessel in the body. UCA are purely intravascular because they are unable to traverse the vascular endothelium . When the microbubbles are exposed to the ultrasound beam, they resonate in a non-linear way, producing harmonics. This oscillation is best achieved at a resonance frequency of 3–5 MHz. These harmonics make it possible to separate their signal from the echoes reflected linearly by the static tissue, this linear signal being suppressible to obtain specific visualisation images of the UCA. This separation is accomplished with the pulse-inversion technique. CEUS provides information both on a macro- and microvascular level. Compared to the contrast agents currently used in computed tomography (CT) and magnetic resonance imaging (MRI), UCAs have a lower risk of adverse reactions. CEUS is also fast, mobile, cost-effective and can be safely repeatable with multiple injections [3, 11, 15].
Penile CEUS technique
We recommend performing the CEUS with a split-screen interface, with B-mode and CEUS images being shown side by side. Low mechanical index (MI) B-mode images (of sub-optimal quality compared to high MI B-mode images) are useful to localise the area of interest. Fusing a contrast-specific image with a low MI B-mode image is also possible. A CEUS examination requires intravenous access for contrast administration. Peripherally inserted 18- to 22-G IV catheters are recommended for injecting the UCA. CEUS has an excellent safety profile [11, 15]. However, there is a low incidence of anaphylactic reactions; therefore, it is advisable to ensure quick access to resuscitation equipment .
As a linear high-frequency transducer is used for penile evaluation, a higher dose of 4.8 mL of the SonoVue/Lumason (Bracco SpA, Milan) should be used for achieving optimal enhancement. This is because at higher frequencies the range of sizes of the microbubbles that resonate is less, requiring a higher MI, which results in an accelerated burst of microbubbles.
For a more comfortable examination, it is useful to have an assistant in charge of administering the ultrasound contrast. Before proceeding with the examination, make sure that the ultrasound machine is ready with the settings described above, that a peripheral venous line is placed and the assistant has one syringe of 4.8 mL of SonoVue™ (Bracco SpA Milan) as the UCA and the other with 10 mL of 0.9% normal saline, acting as the flush. At the time of the injection of the UCA by the assistant, the operator should start the timer on the ultrasound machine for recording the examination .
CEUS technique tips (adapted from )
The focus should be just deep to the target, so energy is distributed homogeneously over the imaging plane.
Before injecting the UCA, it is recommended to adjust the gain, so no microbubbles are lost due to non-visualisation when too low gain, or an excess of noise and acoustic shadowing because of signal saturation when too high gain. For reference, the image acquired before the administration of UCA should be nearly black, except for structures with high reflectivity, such as the symphysis pubis.
The dynamic range (the range of signal intensities displayed) should be wide if looking for subtle differences in enhancement, while it can remain low if we want to assess the vasculature itself, ensuring a good contrast of the vessel with the background.
For assessing fast-flowing blood, as in active bleeding, a frame rate of ≥ 10 frames per second is useful. However, it will result in a higher rate of microbubble disruption.
If the MI is set too high, there will be more bubble bursting, especially in the near field, while too low MI leads to worse visualisation of deep structures.
Video clips can be recorded for re-evaluation. This is particularly useful in complex cases.
Continuous scanning of the same area can cause bubble disruption in a very localised area, which can affect the interpretation of the images.
Sonographic findings of penile trauma
Penile haematomas can be cavernosal, septal or extra-tunical.
Cavernosal haematomas (Fig. 2)
Usually, results from injury to the sub-tunical venous plexus or smooth-muscle trabecula secondary to compression of the penis shaft against the pelvic bones [8, 17]. They are often bilateral and can be associated with penile fractures and arterial injuries with high-flow priapism.
CEUS allows a clear delineation of the borders of the haematoma, which may be obscured on B-mode imaging. If the tunica albuginea is intact, the patient can be treated conservatively.
Septal haematomas (please see Additional file 1: Fig. S1)
Injury to the erect penis can produce isolated disruption of the penile septum, resulting in a haematoma with classical characteristics on US and CEUS. Aspiration under US guidance is recommended to prevent circumscribed septal fibrosis and subsequent penile curving and shortening .
