|Year : 2016 | Volume
| Issue : 1 | Page : 35-36
Arteriovenous malformation of the distal penile urethra: A rare cause of spontaneous massive urethral bleed
Gaurav Aggarwal, Samiran Das Adhikary
Department of Urology, Apollo Hospital, Bhubaneshwar, Odisha, India
|Date of Web Publication||5-May-2016|
Department of Urology, Apollo Hospital, Bhubaneshwar - 751 001, Odisha
Source of Support: None, Conflict of Interest: None
Arteriovenous malformations (AVMs) that bleed may be a common occurrence in the human body, however, when they present at such a site, as the distalmost part of the penile urethra, they become, commonly "uncommon." In addition, the distal site also makes them liable to be missed both via imaging as well as cystoscopy. Moreover, those reported are mainly congenital or post-traumatic. Thus spontaneous bleeding AVMs are an even rarer entity, and to the best of our knowledge, this may be an index case in this regard. Thus, our case highlights the need for astute clinical skills as well as a high index of the vigil, during imaging and during introduction or removal of the cystoscope, to avoid overlooking this elusive entity.
Keywords: Arteriovenous malformation, cystoscopic electrocoagulation, distal penile urethra, massive urethral bleed
|How to cite this article:|
Aggarwal G, Adhikary SD. Arteriovenous malformation of the distal penile urethra: A rare cause of spontaneous massive urethral bleed. Saudi Surg J 2016;4:35-6
|How to cite this URL:|
Aggarwal G, Adhikary SD. Arteriovenous malformation of the distal penile urethra: A rare cause of spontaneous massive urethral bleed. Saudi Surg J [serial online] 2016 [cited 2022 Dec 3];4:35-6. Available from: https://www.saudisurgj.org/text.asp?2016/4/1/35/181813
| Introduction|| |
Arteriovenous malformations (AVMs) of the genitalia presenting as urethral bleeds are very rarely encountered and even those reported in literature are either congenital or post-traumatic.  On account of this, there are no specific guidelines to diagnose and manage these AVMs. We present the case of a spontaneously bleeding AVM, encountered at the distal penile urethra, managed adequately endourologically via electrocoagulation.
| Case Report|| |
A 55-year-old man presented to the emergency department with a 1 day history of massive urethral bleed, with no history of trauma or coitus. His physical examination was unremarkable, other than the presence of blood at the meatus.
He was immediately imaged using contrast-enhanced computed tomography scan which showed the distal site of the vascular lesion, confirmed via Doppler to be an AVM [Figure 1]a and b.
|Figure 1: (a) Contrast-enhanced computed tomography scan showing the distal penile vascular malformation. (b) Doppler confirming the arteriovenous malformation|
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The patient was managed with careful cystoscopic electro-coagulation to achieve acute control of the bleed. Postoperative period was uneventful, and he was discharged on the second postoperative day, without event.
A magnetic resonance imaging (MRI) and color Doppler confirmed sufficient local control [Figure 2]a and b and he was asymptomatic at 2 months of follow-up.
|Figure 2: (a) Magnetic resonance imaging scan at 2 months follow-up. (b) Doppler showing the decreased vascularity at 2 months follow-up|
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| Discussion|| |
AVMs of the distal penile urethra are infrequently encountered. Those reported in literature are usually congenital or post-traumatic.  AVMs per se, are notorious for massive urethral bleeding, leading to considerable anxiety as well as morbidity. 
Spontaneously bleeding AVMs are an even rarer entity, and to the best of our knowledge, this may be an index case in this regard. Due to the rarity in presentation as well as infrequent reports, there are no specific guidelines to diagnose and manage them.
Patients may present in a variety of ways, such as penile heaviness, occasional hematuria or even massive bleeds.  The diagnosis depends on clinical foresight as well as imaging modalities ranging from ultrasound and Doppler to CT Scans and MRI, with no set protocol. ,
Management strategies also vary on an individual basis, such as sclerotherapy, embolization, or surgical excision, each with their own set of pros and cons. ,, Acute local control may be achieved via cystoscopic electrocoagulation, as in our case, with a guarded prognosis as well as possibility of re-bleed and need for re-intervention. 
In addition, cystoscope introduction usually negotiates an initial few centimeters of the urethra, making it liable for these lesions to be easily missed, even via invasive strategies.
| Conclusion|| |
AVMs of the distal penile urethra are infrequently encountered. The distal site makes it extremely liable for such AVMs to be missed by both imaging as well as during introduction of the cystoscope, outlining the need for a high index of vigil even during the introduction or removal of the cystoscope to avoid missing this elusive entity.
As is aptly said - "What the mind knows is what the eyes see" is what is to be borne in mind by any astute clinician.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2]