‘Fracture of the penis ’ is the term describing traumatic rupture of the tunica albuginea of the corpus cavernosum, secondary to blunt trauma inflicted when the penis is in the erect state, most commonly during sexual activity. The consequent pain and swelling is usually the cause of presentation; however, despite a consistent and classical clinical picture, many controversies surround the guidelines for optimal management.

Penile fracture is by far the most commonly reported blunt injury to the penis, although an exact incidence cannot be stated. Penile fracture was reported in 183 publications between 1996 and 2001, discussing a total of 1331 cases. Variation in prevalence according to geographic distribution is evident, mostly on account of diversity of sexual cultures and practices. The vast majority of the 1331 cases reported came from the Middle East; namely Iran, Morocco, Turkey, Egypt, and Saudia Arabia. The USA and Canada came second in rank. Patients were mostly in the fourth decade, with the age range between 12 and 82 years.

Pathogenesis

Erection is a prerequisite to rupture of the tunica albuginea in response to blunt trauma or bending, since the high intra-corporal pressure in the erect state stretches the tunica to its limit, thinning it out and rendering it fragile. Forceful bending at this state will lead to a surge of intracorporal pressure that stretches the already taut tunica beyond its limit, causing it to rupture. Bending an erect penis can cause pressure to increase from 180 mmHg to 1500 mmHg. In contrast, a flaccid penis will bend and yield in response to blunt trauma with relatively no rise in intracorporal pressure.

Rupture of the tunica albuginea is usually painful as well as audible (a snapping sound). Blood contained in the corpus cavernosum gushes out, resulting in immediate detumescence, and formation of a hematoma. Edema of penile skin follows.

The tear in the tunica albuginea is mostly unilateral though bilateral tears have been reported. The tear is usually transverse or oblique; nevertheless, longitudinal tears are also encountered. Rupture usually occurs in the proximal shaft but has also been described in the distal third of the penis and, rarely, in the crus.

Rupture of the tunica mostly occurs on the ventral aspect of the penis, particularly if a coital injury is the cause. This can be explained both by the mechanism of injury (direction of the arm of force) and by the sturdy nature of the dorsal aspect of the penis in comparison with the ventral aspect. The tunica albuginea is thicker dorsally than ventrally, and is less liable to stretch beyond its limit in the erect state, thus preventing the erect penis from bending ventrally. It is therefore less liable to rupture. The dorsal aspect is further supported by the neuro-vascular bundle. In case of overwhelmingly forceful ventral bending, the dorsal vessels are more liable to snap than is the dorsal tunica albuginea, and the resulting pain usually brings the traumatic force to a stop, protecting the dorsal tunica from further development of pressure. Accordingly, ventral bending of the erect penis is less likely than dorsal bending, and thus ventral rupture is more likely than dorsal rupture. Nevertheless, though it is rare, dorsal rupture of the tunica albuginea does occur.

Injury of the urethra is widely reported as a complication of penile fracture, occurring in up to 38 % in one case series, and ranging from partial injury to complete disruption. A clear variation in the incidence of urethral injuries has been noticed in correlation with the modality of trauma, being higher in coital injuries. This was explained by the higher magnitude of force with coital trauma in comparison with manipulation injuries.

If surgical repair is not undertaken, the defect usually heals by secondary intention, and the hematoma becomes organized and encapsulated. The healed tear in the tunica albuginea is relatively weak and is therefore liable to aneurysmal dilatation and may be the site of venous leakage, resulting in erectile dysfunction (ED). The neglected hematoma may lead to abscess formation or deformity.

Although fracture of the penis implies rupture of the corpus cavernosum, the resultant hematoma may be exacerbated further by associated injuries, such as rupture of the superficial vessels of the penis or tears in Dartos muscle or in Buck’s fascia, which is firmly adherent to the tunica albuginea.

Etiology

Traumatic event

Penile fracture is the result of blunt trauma or bending force applied to the erect penis. The causative incident is almost always related to sexual activity, whether coital or non-coital. In coital mishaps, the erect penis accidentally propels into the partner’s perineum or pubis. This event can occur in any sexual position, but is more liable to occur in the female dominant position, the so-called reverse coitus. Variation in the traumatic event is noticeable in different geographic regions. The previously mentioned coital injuries are the main cause of fracture penis in the USA and Europe. In contrast, in the Middle East, non-coital injuries (primarily during masturbation) are relatively more common. This can be attributed to religious and social prohibition on pre-marital and extra-marital sex, with possible consequent inclination to masturbation until marriage.

