Penile Fracture

Penile fracture is traumatic rupture of the tunica albuginea of the corpus cavernosum of the erect penis, usually from a sudden blunt force or abnormal bending. It is an uncommon urological emergency, with the majority of cases occurring during sexual intercourse.

Anatomy and mechanism

• The tunica albuginea, which is 2 mm thick when the penis is flaccid, thins to 0.25 to 0.5 mm in erection, making it vulnerable. Rupture requires buckling forces that raise intracavernosal pressure above 1500 mmHg.
• Mechanisms: forceful buckling against the pubic bone or perineum during intercourse (female partner on top is commonly cited, or slipping out and thrusting against perineum), forced bending (rolling over in bed, masturbation, forced manipulation of the erect penis ("taqaandan" in some regions), and trauma from falls, blows or other sexual activity).
• Location: typically unilateral, ventrolateral proximal to the coronal sulcus, and the right corpus is more commonly involved. Bilateral corporal tears and urethral injury (10 to 22%) can occur. Deep dorsal vein injury is less common.
• Patients are usually aged 20 to 50 years. Incidence is estimated at 1 in 175,000 men per year.

Associated injuries

• Urethral injury in 10 to 38% (more common in bilateral tears or complete tears, suspect with blood at the meatus).
• Dorsal penile vein or artery injury, and suspensory ligament injury.

Complications of delayed or inadequate treatment: penile deformity and curvature (Peyronie-like plaques), erectile dysfunction, fibrosis and plaque formation, painful erections, abscess, fistula, urethral stricture and urethrocavernous fistula, and psychological sequelae.

History (the classical clinical syndrome):

• Audible "crack," "pop" or snap at the time of injury, followed by sudden pain, immediate loss of erection (detumescence), and rapid swelling of the penis.
• Delay in seeking help (embarrassment) is common, with median presentation up to 24 hours or more in some regions, which worsens outcomes.

Signs:

• Marked penile swelling and ecchymosis, resulting in the "eggplant deformity" (aubergine sign) when Buck's fascia remains intact and haematoma is confined to the penile shaft.
• If Buck's fascia is torn, the haematoma spreads to the scrotum, perineum, lower abdominal wall and thighs in a "butterfly" pattern (within Colles fascia).
• Penile deviation to the opposite side of the tear, localised tenderness, and a palpable defect or a "rolling sign" (a firm haematoma that rolls under the skin).
• Blood at the urethral meatus, haematuria, dysuria or inability to void suggests urethral injury (0.3 to 38%), but absence of these does not exclude it.

Differential diagnosis:

• Rupture of the dorsal penile vein or superficial vessels (subcutaneous haematoma without a tunica tear, with maintained erection and no popping sound).
• Suspensory ligament rupture (loss of erection angle without detumescence), penile contusion, thrombosis of dorsal vein (Mondor disease), and penile strangulation.

Red flags: blood at the meatus, urinary retention, extensive perineal ecchymosis, bilateral injury, and associated testicular or pelvic trauma.

The diagnosis is mainly clinical (history of snap, detumescence and swelling), with an accuracy exceeding 90% when typical.

Investigations are used when the diagnosis is uncertain or to locate the defect:

• Ultrasound of the penis (high-frequency probe): shows the tunical defect (discontinuity of the hyperechoic tunica), haematoma and cavernosal laceration. It is non-invasive and easy to perform, with sensitivity 50 to 100% (operator dependent).
• MRI with T1 and T2 sequences is the most accurate (sensitivity of 100% in some series): shows a hypointense tunica albuginea discontinuity. It identifies the location and extent, and any associated urethral injury, but it is expensive and not always available, so it should not delay surgery.
• Retrograde urethrography (10 to 20 mL of contrast) when there is blood at the meatus, haematuria, dysuria or difficulty voiding. Flexible cystourethroscopy is an alternative.
• Cavernosography is largely obsolete.
• Laboratory: urinalysis (haematuria), blood count, and coagulation profile.

Diagnostic principle: exploration is justified based on clinical suspicion, and a negative imaging study should not prevent surgery if history and examination are classic.

Surgical repair (standard of care)

• Urgent surgical exploration and repair (ideally within 24 hours, and best within 8 to 12 hours) gives superior outcomes: fewer complications (curvature, erectile dysfunction, plaques) than conservative treatment (complication rate about 30 to 50%, vs under 10% with early repair).
• Preoperative: informed consent (urethral injury, erectile dysfunction, curvature), broad-spectrum antibiotic prophylaxis (cefazolin 1 to 2 g IV or ceftriaxone 1 g), tetanus where indicated, and urethral catheter if urethral injury is suspected (avoid blind insertion if blood at the meatus, first do urethrography).
• Anaesthesia: general or regional.
• Technique:
• Circumcising (degloving) incision, distal to the coronal sulcus, for access to both corpora and the urethra. Alternatively a longitudinal penoscrotal or direct incision over the haematoma when the location is clear on examination or imaging.
• Evacuate the haematoma, identify and debride the tunical tear edges, and inspect both corpora and the urethra (with urethral catheterisation or intraoperative check).
• Close the tunica with interrupted absorbable (2-0 or 3-0 polyglactin or polydioxanone) or non-absorbable sutures with inverted knots (buried), assessing integrity with an artificial erection (saline infusion via butterfly needle).
• Repair the urethra primarily with absorbable sutures (spatulated, tension-free end-to-end anastomosis) over a catheter, if injured.
• Ligate any bleeding vessels, close Buck's fascia and skin, insert a drain if necessary, and apply a compressive dressing.
• Minimally invasive approaches with a small incision directed by MRI or ultrasound localisation have been described.

Postoperative care

• Catheter (urethral) left for 1 to 3 days (7 to 14 days after urethral repair), analgesia (paracetamol 1 g and NSAID, ibuprofen 400 mg), and antibiotics (cefalexin 500 mg four times daily for 3 to 5 days).
• Erection suppression for 2 to 4 weeks: diazepam 5 mg at night, diethylstilboestrol 1 mg, ketoconazole 200 to 400 mg, sildenafil, or oestrogen, to reduce painful erections. Use of PDE5 inhibitors (sildenafil 25 to 50 mg nocturnal) has been used to promote early erectile rehabilitation in some reports.
• Abstain from sexual intercourse and masturbation for 4 to 6 weeks (until the swelling and tenderness have resolved) to prevent repair breakdown.
• Follow-up at 2 weeks, 3 months, and 6 to 12 months for erectile function (IIEF-5), curvature, plaque and urinary function. Consider penile Doppler ultrasound and urethrography if symptoms develop.

Conservative management

• Reserved for stable minor injuries or when surgery is not possible: ice packs, pressure dressing, anti-inflammatory drugs, antibiotics, suprapubic or urethral catheterisation, erection suppression, and splinting. It has a high rate of complications (penile curvature in 10 to 15%, abscess, erectile dysfunction in 10 to 30%), and delays recovery.

Complications and late management

• Plaque and curvature: medical management (collagenase clostridium histolyticum), traction therapy, and penile plication or grafting after the stable phase (more than 6 to 12 months).
• Erectile dysfunction: PDE5 inhibitors, vacuum devices, injections, and penile prosthesis for severe cases.
• Urethral stricture or fistula: urethroplasty or fistula closure.
• Infection or abscess: drainage and antibiotics.
• Psychosexual counselling for anxiety and relationship concerns.

Prevention

• Counsel on safe positions during intercourse (avoid forceful thrusting when penis slips out), avoid forceful bending of the erect penis, and seek immediate care after any suspected fracture.