MRI of the penis
A KIRKHAM, FRCS, FRCR
University College Hospital, London, UK
ABSTRACT. MRI of the penis is an expensive test that is not always superior to clinical
examination or ultrasound. However, it shows many of the important structures, and in
particular the combination of tumescence from intracavernosal alprostadil, and high-
resolution T2sequences show the glans, corpora and the tunica albuginea well. In this
paper we summarise the radiological anatomy and discuss the indications for MRI. For
penile cancer, it may be useful in cases where the local stage is not apparent clinically.
In priapism, it is an emerging technique for assessing corporal viability, and in fracture
it can in most cases make the diagnosis and locate the injury. In some cases of penile
fibrosis and Peyronie’s disease, it may aid surgical planning, and in complex pelvic
fracture may replace or augment conventional urethrography. It is an excellent
investigation for the malfunctioning penile prosthesis.
Received 3 October 2011
Revised 14 March 2012
Accepted 15 March 2012
’ 2012 The British Institute of
The penis is predominantly a superficial organ, and for
the most part easily examined by palpation or with
ultrasound. Although MRI can be used to assess most
penile pathologies, it needs to demonstrate clinical utility
tojustifyitsexpense.Beforediscussing the benefits ofMRI
for a number of pathologies, we will briefly summarise
the radiological anatomy and scanning techniques.
The corpus spongiosum and corpora cavernosa are of
high signal on T2weighted sequences, and intermediate
to low on T1 weighted sequences . The tunica
albuginea is a fibrous sheath surrounding all three
(Figure 1), and is low in signal on all sequences, with
the contrast between it and the higher signal corpora
greatest on T2(Figures 2 and 3). The septum divides the
two corpora cavernosa and is generally porous, allowing
the passage of blood (and agents injected intracaverno-
sally) from one side to the other .
Close to the tunica albuginea is Buck’s fascia, a slightly
less dense fibrous sheath that is only sometimes
distinguishable from the deeper tunica . It fuses with
the deep perineal fascia, so that haemorrhage from a
penile fracture which does not compromise Buck’s fascia
is confined to the penis, rather than spreading to the
perineum. Superficial to Buck’s fascia is the thin,
incomplete Dartos fascia (not clearly seen on MRI), then
loose subepithelial connective tissue and skin. In the
glans, the tunica albuginea is hard to distinguish from
the more superficial subepithelial connective tissue and
the two fuse towards the tip .
The deep parts of the corpora cavernosa are closely
related to the inferior pubic ramus on each side, and
surrounded by the ischiocavernosus muscle. The most
proximal part of the corpus spongiosum is the bulb,
which is surrounded by the bulbospongiosus muscle and
is pierced by the urethra. The corpus spongiosum is
continuous with the glans, and the two generally have
the same signal characteristics on MRI.
The vascular anatomy of the penis is very variable ,
but the common penile artery, a branch of the internal
pudendal artery, gives three relatively constant branches:
crural, dorsal penile (supplying more distal corpus
spongiosum and glans) and cavernosal, supplying the
corpus cavernosum on each side and often duplicated.
Side branches (the helicine arteries) are easily seen on
ultrasound but are not usually visible on MRI. The
venous anatomy is variable but the largest branches are
the superficial and deep dorsal, in the midline, separated
by Buck’s fascia.
The mainstay of penile MRI is high-resolution (matrix
size $200), small-field-of-view, thin-slice (ideally 3 mm)
T2weighted spin echo sequences in 3 orthogonal planes,
with the penis in the anatomical position (resting on the
anterior abdominal wall in the midline, although others
place it dependently to minimise breathing artefact ).
This is our routine protocol, with further sequences
added as required. T1weighted images may be useful for
the detection of haemorrhage and thrombosis within the
corpora or draining veins. Small field-of-view short-tau
inversion–recovery (STIR) sequences may show inflam-
mation, and sometimes the deep veins of the pelvis well.
sequences, with 3–4-mm slice thickness and a small field
of view, usually in the coronal plane, as it shows the
vessels in the base of the penis best. For assessment of
London NW1 2BU, UK. E-mail: email@example.com
The British Journal of Radiology, 85 (2012), S86–S93
S86The British Journal of Radiology, Special Issue 2012
cavernosal viability in priapism, the dynamic scans
show early perfusion, but there should be one scan at
least 10min after contrast—ideally a small field of view
spin echo T1 weighted sequence, with an identical
sequence obtained before contrast for comparison.