In addition to aggressive masturbation, non-coital fractures are caused by intentional bending of the erect penis to induce detumescence. The latter is a cultural habit reported in some Middle Eastern countries, where it is referred to as taqaandan or qolenj shekestan (meaning ‘to click’ or ‘to snap’). The erect penis is pushed forcibly downwards, upwards, or laterally to achieve detumescence or pleasure, in many cases habitually.

Other rare incidents and modalities of trauma have been reported, including attempts at manual correction of a congenital chordee, attempts to tuck an erect penis into underwear, falling from the bed onto an erect penis during sleep, rolling over in bed during nocturnal tumescence, and masturbating with the tubing of a vacuum cleaner.

Predisposing factors

To date, factors predisposing to penile fracture have been ambiguous. An association was noted with Peyronie’s plaques in four penile fracture cases. This was theoretically explained by aberrant elasticity and deviation of the penis in the erect state, both rendering the penis more prone to trauma upon sexual activity. In addition to Peyronie’s disease, fibrosclerosis of the tunica albuginea and chronic cell infiltrates were observed in five cases of fracture penis. Periurethral inflammation, as occurs in gonococcal urethritis, was also noted in association with penile fracture.

Clinical picture

The unique and classical clinical picture notorious to fracture of the penis may suffice in many instances for a clinically based diagnosis without resorting to investigations. Presentation may be early or late, depending on the extent of injury that is the motivation to seek urgent medical assistance if significant, availability of specialized medical expertise, as well as other social circumstances.

Early presentation

Blunt trauma to the erect penis sufficient to cause rupture of the tunica albuginea results in a tell-tale cascade of events: acute pain mostly during sexual intercourse, a characteristic popping or snapping sound, immediate detumescence, progressive swelling, and ecchymosis.

Initially, the ecchymotic swelling increases progressively, as does edema of the penile skin. After a brief period, progression of the hematoma declines, probably owing to detumescence and pain-induced vasoconstriction, both of which arrest the bleeding. Distribution of the hematoma depends in part on the integrity of fascial layers of the penis. If Buck’s fascia is intact, ecchymosis is confined within Buck’s fascia over the tear, and the patient has a well-defined collection and the so-called eggplant deformity. When Buck’s fascia is compromised, the collection seeps to Colle’s fascia, in which case extravasation is diffuse and assumes a ‘butterfly’ pattern over the perineum, scrotum, and lower anterior abdominal wall. In cases of early presentation, this distribution may be masked by edema. It should be noted that the hematoma does not necessarily coincide with the defect. If Buck’s fascia is torn, blood may proceed to Colle’s fascia and assume a wide, nonspecific distribution. Patients may have angulation of the penis, commonly away from the site of rupture. Deviation in this early stage is caused by hematoma and edema.

The defect may be palpable over the fracture site, referred to as the ‘rolling sign ’. The tenderness encountered and the overlying swelling and edema may prevent palpation of the defect without causing significant discomfort to the patient. This sign is best elicited under anesthesia. Injury of the urethra is not uncommon, and usually manifests itself by bleeding from the urethral meatus or frank hematuria. Retention of urine and a weak stream are possible presentations. Bleeding from the urethra does not necessarily imply rupture of the urethra. In some cases with meatal bleeding, ascending urethrography excludes urethral rupture, while urethroscopy demonstrates mucosal injury rather than frank rupture.

Late presentation and complications

If a fractured penis is neglected, the initial manifestations, namely edema and hematoma, subside gradually. Patients with delayed presentation usually report the classic history but also complain of the resulting complications, such as ED, penile deviation, and a palpable mass, erectile dysfunction, or penile deviation. Erectile dysfunction is caused by possible venous leakage at the site of the healed tear. Deviation may be caused by contracture of scar in the tunica albuginea or by organization of the hematoma. Contrary to the initial early deviation that follows fracture, late deviation may be towards the ipsilateral side of the healing tear and hematoma, the opposite side of the initial earlier deviation. Less frequently, patients may present with poor urinary stream, urinary retention, a urethrocavernous, or a urethrocutaneous fistula.

