Penile fracture is an uncommon condition that results from the abrupt bending of the erect penis. These forces result in a tear in the tunica albuginea (the lining of the erectile bodies). This results in the instantaneous loss of the erection. In extreme cases, a tear in the urethra (urine channel) can also occur.
Penile fracture is considered a urologic emergency and when a penile fracture is suspected an urgent urologic consultation is needed. Failure to repair the tunica albuginea injury is associated with the development of delayed penile curvature and erectile dysfunction (ED).
RISKS & CAUSES
Penile fracture results from direct trauma to the erect penis. The classic scenario involves a couple having sexual relations with the female partner on top. In this scenario the penis accidentally comes out of the vagina and the female exerts her body weight downwards onto the penis. Other mechanisms that have been described include anal penetrative intercourse, aggressive masturbation and rolling over onto an erect penis during sleep. In certain ethnicities, the practice of “Taqaandan” (purposeful forceful bending of the erect penis during masturbation) can be the cause.
SYMPTOMS AND EVALUATION
It is not unusual for the patient to delay (up to several days) presenting to his physician or emergency department.
Men commonly complain of a bending force of the erect penis with associated pain and instantaneous loss of erection. Oftentimes men will also admit to hearing an “audible pop”. If an instant loss of erection has not occurred, then it is unlikely that a penile fracture has occurred.
Associated with this event can be profuse subcutaneous bleeding leading to the development of massive penile shaft and scrotal bruising and swelling. This is commonly referred to as an eggplant deformity of the penis. In extreme cases, a tear in the urethra (urine channel) can also occur. The hallmarks of this are the presence of blood in the urine (gross or microscopic) or the inability to pass urine.
When the patient presents for evaluation it is essential that an urgent urologic consultation be sought. Failure to repair the tunica albuginea rupture is associated with the development of delayed penile curvature and erectile dysfunction (ED). A sensitive but thorough history should be taken from the patient. A directed genital physical exam should be performed with attempt to palpate a tunica albuginea defect. The patient should be asked to void. A urinalysis should be performed on this specimen. If blood is present in the specimen an X-ray of the urethra (retrograde urethrogram) should be performed to identify the site and degree of the urethral tear. If a urethral injury is found, repair depends on the degree and extent of injury.
The diagnosis of a penile fracture largely depends on the history and a focused physical exam. Occasionally, if an aspect from the history or physical exam is not suggestive of a penile fracture, radiologic imaging may be obtained.
Historically, cavernosography was used to identify the site of the tunica albuginea tear. This investigation has been replaced by MRI or penile ultrasound. These imaging modalities are reserved for those cases where either the history or physical findings are not fully consistent with penile fracture, in an effort to spare the patient a visit to the operating room.
If a penile fracture is suspected immediate operative exploration is recommended. Even in the case of delayed presentation longer than 48-72 hours after injury, repair of a penile fracture has been shown to decrease the rate of penile curvature and erectile dysfunction when compared to observation.
The operative procedure is usually relatively simple and involves drainage of accumulated blood, and locating and repairing the defect. If a concomitant urethral injury is present, either urethral catheterization is performed or directed urethral repair is undertaken. Patients are routinely discharged home on the same day following the operation.
No sexual relations are permitted for a full 4 weeks post-injury and repair. This management approach results in excellent preservation of both penile anatomy and function.