Contrast enhancement for staging tumours is usually
not helpful .
Tumescence and intracorporal agents
There are two reasons for using intracavernosal agents
to produce tumescence. First, the normal corpora become
uniformly high in T2signal, and the tunica albuginea is
seen as a thin, regular low signal layer around them. This
makes it much easier to see both intracavernosal fibrosis
and tunical plaque, as well as other intracavernosal
pathologies such as fistula or tumour. Second, position-
ing of the tumescent (though ideally not fully so) penis in
the midline makes it considerably easier to scan in true
sagittal, coronal and axial planes. For young males with
normal erectile function we use 5mg of alprostadil, and
for older males with erectile dysfunction the full dose of
20mg. Priapism is rare, but can be treated in most cases
by aspiration . Sildenafil and manual stimulation may
produce tumescence in most patients but, especially for
MRI, they are not as reliable as intracavernosal agents
MRI for penile cancer
The great majority of penile lesions are primary
squamous cell tumours, although melanoma, basal cell
carcinoma, sarcoma and lymphoma have been reported,
and metastases are common enough to account for
several cases series, with bladder the commonest site of
origin—either haematogenous or from urethral spread of
transitional cell carcinoma [10, 11]. Anterior urethral
tumours are rare, and usually of the squamous rather
than the transitional type .
Local staging (the classification is shown in Table 1) of
penile cancer may be useful to plan the surgical
approach. There is some controversy about the current
classification, especially within the glans, which is the
site of the majority of tumours  (Figure 4). It was
noted in an early ultrasound study that the tunica
albuginea in the glans becomes difficult to see and
blends with subepithelial connective tissue . Not only
is the distinction between T1 and T2 disease therefore
more difficult, but the finding of T2 disease in the glans
has different implications for the same stage in the shaft,
Figure 1. Cross-sectional penile
Figure 2. T2(a) and T1(b) weighted
sequences through the tumescent
penis. Black arrowheads mark the
tunica albuginea, and white arrow-
heads Buck’s fascia. In (a) the thick
white arrow shows the superficial
dorsal vein and the thinner white
arrows the deep dorsal vessels. The
cavernosal arteries are marked by
black arrows. The urethra, lying in
the middle of the corpus spongio-
sum, is marked by an asterisk.
MRI of the penis
The British Journal of Radiology, Special Issue 2012S87
with glansectomy (partial or complete) the treatment of
choice [14, 15] as opposed to partial or complete
penectomy (and a significantly worse prognosis) in T2
disease involving the corpora cavernosa in the shaft .
The T3 classification is also problematic: involvement of
the urethra is commonly near the meatus and may have a
better prognosis than T2 involvement of the corpus
spongiosum in the shaft . These issues have led to the
proposal of a new staging system more closely related to
prognosis, also shown in Table 1 .
Tumour is seen as low signal compared with corpus
spongiosum or cavernosum on T2sequences, but usually
higher than the tunica (Figure 4). Although MRI pro-
vides excellent soft-tissue definition, it does not necessa-
rily follow that it is superior to clinical examination for
local staging, and early studies, usually without intraca-
vernosal agents and in small numbers of patients, did not
show definitively that it was of benefit. It must be borne
in mind that the clinical stage is usually most accurately
determined at operation and with the use of frozen
section analysis. Later studies, with the use of intraca-
vernosal agents, have shown that MRI was useful when
infiltration of the corpora ‘‘could not be determined
properly by clinical examination’’ and that MRI is
probably better than ultrasound in this context . In
particular, several studies have shown that invasion of
the corpora cavernosa is rarely missed [7, 19, 20], and
proximal tumours, which are hard to scan on ultrasound
and difficult to palpate, are shown well. However, even
with intracorporal agents MRI can sometimes overstage
tumours, and in one study of 55 patients 6 patients with
T1 lesions were staged as T2 . This was ascribed to
technical factors—poor response to prostaglandin, pre-
vious radiotherapy, motion artefact and infection—but it
is likely that some of the error was also due to
fundamental limits to the resolution of MRI and the
difficulty in distinguishing abutment and bulge from
true invasion. No cases of priapism were seen, although
in a previous smaller study priapism occurred in 1 out of
10 patients . The use of contrast has been anecdotally
described as useful , but the larger studies do not
support its routine use . For superficial lesions clinical
examination is usually sufficient.