Atypical presentation

In rare incidents, the characteristic story of penile fracture is not evident. The relationship of the onset to sexual activity may not be reported, commonly on account of embarrassment, and less frequently because of a failure to correlate the sexual act with the symptoms on the part of the patient. Fractures close to the pubic insertion of the corpora may result in scrotal and perineal pain, and a totally normal penis, and may be misdiagnosed and managed as epididymoorchitis. The correct diagnosis may be reached by cavernosography.

Recurrent fracture

Penile refracture following surgical repair of an initial instance has been described in a few case reports. In one case, refracture occurred 10 weeks after repair of the initial fracture, and was associated with extension into the urethra, unlike the initial fracture, in which there was no urethral injury. Refracture was attributed to early resumption of sexual activity, specifically vigorous intercourse. This emphasizes the importance of abstinence following repair. Non-absorbable sutures have been suggested as a measure taken to avoid refracture.

Differential diagnosis

Several conditions may simulate fracture of the penis. Rupture of the deep dorsal vein is one of the most common. In one study, 2 out of 21 cases with the classic picture of fracture penis had intact corporeal bodies and a ruptured deep dorsal vein. Less commonly reported are rupture of the dorsal penile artery and non-specific Dartos bleeding.

A rare entity is ruptured Mondor’s disease of the penis. Mondor’s disease is thrombosis of the superficial dorsal vein of the penis, usually related to trauma, including sexual intercourse. Thrombophlebitis may occur on top, rendering the vessel wall fragile and prone to rupture upon coital trauma. Ruptured Mondor’s disease therefore exhibits a similar sequence of events to those of a fractured penis: acute pain and a popping sound during coitus. A recent history of a painful, firm, cord-like structure on the dorsum of the penis, possibly extending to the inguinal region, may be suggestive.

Considering that rupture of the corpus cavernosum occurs mostly ventrally, a hematoma oriented on the dorsal aspect of the penis should raise questions as to other possibilities. Imaging, especially cavernosography, may discriminate between the aforementioned possibilities. In many situations, surgical exploration alone can reveal the underlying pathology.

Investigations

Diagnosis of penile fracture may be established solely on clinical grounds considering the characteristic sequence of events and the possibility of directly palpating the defect in the tunica albuginea. Exclusive dependence on clinical impression is advocated by some authors, based on the experience that radiological assessment contributes little to decision-making, especially with surgical exploration being inevitable in the opinion of the majority. In addition, investigations are subject to availability of expertise and equipment, which may be an obstacle. Considering the invasive nature of some of the diagnostic tools, patient disapproval may be encountered.

On the other hand, investigations can help to ascertain the diagnosis, localize the site and number of breaches in the tunica, identify the presence of associated complications, and exclude other possible diagnoses. This in turn may influence the treatment plan and whether a conservative or surgical approach is undertaken.

Ultrasonography

The defect in the tunica albuginea may be palpated directly or its site deduced from the overlying hematoma. Amidst tense edema and tenderness, it can be difficult to determine the site of the hematoma and more importantly the site of the defect in the corporeal bodies by palpation. Both the hematoma and defect can be delineated by ultrasonography without causing patient discomfort. Ultrasonography is fast, reliable, and non-invasive. However, a contradictory opinion is that ultrasonography may fail to localize the exact site of the tear (as checked by surgical exploration) and may fail to diagnose multiple tears. Instead, it gives provisional information about the probable site of the tear, by demonstrating the hematoma.

Cavernosography

Cavernosography is capable of accurately demonstrating the site and number of defects in the tunica albuginea. It can also diagnose some of the possible complications such as a caver-no-urethral fistula. Despite its value and accuracy, some authors believe that cavernosography will unnecessarily delay surgery. The same information issued by cavernosography can be obtained upon surgical exploration, which is in many cases inevitable. Furthermore, cavernosography has been reported to yield false negative results in some cases, as checked by surgical exploration, where a tunical breach found upon exploration is not demonstrated in the cavernogram. Cavernosography cannot exclude vascular injuries that may be the underlying pathology, rather than disruption of the tunica albuginea, thus giving a misleading indication for conservative management.

The painful and invasive nature of this examination and the possible complications (including infection and allergy to the dye used) may discourage its application. It is my opinion that cavernosography may be reserved for decision-making in ambiguous cases with atypical presentation, such as those with crural rupture manifesting with scrotal pain and a normal penis, cases of late presentation and non-progressive course where conservative management is a possible option, and cases with suspicion of a cavernourethral fistula, in which cavernosography is the diagnostic modality of choice.