Extra-tunical haematomas (Fig. 3)
These are secondary to rupture of the dorsal penile vessels and can be either superficial or remain under Buck’s fascia, depending on the site of involvement of the penile veins. It can be associated with an arterial lesion (such as an arteriovenous fistula) or thrombosis of the superficial and deep dorsal penis veins, which is a urological surgical emergency.
The B-mode appearance of a penile haematoma varies with age. In the acute phase, a haematoma is typically hyperechoic. In chronic stages, it becomes a cystic abnormality often with septation . In the long-term, fibrosis can develop, which at US appears as an ill-defined echogenic scar .
On CEUS, a penile haematoma appears as a non-enhancing area, corresponding to the B-mode abnormality. CEUS allows a confident diagnosis and a better delineation of the haematoma . The absence of contrast extravasation improves the operators’ confidence in excluding an underlying vascular injury .
Patients with penile fractures often report hearing a cracking or popping sound at the time of injury, followed by pain and quick reduction of the erection, swelling and discolouration, resulting in the commonly described ‘aubergine deformity’. Penile fractures consist of a tear in the tunica albuginea, typically in the mid or proximal shaft. A penile rupture is considered a urological surgical emergency and requires immediate surgical exploration . In approximately 10–20% of the patients, there is also an injury to the penile urethra. It should be suspected if there is blood in the urethral meatus or in cases of bilateral cavernosal injury . A retrograde ‘intra-cavitary’ CEUS urethrogram  (Fig. 7) would be confirmatory for a urethral injury .
Ultrasound can detect the exact location and size of the disruption of the tunica albuginea, seen as a tear of the hyperechogenic line surrounding each corpus cavernosum, and herniation of the cavernosal parenchyma if present. Haematomas are commonly present at the fracture site, and in rare cases, a focus of active bleeding may be detected on CEUS [2, 8]. Preoperative US can be useful for surgical planning, allowing for more conservative surgery rather than extensive exploratory intervention [10, 21]. Ultrasound is also of great value in assessing possible complications after the surgical repair of the penile rupture .
Contrast enhanced ultrasound provides a confident evaluation of the site of rupture of the tunica albuginea when oedema and bleeding hinder visualisation on B-mode images, confirming the extent and detection of vascular complications. A tear of the tunica albuginea is shown as a non-enhancing area interrupting the linear echogenicity of the tunica .
Often a heterogeneous hyperechoic abnormality is found next to the rupture site, which raises the differential between a cavernosal parenchyma herniation or the presence of a haematoma. On CEUS, a herniated cavernosal parenchyma is depicted as an enhancing area continuous with the orthotopic cavernosal corpus, whereas a haematoma will not enhance . Moreover, with its ability to image in real time, CEUS may be able to depict active contrast extravasation, by implication active bleeding, and its origin .
In both penetrating and blunt penile traumas, an injury to a cavernosal artery can occur. This leads to intra-cavernous bleeding, with the patient presenting with high-flow priapism, typically painless. As the venous outflow is preserved, there is a much lower risk of ischaemia. Ultrasound evaluation achieves a precise diagnosis and guides focal compression, embolisation or surgery if needed.
On US, there is usually a haematoma adjacent to the cavernosal artery. When a vascular injury is present, there is an abnormal contour in the B-mode images, with wall discontinuity and/or focal outpouching if there is a pseudoaneurysm. On colour Doppler mode the classic ‘yin-yang’ appearance may be found .
On CEUS, the haematoma will appear as a non-enhancing area. CEUS allows clear visualisation of the vascular lumen and demonstrates confidently active extravasation and the presence of pseudoaneurysms .
Traumatic thrombosis of corpus cavernosum (Fig. 11)
Repetitive perineal compression, such as in bicycle users, can lead to partial thrombosis of the corpus cavernosum. Its incidence is increased in proliferative, coagulation and haematological disorders and when there is the use of drugs or medications such as tamsulosin or sildenafil. The thrombus is commonly unilateral and proximally located. The presence of a fibrous connective tissue septum at the cruro-cavernous junction has been associated with its development .
Ultrasound shows a swollen, non-compressible corpus cavernosum with the absence of vascularisation in CEUS.