MRI of the primary tumour can be combined with an
examination of the pelvic nodes. Tumour in virtually all
cases involvessuperficial groin nodes first, andfrom there
spreads to deep groin and pelvic nodes . Certain
features on MRI are highly specific for involvement—in
particular, a fluid component indicating necrosis —but
are not common, and in general the most commonly used
criterion to determine nodal involvement is short axis
diameter. The fundamental limits to MRI are that (1) a
small degree of infiltration will not significantly affect the
size of a node, and (2) reactive nodal enlargement from
penis, and the cause of nodal enlargement in 25–50% of
palpable groin nodes at presentation [23, 24], although
palpable nodes at follow-up are almost always malignant
Figure 3. T2 weighted sagittal sec-
tion close to the midline (a) after
intracavernosal alprostadil and (b)
without tumescence. Black arrows
mark the tunica albuginea, large
white arrows the corpus spongiosum,
small white arrows the urethra
within it, and small black arrows the
bulbocavernosus muscle. The white
arrow head indicates the entry of the
urethra into the roof of the bulb, and
an asterisk marks the glans. In (a) the
‘‘corrugated’’ appearance of the cor-
pus cavernosum is because of the
midline septum, and normal. Note
the considerably thicker tunica albu-
ginea in the detumescent state, and
the lower signal in corpus caverno-
sum; the glans is not in the midline
Table 1. Current and proposed classification for the local staging of penile cancer
T stage Current definition Proposed definitiona
Cannot be assessed
No evidence of primary tumour
Carcinoma in situ
Non-invasive verrucous carcinoma
Tumour invades subepithelial connective tissue
Tumour invades corpus spongiosum or corpus
Tumour invades urethra or prostate
Tumour invades other adjacent structures
Cannot be assessed
No evidence of primary tumour
Carcinoma in situ
Non-invasive verrucous carcinoma
Tumour invades subepithelial connective tissue
Tumour invades corpus spongiosum
Tumour invades corpus cavernosum
Tumour invades adjacent structures (including prostate)
aAccording to Leijte et al .
S88The British Journal of Radiology, Special Issue 2012
. The accuracy of size criteria is little better for pelvic
nodes [26, 27].
The first important distinction in priapism (prolonged,
often painful erection) is the distinction between low-
and high-flow states. Low flow is the commonest type and
a form of compartment syndrome; as elsewhere in the
body if untreated it leads to infarction and fibrosis . It
may be caused by several drugs, both therapeutic
(including phosphodiesterase inhibitors and intracaver-
nosal agents) and recreational, sickle cell disease,
leukaemia and malignant infiltration, although in 30–
50% of cases it is idiopathic . In contrast, in high-flow
priapism there is often an arteriolacunar fistula, the
corpora are at least initially well oxygenated and there is
usually no pain. The distinction between the two states is
important, because low-flow priapism requires emer-
gency treatment, but the diagnosis can normally be
achieved either clinically, by measurement of blood
gases in an aspirate, or on Doppler ultrasound .
There are two main indications for MRI. In low-flow
priapism (Figure 5) the degree of corporal infarction may
influence the decision to intervene, but more definitively
if the corpora cavernosa are completely thrombosed after
surgical attempts at a shunt, the best functional outcome
may be achieved by early insertion of a penile prosthesis
. The degree of infarction on MRI correlates well with
more established (but less anatomically accurate) meth-
ods of assessment such as Doppler and blood gas
measurement, and with histology . It is important
to emphasise that perfusion of the corpora can be slow,
and in addition to dynamically enhanced sequences to
assess the patency of the cavernosal arteries, delayed
sequences at 5 and 10min after contrast are necessary to
assess tissue viability.
In high-flow priapism, a fistula can be suspected on the
dynamic post-contrast images when there is asymme-
trical, early enhancement in one corpus, and is often seen
as a focus of heterogeneous flow void on T2weighted
sequences (Figure 6). However, the combination of ultra-
sound  and angiography is more conventionally used,
and is probably more sensitive than MRI, although no
direct comparisons have been published.