Urethrography

Retrograde urethrography is well indicated in cases with hematuria or difficult micturition. Nevertheless, urethrogra-phy has demonstrated urethral tears in cases of penile fracture with neither meatal bleeding nor micturition problems. It is not yet agreed whether this justifies routine application of urethrography for cases with penile trauma.

On the other hand, urethrography may give false negative results. Bleeding from the urethra may be on account of injury of the urethral mucosa rather than because of a frank tear. Mucosal injury is diagnosed by urethroscopy rather than urethrography.

Urethroscopy

Exploration of the urethral mucosal surface following fracture of the penis has demonstrated injury of the mucosa despite a negative urethrogram. Flexible cystoscopy is more suitable for this purpose but cannot be advocated for routine use.

Magnetic resonance imaging

Accuracy of magnetic resonance imaging (MRI) has been verified by several reports, one of which ascertained its superiority over ultrasonography and cavernosography in ambiguous cases. Despite its accuracy, MRI cannot be recommended for routine use in the diagnosis of fractured penis considering the time and cost involved. It can be a valid option in vague cases where clinical examination and the aforementioned investigations neither confirm nor exclude a defect in the tunica albuginea, and conservative treatment is strongly considered. To sum up, imaging is a useful adjunct to clinical diagnosis, especially in cases with atypical presentation or those in which conservative treatment is an option to be considered. Nevertheless, surgical exploration is still the gold standard for the evaluation and management of suspected penile fracture, and whenever indicated, it should not be delayed awaiting the availability of a diagnostic measure.

Penile fracture: Treatment

Prior to intervention, adequate patient counseling is mandatory, and so is a written informed consent. The mainstay in the management of suspected fracture of the penis is immediate surgical exploration. Nevertheless, controversy still exists. Some experts advocate delayed repair. Others recommend conservative treatment in selected cases. Each of these opinions has its rational basis.

Choice of treatment

Most authors advocate urgent surgical intervention for cases of suspected penile fracture. Unintentional delay of the repair up to 48 hours (depending on the time of presentation) was not associated with exceptional difficulty or exaggerated complications in comparison with immediate repair. Intentional delay for 7 – 12 days has been suggested, allowing resolution of edema and organization of the hematoma, in which case the hematoma would be clearly palpable and would then be taken as a guide for an incision at the site of the tear in the tunica albuginea. There are reports of successful outcome with this approach, without significant complications. Nevertheless, the site of the hematoma may be misleading, since it does not always lie over the tear. Moreover, delayed repair may lead to prolongation of morbidity and possibly a heavier psychological impact.

As to conservative treatment, its advocates base their opinion on experience with patients who were not operated upon, either because of patient disapproval of surgical intervention or because of delayed presentation. This subset of patients did exhibit a higher rate of complications in comparison with those who were operated upon, but the complications were not significant enough in frequency and magnitude to rule out conservative treatment completely. A review of the literature reported complication rates of 29 % and 0 % for conservative and operative approaches, respectively. Another review reported complication rates of 40.7 % and 8.2 %, respectively. Complications issuing from conservative treatment included pain, ED, urethral stenosis, and persistent hematoma. In favor of conservative treatment is the shorter hospital stay and lower physical burden.

No clear-cut guidelines have been proposed for patient selection to receive conservative treatment or surgery. While patient rebuttal of surgery is an absolute indication for conservative therapy, other indications include milder cases without major progressive tissue swelling, without urinary complications, without deformity, without an extracorporeal source of bleeding and with intact corporeal bodies as confirmed by imaging techniques. Cases with delayed presentation and promising clinical condition may also be candidates for the conservative approach.

Principles of surgical repair

The procedure should be performed under antibiotic coverage. Palpation of the defect and imaging techniques such as cavernosography and urethrography may guide the surgical plan, and can be performed intra-operatively under anesthesia. A trial at urethral catheterization may commence the procedure. If this fails, options are cystoscopy and catheterization along a guidewire, or suprapubic cystostomy. Some authors recommend a cautious approach to catheterization so as to reduce the risk of infection and further trauma to the urethra.

