Introduction
A penile fracture is a rare urological emergency which warrants prompt surgical intervention in order to restore form and function.
Whilst it can occur at any age, the predominant age group presenting with penile fracture is 30-40yrs. There is also a reported predilection for the damage occurring to the right side.
Pathophysiology
A penile fracture is the traumatic rupture of corpus cavernosa and tunica albuginea in an erect penis.
It is caused by blunt trauma*, where the penis is violently deviated away from its axis; common mechanisms of injury include penetrative intercourse with the partner on top, forceful masturbation, falling from bed with an erect penis, or forceful correction of a congenital chorde.
The tunica albuginea is around 2mm in a flaccid penis, however this thins to 0.5mm during an erection. Pressures of up to 1500mmHg in the corpus cavernosa through the blunt trauma can result in its rupture.
*Sporting or other violent traumas to the corpus cavernosum of a flaccid penis are not considered a fracture
Figure 1 – The erectile tissues of the penis
Clinical Features
Patients will often report slipping of the penis from the vagina (or rectum), with a forceful thrusting to the pubic symphysis or perineum of the partner.
This will then be followed by a popping sensation or hearing a “snap”, with immediate pain, swelling, and detumescence.
On examination, the patient will have penile swelling and discolouration (secondary to the haematoma), colloquially termed “aubergine sign”, with potential deviation towards the opposite side of the lesion.
A firm immobile haematoma may be palpated in the shaft, called “rolling sign”. A butterfly shaped haematoma in the perineum may suggest a urethral injury.
Differential Diagnosis
The main differentials to consider are rupture of the dorsal artery or veins, or rupture of the the suspensory ligaments. However, with both of these, there is commonly a lack of the “popping” sensation felt.
Investigations
Most cases of penile fracture are diagnosed clinically. Patients suspected of a penile fracture should be worked up with routine pre-operative blood tests, as such cases will commonly require urgent repair.
Cavernosography can be used in cases of suspected penile fractures or in delayed presentation, as well as intra-operatively, to identify the rupture site. However, it has been associated with both complications* of priapism and fibrosis of the corpus cavernosum.
Ultrasonography, whilst having benefits of being cheap and non-invasive, is user-dependant and not routinely used in cases of suspected penile fracture.
If the patient has concurrent symptoms suggesting urethral injury, such as voiding difficulties or blood at the meatus, retrograde urethography should be performed (this is often done routinely at some centres in cases of penile fracture even in the absence of urethral symptoms).
*There is also a risk of false negative cavernosogram when the rupture site is sealed by a clot
Management
Patients should be provided with analgesia and anti-emetics, before urgent surgical exploration and repair.
Surgical exploration is typically performed via a circumferential incision and the penile skin de-gloved proximally up to the base. The haematoma should be evacuated, before the tear is identified and repaired using absorbable sutures.
Abstinence from all sexual activities for 6-8 weeks is recommended post-surgery
Delayed Presentation
As long as a patient with a penile fracture presents within a week of the injury, the vast majority of cases can undergo surgical management (i.e. treat as normal for penile fracture)
For patients presenting beyond 1 week of injury, they can be monitored as an outpatient, specifically for signs of erectile dysfunction and Peyronie’s disease (which can be managed as needed in time). Fortunately, most patients present immediately though so this is rarely an issue.
Complications
Complications following repair include penile curvature during erection, penile paraesthesia, and dyspareunia / painful erection.
Prompt diagnosis and surgical repair carry a good prognosis, with post-operative complications only present in around 5% of cases.
Key Points
- Penile fracture is a rare surgical emergency
- It involves the traumatic rupture of corpus cavernosa and the tunica albuginea in an erect penis
- Presents typically during intercourse with a popping sound, pain, and immediate detumescence
- Diagnosis is mainly clinical and cases require urgent surgical exploration and primary repair