Penile fracture is a traumatic disruption of the tunica
albuginea, often felt as a ‘‘snap’’ and usually associated
with complete and rapid detumescence. It usually
requires urgent surgery to prevent subsequent deformity
and erectile dysfunction .
The penis should ideally be scanned in the anatomical
position (to prevent confusing ‘‘kinking’’) and without
intracavernosal agents. The hallmark of a fracture is an
interruption of the low-signal tunica albuginea (Figure 7),
usually best seen on T2weighted sequences. However, a
T1spin echo sequence may show the associated haema-
toma best, and in one small series was the only sequence
that showed the fracture well in three patients; enhance-
ment was not necessary .
Identification of the fracture may be useful to the
surgeon because a localised exploration may then be
performed, rather than an extensive subcoronal deg-
loving procedure , which probably has a higher
Figure 5. T1weighted scan 10 min after caverject in low-
flow priapism after a right-sided Winter shunt. The left
corpus cavernosum (L) is infarcted, and a little expanded, but
the right (R) enhances normally. This is an unusual pattern
but can be produced by surgical intervention.
Figure 4. Ulcerating lesion on the glans (white arrowheads,
with a white arrow showing the ulcerated part), pT2 on
histology and correctly called T2 on MRI. CC, corpus
cavernosum; S, the spongiosal part of the glans.
MRI of the penis
The British Journal of Radiology, Special Issue 2012 S89
post-operative morbidity . MRI detects most frac-
tures (seven out of nine in one series) , but should be
used with caution when excluding the diagnosis,
although there is little doubt that it is more sensitive
than ultrasound and cavernosography . Associated
urethral injuries may be found in around a quarter of
patients, and can be suspected on MRI , although
urethrography remains the gold standard for their
detection. MRI may also detect several pathologies that
mimic penile fracture—in particular intracavernosal
haematoma  and rupture of a superficial vein.
Although we have been able to diagnose suspensory
ligament rupture in one case , we do not know the
accuracy of MRI in this condition.
Fibrosis and Peyronie’s disease
Fibrosis within the corpora or in the tunica albuginea
may result from priapism, trauma or intracavernosal
agents , but the commonest cause (occurring in
around 3% of males) is Peyronie’s disease, defined
clinically as a palpable plaque, usually with associated
curvature , and possibly due to an aberrant healing
response to repeated shear strains .
Tumescence with intracavernosal agents both improves
the sensitivity for plaque and intracavernosal fibrosis
(both seen as focal areas of low T2signal) and demon-
strates associated angulation or waisting  (Figure 8).
Although ultrasound may also demonstrate most plaques
(and is superior for the detection of calcification) , it is
probably a little less sensitive (with 67% and 61% of
palpable plaques demonstrated on MR and ultrasound in
one study ). Except at the base of the penis, MRI is still
probably less sensitive for tunical plaque than clinical
examination , and is probably not indicated routinely,
although it can be useful for surgical planning.
One potential benefit of MRI is the demonstration of
tunical enhancement, which in a small series 
Peyronie’s disease, when most surgeons advise against
surgery. However, there is little correlation with pain—the
most commonly used indicator of active disease —and
the significance ofplaque enhancementremains uncertain.
Intracavernosal fibrosis (both in Peyronie’s disease
and post traumatic) may be seen as areas of low-signal
stranding, but should not be overdiagnosed: some low-
signal stranding in the distal corpora cavernosa is seen in
normal males .
Figure 7. Transverse T2weighted image in a patient with
surgically confirmed penile fracture. The white arrowheads
show the tunica albuginea, and the white open arrowheads
a little of Buck’s fascia. A urinoma (F) lies below the Dartos
fascia (black open arrowheads). The fracture is seen as a
defect in the ventral aspect of both corpora cavernosa (black
arrowheads), with, in addition, disruption of the normally
high-signal corpus spongiosum (black asterisk).
Figure 6. Axial T2 (a) and early
dynamic post-contrast gradient echo
images (b) in high-flow priapism.
