https://orcid.org/0009-0000-6595-5586
Abstract
Partial segmental thrombosis of the corpus cavernosum (PSTCC) is a rare urological condition presenting as localized perineal pain and asymmetric corporal swelling. We report a 27-year-old male with subacute penile pain and decreased erectile rigidity following a prolonged erection. The patient had a contrast-enhanced computed tomography (CT) scan showing asymmetrical enlargement with thrombus of the left corpus cavernosum. He was managed conservatively with rivaroxaban and referred for thrombophilia testing, which returned negative. While magnetic resonance imaging is the gold standard for diagnosing PSTCC, this case demonstrates that contrast-enhanced CT can serve as an effective diagnostic tool in the acute setting, supporting a non-invasive diagnostic and treatment approach.
Introduction
Partial segmental thrombosis of the corpus cavernosum (PSTCC) is an extremely rare urological condition that predominantly affects young men [1]. The condition was initially described as ‘partial priapism’ by Gottesman et al. in 1976; it is described as the same entity as partial thrombosis of corpus cavernosum [2]. Priapism, characterized by a persistent and painful penile erection, must be distinguished from isolated thrombosis of corpus cavernosum [3]. PSTCC involves thrombosis of the proximal segment of the corpus cavernosum, in contrast to classical ischemic priapism, which primarily affects the distal portion [4]. Although the underlying mechanism has not been definitively established, several precipitating factors have been proposed, including blunt perineal trauma, hematological disorders, recreational drug use such as cocaine or marijuana, and pharmacologic agents including tamsulosin and sildenafil. Repetitive mechanical stress during sexual intercourse or prolonged cycling may also contribute to thrombus formation [5, 6]. Clinical manifestations commonly include a tender, palpable perineal mass accompanied by varying degrees of erectile dysfunction [4, 7]. Furthermore, imaging plays a central role in diagnosis. Ultrasonography typically shows asymmetric enlargement of the involved corpus cavernosum containing heterogeneous material and lacking vascularization on color Doppler study. Correspondingly, magnetic resonance imaging (MRI) reveals cavernosal expansion with signal alterations compatible with thrombus formation [7]. Management is preferably conservative and typically includes systemic anticoagulation and adequate analgesia. Surgical intervention should be considered only in cases of persistent or refractory pain, development of erectile dysfunction, or recurrence despite appropriate medical therapy [7, 8].
Case presentation
A 27-year-old male presented to the emergency department with a 1-month history of penile pain radiating to the left thigh. The symptoms began following an episode of prolonged erection lasting ˃4 h, which resolved spontaneously without medical intervention. Subsequently, the patient experienced recurrent episodes of penile pain occurring in the flaccid state, with exacerbation during erection. He also reported a recent decline in erectile rigidity. His past medical history was notable for asthma and a history of substance abuse; otherwise, it was unremarkable, with no prior surgical history. The patient denied any history of sexual trauma, dysuria, or urethral discharge. He also reported no excessive cycling, recent masturbation-related trauma, or long-distance travel.
On physical examination, the patient appeared to be in discomfort. The penis was flaccid, with no evidence of erection. There was marked tenderness along the left penile shaft extending to the perineum and left gluteal region. No erythema, fluctuance, crepitus, or signs of infection were observed. Both testes were normal in size and position, without swelling or tenderness.
An enhanced computed tomography (CT) scan of the abdomen and pelvis was performed (Fig. 1), revealing asymmetrical enlargement of the left corpus cavernosum with internal peripherally enhancing hypodensity, consistent with segmental thrombosis of the corpus cavernosum.
CT abdomen and pelvis with contrast (axial view) asymmetrical enlargement of the left corpus cavernosum with internal peripherally enhancing hypodensity, suspicious for partial thrombosis.
A conservative management was initiated, consisting of anticoagulation therapy (Rivaroxaban 20 mg once daily) for a planned duration of 3–6 months. He was also referred to hematology for thrombophilia evaluation, which was negative. Scheduled for urological follow-up at 3 months. At the time of manuscript preparation, he had not yet returned for clinical reassessment.
Discussion
PSTCC is an uncommon condition primarily described in case reports and small series. Earlier literature referred to this entity as ‘partial priapism,’ but more recent publications recognize it as a localized cavernosal thrombotic process distinct from classical ischemic priapism [1, 7]. Unlike diffuse rigid erection seen in classical priapism, PSTCC typically presents with localized proximal corporal pain and asymmetric enlargement without complete tumescence [7].
Pain is the primary symptom, and erectile dysfunction, when present, is variable in onset and severity [1, 9]. Ilicki et al. noted that erectile dysfunction resulting from PSTCC often improves with conservative therapy [1], while Christodoulidou et al. suggested it may evolve rather than occur immediately at presentation [9]. In our patient, the decline in erectile rigidity following a prolonged erection supports a subacute thrombotic process rather than classical ischemic priapism.
The etiology of PSTCC is frequently idiopathic [1, 10]. A proposed ‘two-hit’ hypothesis suggests that localized thrombosis of the intracavernosal septum occurs when a hemodynamic trigger acts on an anatomically predisposed site [7]. In our patient, a prolonged erection exceeding 4 h likely induced sufficient venous stasis to precipitate thrombosis, in the absence of identifiable trauma or thrombophilia. Sildenafil exposure and physical exertion have also been cited as potential triggers in the literature [5, 11].
Imaging is central to both diagnosis and exclusion of alternative pathology. MRI remains the gold standard, offering superior soft-tissue characterization and thrombus assessment [7, 12]. However, contrast-enhanced CT can effectively identify the hallmark findings of asymmetric cavernosal enlargement with internal hypodensity and peripheral enhancement. Patel et al. previously reported CT findings consistent with unilateral proximal cavernosal enlargement suggestive of thrombosis, subsequently confirmed on MRI and follow-up imaging [10]. Our case similarly demonstrates that CT alone can provide sufficient diagnostic confidence to proceed with conservative management, particularly when MRI is unavailable. We recognize the absence of confirmatory MRI as a limitation, as it would have allowed more complete anatomical assessment.
Management has evolved away from aggressive surgical intervention—including direct exploration or shunt placement, often performed secondary to incomplete diagnostic evaluation—toward conservative strategies [1, 7, 13]. Anticoagulation with a DOAC—specifically rivaroxaban—combined with analgesia has proven effective in recent reports and was used in our patient for 3–6 months [1, 5, 14]. Routine thrombophilia screening is not recommended, but targeted evaluation is warranted in young patients without a clear precipitant or with recurrent episodes [1, 15]. Our patient’s thrombophilia workup returned negative.
Conclusion
PSTCC is a rare but important differential diagnosis for young men presenting with localized perineal or penile pain. While the ‘two-hit’ hypothesis involving venous stasis and anatomical predisposition remains a likely mechanism, many cases present without clear mechanical trauma. Although MRI is the preferred diagnostic modality, our case demonstrates that contrast-enhanced CT is a viable tool for identifying characteristic thrombotic changes when MRI is unavailable. Current evidence strongly supports a conservative management strategy using anticoagulation and analgesia, which typically results in symptomatic resolution and prevents unnecessary surgical intervention.
Conflicts of interest
None declared.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Consent to participate
Written informed consent was obtained from the patient for publication.
Ethical consideration
Ethical approval is not required at our institution to publish an anonymous case report.
