Penile Fracture

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 immediate detumescence (a defect in the corpora will prevent normal erections). Ask about urinary retention or visible haematuria, as this may be present when there is an associated urethral injury

On examination, the patient will have penile swelling and discolouration (secondary to the haematoma), colloquially termed “aubergine sign”. 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 suspensory ligaments. However, with both of these, there is commonly a lack of the “popping” sensation felt, and there is not immediate detumescence following injury.

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.

MRI penis imaging can be helpful is there is doubt clinically. They can also be used to identify the exact location of the tunical tear, however, these imaging modalities can be difficult to obtain out of hours and require a skilled operator to be useful. If there is clinical suspicion, the patient should undergo exploration irrespective of additional imaging.

An on-table urethrogram should be performed at the time of tunical repair. Although penile fractures can be repaired up to 1 week post injury, the recommendation is for repair within 24hours and this should be sooner if there is an associated urethral injury.

Management

Patients should be provided with analgesia and anti-emetics, before urgent surgical exploration and repair.

The preferred initial incision is penoscrotal, unless the site of defect is unknown or suspected to be in distal penile shaft. The haematoma should be evacuated, before the tear is identified and repaired using absorbable sutures.

Degloving of the penis often necessitates circumcision (at time of index procedure if foreskin is tight, or delayed due to subsequent post operative swelling) and patients should be counselled regarding this as part of consent process.

Abstinence from all sexual activities for 6-8 weeks is recommended post-surgery

Complications

Although surgical repair aims to reduce incidence of fibrosis and penile curvature (from 35% to 5%), and erectile dysfunction (from 62% to 5%), this remains a possible complication post-procedure. Other post operative complications include painful erections and altered sensation.

Prompt diagnosis and surgical repair carry a good prognosis, with post-operative complications only present in around 5% of cases.