The fistula (confirmed on ultra-
sound and angiography) is shown
by the arrowheads in each. It is seen
as an area of heterogeneous signal
(with elements of flow void) on T2,
and is associated with earlier
enhancement in the right corpus
cavernosum (R) than the left (L).
S90The British Journal of Radiology, Special Issue 2012
Inflatable implants are all safe in 1.5T systems but
two malleable prostheses (OmniPhase and DuraPhase;
Dacomed, Minneapolis, MN) containing metallic ele-
ments show fairly strong deflection in 1.5T magnets 
and should not be scanned.
Inflatable implants are well seen on T2 and STIR
sequences , and we scan with the device inflated
when possible. Although ultrasound is sufficient in
many cases to check for adequate fluid in the device,
several abnormalities are best seen on MRI. In particular,
kinking from overlong cavernosal components can be
hard to detect clinically, and in one study an anatomical
abnormality was seen on MRI in all 14 patients with
pain, apparent clinically in only 5 . Crossover of
cavernosal components is relatively rare, but well seen
, as is aneurysmal dilation of the cavernosal compo-
nents, which may lead to bulge and underinflation
(Figure 9). The hypermobile glans, leading to a ‘‘super-
sonic transporter deformity’’ , can be diagnosed
clinically or by ultrasound.
Infection occurs in around 2–4% of inflatable implants
(although subclinical infection is more common)  and
is often associated with periprosthetic fluid and strand-
ing (seen in particular on STIR sequences) , but these
findings should be interpreted with caution: some fluid
does not necessarily imply infection, and stranding may
be seen for several months after insertion. We have
found that infections that are convincingly shown on
MRI are usually clinically apparent as well.
Peyronie’s disease and penile fibrosis can both cause
erectile dysfunction and can be imaged on MRI.
However, clinical tests of nocturnal penile tumescence,
response to phosphodiesterase inhibitors and intra-
cavernsoal agents, together with penile Doppler ultra-
sound remain the mainstay of imaging investigation [48,
49]. MR angiography may demonstrate the branches of
the internal iliac vessels, and can be used to plan pelvic
revascularisation, but is not of adequate resolution to
show the penile vessels well, and conventional angio-
graphy is superior .
MR urethrography is technically feasible, but not
necessarily straightforward. Compared with conventional
urethrography it may sometimes show fistula, tumour,
and spongiofibrosis better , but similar benefits are
seen with ultrasound urethrography of the anterior
urethra  and both MRI and ultrasound are consider-
ably more cumbersomethana fluoroscopicascending and
descending urethrogram, which is quick, demonstrates
Figure 9. Aneurysmal dilation of the penile prosthesis
(white arrow), causing a palpable lump and poor inflation.
Note the tubing extending to the pump in the scrotum
(white arrowheads). No fluid is seen around it to indicate
Figure 8. Peyronie’s disease. T2 coronal image showing
tunical plaque in the distal right corpus cavernosum (white
arrowheads), with moderate distal waisting. Intracavernosal
fibrosis is seen on the left (white arrows).
MRI of the penis
The British Journal of Radiology, Special Issue 2012 S91
fistulas well and can show the posterior urethra during
sequences and saline or jelly  or T1gradient echo
sequences around an hour after injection of intravenous
gadolinium . One place where MRI may be useful is
after pelvic trauma, where as well as delineating the
urethral lumen it may demonstrate the anatomical
abnormality and degree of prostatic displacement ;
in particular, one report has suggested that it may be
more accurate than conventional urethrography at
determining the length of the obliterated segment ,
but it must be stressed that obtaining good urethral
distension can be technically challenging. Periurethral
enhancement correlates with inflammation but is as yet
of uncertain clinical significance .
be performed withT2
MRI can be used to define the location of injected
silicone  (in particular using silicone-suppressed
sequences) or other substances, and T2 and STIR
sequences will show dilated Cowper’s ducts. Finally,
MRI is an excellent tool for defining the anatomy in cases
of ambiguous or abnormal genitalia .
MRI can contribute useful information for many
different pathologies in the penis, but is in many cases
not convincingly superior to clinical examination or
ultrasound to justify its routine use. It is probably most
useful in the investigation of the painful penile implant
and acute low-flow priapism. It is sometimes useful for
the local staging of penile cancer, for the localisation of
penile fracture and for imaging complex cases of fibrosis.
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