Several incisions have been proposed for exploring the penile shaft, the most popular of which is the circumferential subcoronal degloving incision. The hematoma is evacuated and ‘bleeders ’ in Buck’s or Dartos layers are ligated. The three corporeal bodies are inspected for defects. This may be assisted by injection of methylene blue or saline into the corpora and through the meatus. The irrigation fluid flows back from the defect (if present), facilitating identification. When a defect in the tunica albuginea of the corpora cavernosa is encountered, the edges are freshened and sutured ‘water-tight ’ in the direction of the defect. In the case of a longitudinal defect, if narrowing is anticipated, the edges are approximated transversely. In some instances, a transverse defect in the tunica may proceed medially behind the corpus spongiosum. In such cases, subtle mobilization of the spongiosum may assist full exposure and repair. The shaft should be explored for a second defect. This, as well as competence of the repair, can be checked by repeating the previously mentioned transcorporeal irrigation.

Continuous sutures are more ‘water-tight ’. Relaxing interrupted sutures across the continuous suture line will support the latter and help prevent dehiscence upon future erections. Interrupted stitches are adopted by some authors, especially in cases of penile refracture. Absorbable or non-absorb-able suture materials are a matter of personal preference. If non-absorbable stitches are to be used, the knots should be inverted. Non-absorbable suture materials were recommended following some instances of penile refracture. Although no clearly definitive information is available, it seems that the type of suture material used is not critical, much the same as with abdominal fascial closures. I recommend slowly absorbable suture materials such as polydioxanone, to maintain a good balance between the virtues of the two.

As to urethral injuries, an indwelling catheter may suffice for a tiny defect to heal. Suprapubic cystostomy is also a possible resort if catheterization fails. Larger defects should be formally repaired by freshening and suturing the edges, preferably in two layers, and diverting urine for a sufficient period postoperatively. An end-to-end anastomosis may be necessary in the rare cases of complete transection of the urethra.

The utility of a drain is controversial, since its value in drainage may be compromised by the possibility of introducing infection. The penis should be dressed in the vertical position to decrease edema. Dressing should be snug but never tight enough to cause skin necrosis. Postoperative antibiotic coverage and analgesia are prescribed. The use of antierectogenic drugs for the convalescence period is controversial.

The catheter is usually removed on postoperative day 2 unless urethral injury is suspected. Dressing is removed on postoperative day 7. Abstinence from sexual activity for an adequate period of time is important to avoid penile refrac-ture. Although the healing time of tunical tissue is not known, it seems appropriate for patients to remain sexually abstinent for a minimum of 6 weeks and to refrain from high-impact sexual activity thereafter.

The choice of incision for the repair of penile fracture is probably a matter of custom or preference. A subcoronal circumferential degloving incision is one of the most popular, allowing excellent exposure of the three corpora but it may be complicated by lymphedema. It is my experience that the postoperative erections may pull on the suture line and result in gaping in some cases, especially with the sutures tearing through edematous skin. A horizontal semicircular incision on the ventral aspect of the distal penis has been proposed, preferably in the area that suffers edema the least. This incision is more secure to gaping upon erection, and the shaft can be delivered through it. A direct longitudinal incision over the presumed site of fracture may provide simple direct access, but may also be misleading since the hematoma does not always coincide with the defect, and may give poor cosmetic result. A high scrotal midline raphe incision avoids the excessive dissection in the process of degloving and is relatively concealed with better cosmetic outcome. It can also be a route for a proximal degloving procedure. A suprapubic incision gives access to the three corporeal bodies and is away from the edematous area. However, access to the ventral aspect of the penis is more difficult in comparison with the subcoronal incision. With several options for the incision, none is unanimously adopted, or ideal for all situations.

Principles of conservative treatment

Conservative treatment comprises cold compresses, pressure dressings, and anti-inflammatory drugs. Antibiotics are used empirically in some cases although no evidence exists as to their value. The use of sedatives and estrogens to suppress erection during convalescence is probably unnecessary. Furthermore, it has been suggested that the presence of erections after a penile fracture reduces the patient’s anxiety about impotence and may have an overall beneficial psychological effect. Although patients with urethral injuries are not recommended for conservative treatment, those who do decline surgery may receive a suprapubic cystostomy or a transurethral catheter, which should be left in place for 1 – 6 weeks under antibiotic prophylaxis.

Osama KZ Shaeer and Kamal ZM Shaeer

 

Selections from the book: “Textbook of Erectile Dysfunction”, 2009

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