Overview
Definition:
Penile fracture refers to a tear in the tunica albuginea, the fibrous sheath encasing the corpus cavernosum, typically occurring during forceful penile bending while erect
It is a urological emergency requiring prompt surgical intervention to minimize long-term complications.
Epidemiology:
Penile fracture is rare, with an incidence estimated between 1 in 1,600 to 1 in 30,000 male emergency room visits
It most commonly occurs in sexually active men aged 15-55 years, with peak incidence in the 20-40 year age group
The mechanism is usually aggressive sexual intercourse or penile manipulation during masturbation.
Clinical Significance:
Failure to promptly diagnose and surgically repair penile fracture can lead to significant long-term morbidity, including erectile dysfunction, penile curvature (Peyronie's disease), and painful erections
Timely surgical intervention is crucial for optimal functional recovery and patient satisfaction.
Clinical Presentation
Symptoms:
A sudden, audible "snap" or "crack" sensation during intercourse
Immediate severe penile pain
Rapid detumescence (loss of erection)
Significant penile swelling and ecchymosis (bruising), often described as a "eggplant deformity." Hematuria (blood in urine) if the urethra is also involved
Inability to urinate due to urethral injury or severe swelling.
Signs:
Gross penile deformity, typically a deviation from the midline
Marked penile swelling and discoloration, often extending to the scrotum and perineum
Palpable defect or fluctuance along the penile shaft
Tenderness on palpation
Urethral bleeding from the meatus or signs of urethral disruption (e.g., urinary extravasation).
Diagnostic Criteria:
The diagnosis is primarily clinical, based on a history of the characteristic mechanism of injury and the presence of a palpable defect in the tunica albuginea during erect or semi-erect state
Imaging is generally not required for diagnosis if a clear defect is felt, but may be used in equivocal cases.
Diagnostic Approach
History Taking:
Detailed history of the injury mechanism is paramount
ask about sexual activity, penile position, and any audible or palpable sensations
Inquire about prior penile trauma, surgery, or history of erectile dysfunction or Peyronie's disease
Assess for any concurrent injuries.
Physical Examination:
A thorough examination of the external genitalia is essential
While not always feasible or necessary in a conscious patient, an artificial erection test (e.g., using saline injection into the corpus cavernosum) can help localize the injury and assess the extent of the tear if the diagnosis is uncertain
Examine for urethral meatal bleeding or hematoma extension.
Investigations:
No routine laboratory investigations are required for the initial diagnosis
However, urinalysis may reveal hematuria if the urethra is injured
Ultrasound of the penis can sometimes delineate the tear in the tunica albuginea and corpus cavernosum, but its sensitivity is operator-dependent and it should not delay surgical intervention
Retrograde urethrography is indicated if urethral injury is suspected (e.g., meatal bleeding, inability to void).
Differential Diagnosis:
Hematoma formation without a true tunica albuginea tear (e.g., from direct blunt trauma)
Fournier's gangrene (though usually associated with infection and rapidly progressing necrosis)
Penile priapism (persistent erection)
Trauma to the scrotum or perineum.
Management
Initial Management:
Immediate referral to a urologist or emergency surgeon
Pain control with analgesics
Broad-spectrum intravenous antibiotics to cover gram-negative organisms and anaerobes, especially if urethral injury is suspected
Catheterization should be avoided if possible, especially if urethral injury is a concern
suprapubic catheterization may be necessary if urinary retention is present.
Medical Management:
Primarily supportive, focusing on pain relief and infection prophylaxis
No medical management can repair a ruptured tunica albuginea.
Surgical Management:
Emergency surgical exploration and repair is the gold standard for penile fracture
Indications include a palpable tear in the tunica albuginea and/or corpus cavernosum
The procedure involves longitudinal incision along the penile shaft to expose the tunica albuginea
The tear(s) are then meticulously repaired with absorbable or non-absorbable sutures (e.g., 3-0 or 4-0 polydioxanone or Prolene)
If the urethra is injured, it should also be repaired primarily
Following tunical repair, a saphenous vein graft or dura mater graft may be considered for very large or multiple defects, though this is less common
Hemostasis is achieved, and a drain may be placed
A compressive dressing is applied post-operatively.
Supportive Care:
Close monitoring for signs of infection, hematoma, or wound dehiscence
Pain management
Counsel on sexual activity restrictions (typically 6-8 weeks)
Antibiotic prophylaxis continuation as per local protocols
Encouragement of early ambulation.
Complications
Early Complications:
Hematoma formation
Wound infection
Dehiscence of the surgical repair
Urinary retention
Urethral injury exacerbation.
Late Complications:
Erectile dysfunction (persistent or new-onset)
Penile curvature (Peyronie's disease)
Painful erections
Loss of penile sensation
Fibrous plaque formation within the corpus cavernosum
Sexual dissatisfaction.
Prevention Strategies:
Prompt and meticulous surgical repair of the tunica albuginea is the most crucial preventive measure against late complications
Careful handling of tissues during surgery
Adherence to post-operative instructions regarding sexual abstinence
Early identification and management of wound infections.
Prognosis
Factors Affecting Prognosis:
Timeliness of surgical intervention
Extent and number of tears in the tunica albuginea
Presence and severity of associated urethral injury
Patient's pre-injury erectile function
Adherence to post-operative rehabilitation protocols.
Outcomes:
With prompt surgical repair, the majority of patients have a good prognosis for regaining satisfactory erectile function and avoiding significant long-term sequelae
Studies report success rates of 70-90% for preserving erectile function
However, some degree of penile curvature or dyspareunia can persist in a minority of patients.
Follow Up:
Regular follow-up appointments are essential, typically at 1 week, 1 month, and 3-6 months post-operatively
These visits assess wound healing, monitor for complications, and evaluate erectile function
Patients should be advised to avoid sexual activity for at least 6-8 weeks and to report any new or worsening symptoms immediately.
Key Points
Exam Focus:
Penile fracture is a tear of the tunica albuginea
a surgical emergency
The classic history is a "snap" during intercourse followed by pain and detumescence
Surgical repair involves suturing the tunica albuginea
Prompt repair is key to preventing erectile dysfunction and Peyronie's disease.
Clinical Pearls:
Always consider penile fracture in any male patient presenting with penile trauma and rapid detumescence
A palpable defect is usually pathognomonic
Do not delay surgery
ultrasound is an adjunct, not a substitute for exploration
Ensure adequate antibiotic coverage, especially if urethral injury is suspected.
Common Mistakes:
Delaying surgical intervention due to uncertainty or preference for conservative management
Inadequate exploration and repair of all tunical tears
Failure to consider and manage associated urethral injuries
Insufficient post-operative counseling regarding sexual restrictions.