Traumatic thrombosis of the dorsal veins
Thrombosis of the superficial and deep dorsal penile veins is a urological surgical emergency. It can be secondary to trauma or strenuous sexual activity. It may present clinically similar to penile fracture.
B-mode US shows a non-compressible dorsal vein without internal signal on colour Doppler US . In difficult cases, CEUS can help confirm or exclude thrombosis with the demonstration of the presence of microbubbles within the vessel lumen.
Dorsal vein rupture
These injuries can mimic penile fractures. Rupture of small venous collaterals is more common than injury to the main branches.
In most cases, torn veins are not visible directly on US as they are collapsed. It can sometimes be associated with a traumatic arteriovenous fistula, showing an alteration in the morphology of the affected vessels and the presence of pulsatility in the vein. Doppler US reveals low-resistance high-velocity arterial flows and turbulent high-velocity venous flows .
Traumatic dislocation of the penis—‘buried penis’ (Fig. 12)
Penile dislocation following pelvic trauma is very rare. It is generated by a high-energy impact on the pelvis, causing a displaced fracture with dislocation of the pubic symphysis. The retraction of the pubic bone draws on the penis by its suspensory ligament, retracting violently the penis and causing a circumferential tear around the prepuce with separation of penile skin from the shaft. The penis shaft may be displaced into the inguinal canal, scrotum or subcutaneous tissue in front of the pubis, depending on the direction of the pull. The patient may present with a suspected amputation of the penis, so the dislocation remains unnoticed [29, 30].
Ultrasound may be useful in identifying a dislocated penis. If the exploration is inconclusive, an MRI would be definitive in confirming or ruling out a penile dislocation .
CEUS may be useful to confirm the ectopic presence of penile tissue and its viability. A non-enhancing dislocated penis may be ischaemic and lead to surgery with a non-reconstructive intention.
Penile trauma is a urological emergency often underdiagnosed and can lead to severe complications, requiring rapid evaluation both clinically and by imaging. Multiparametric US is an ideal diagnostic tool in penile traumatic injuries, with high resolution, is ready availability at the patient’s bedside with a good safety profile. Contrast enhanced ultrasound provides greater diagnostic accuracy and certainty to guide the treatment of traumatic penile injuries, improving the efficacy of baseline US techniques.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.
American Association for the Surgery of Trauma
Contrast enhanced ultrasound
Magnetic resonance imaging
Ultrasound contrast agent
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We thank Dr Thamara Uyangada for providing the images and clinical outcome of one of the included figures.
No funding was received by the authors regarding the publication of this manuscript.
Ethics approval and consent to participate
All data was collected as part of routine clinical practice. The radiology reporting database was analysed for all CEUS examinations performed for penile trauma. This study was not defined as a research study according to the National Health Service (NHS) ‘defining research’ decision tool and therefore in the UK there was no requirement for a submission to be made for ethics committee approval.
Informed consent was acquired from every patient to perform a clinical CEUS study. No written informed consent was obtained to report each image in this study, as all images are anonymised.
Consent for publication
Informed written consent was not acquired from every patient, as this is a retrospective review of many different images.
PSS has received lecture fees from Bracco, Siemens, Samsung, Philips and Hitachi. DYH has received lecture fees from Bracco. The rest of the authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Fig. S1. Isolated septal haematoma. A 47-year-old patient experienced acute pain after accidental bending of the erect penis during intercourse. The penis remained rigid, but a palpable lump appeared after the erection, painful at palpation. An anechoic lesion was found at US in the cavernosal septum (arrow in a), lacking vascularisation at CEUS (arrow in b), consistent with isolated septal haematoma. Blood content is confirmed at MRI, being isointense to corpus cavernosum on T2WI (arrow in c), hyperintense on fat-saturated T1WI (arrow in d), without changes in signal on post-contrast T1WI (arrow in e) confirmed on subtraction images (arrow in f). Please note that the patient has Peyronie’s disease (unaware before the trauma), a predisposing factor for this injury.
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Gómez-Bermejo, M.A., Huang, D.Y., Bertolotto, M. et al. Utility of contrast enhanced ultrasound (CEUS) in penile trauma. Insights Imaging 14, 158 (2023). https://doi.org/10.1186/s13244-023-01499-2