Introduction

Penile fracture is defined as the traumatic rupture of the tunica albuginea of the corpus cavernosum.¹ It is relatively frequent in the Mediterranean Muslim region.² This seems to be a simple numerical fact and no explanations have been scientifically proven. It occurs mainly in the young adult. The rupture may extend to affect the corpus spongiosum and the urethra.¹ The combination of lesions of the penile urethra and the corpus cavernosum is rare and likely to go unremarked. It worsens the immediate and long-term prognosis and poses a problem of management.

We report a series of 10 cases of traumatic corpora cavernosa rupture associated with urethral rupture. These cases were recorded among a series of 312 patients with penile fracture treated at the department of Urology in 'Charles Nicolle' Hospital in Tunis.

Our aim is to study the particular clinical and therapeutic features of this urologic emergency, which may lead to disabling urethral and erectile sequelae in case of non-adapted or late management.

Patients and methods

We carried out a retrospective study of a series of 10 cases of urethral rupture associated with penile fracture. Patients were treated at our institution between December 1975 and December 2006. All data were collected from medical records. This study was approved by our Institutional Review Board.

Results

The median patients' age was 30 years (range: 19–46 years). Seven patients were single and three were married. The median time from injury to presentation was 10 h (range: 1–20 h). Six patients reported traumatic penile manipulation during erection and four others reported that the fracture occurred while rolling over in bed during nocturnal tumescence. A painful cracking sound from the erect penis followed by immediate detumescence was noted in all cases. Eight patients presented with dysuria and two others with complete urinary retention. Bloody urethral discharge was noted in all patients.

On physical examination, the 'Eggplant Deformity' and urethral bleeding were noticed in all cases. In addition, bladder distension was noted in two patients. No perineum or scrotal hematoma was identified.

No preoperative radiographic investigations such as urethrogram were necessary to make the diagnosis of penile fracture possibly associated with urethral lesion.

Urgent surgical exploration was done for all patients. The median time from injury to surgery was 19 h (range: 3–24 h). The type and location of the incision was variable. The incision was elective and hemi-circumferential in four patients who had a well-localized penile hematoma. In the other six patients, a distal circumferential degloving incision was done.

The penile fracture was transverse in all cases. It occurred in the right corpus cavernosum in six cases and the left corpus cavernosum in four cases. The laceration in the tunica albuginea was localized in the proximal corpora in five cases, the mid-corpora in four cases and the distal corpora in one case. The median length of this laceration was 24 mm (range: 10–40 mm).

Urethral injury was partial and localized at the same level as the corpus cavernosum tear in all cases (Figure 1). Urethral and tunica injuries were treated with local debridement followed by transurethral catheterization and interrupted absorbable sutures. A penrose drain was applied to drain the surgery site. Supra-pubic cystostomy tube was placed at the end of the operation in all patients.

Figure 1.

Urethral rupture at the level of the corporal tear (sutured).

Full figure and legend (179K)

All patients were treated postoperatively with benzodiazepine. They were given diazepam at the dose of 10 mg daily during 3 weeks to avoid erection. Early postoperative outcome was uneventful.

The median duration of transurethral catheterization was 13 days (range: 10–15 days). Urethrography was done for all patients using the supra-pubic cystostomy tube after the removal of the transurethral catheter. No contrast material extravasation was noticed. The median hospital stay was 14 days (range: 10–16 days).

The median follow-up was 18 months (range: 8–32 months). We did not notice erectile dysfunction, penile deviation or painful erection in any patient at follow-up. No patient presented dysuria requiring urethral investigation. Urinary flow made 6 months after surgery for all patients were normal.

Discussion

Penile fracture refers to the traumatic rupture of the corpus cavernosum caused by a blunt trauma of the tunica albuginea of an erect penis. The vulnerability of the erect penis is explained by the thinning of the tunica albuginea from 2 mm when the penis is flaccid to 0.5 mm—or even 0.25 mm—when erect¹ and by pre-existing fibrosclerosis and inflammation of this tunica.³

Penile fracture is a relatively uncommon urologic emergency. Until 2001, 1642 cases had been reported in the literature.^{2, 4} Among the 312 cases included in our series, 10 are complicated with urethral rupture, which makes a prevalence of 3.2%. This rate is highly inferior to those reported in the United States and Europe which range from 10 to 30%, but it resembles to those reported in Asia and the Middle East.^{5, 6, 7, 8, 9}

Several causes of penile fracture have been reported, including traumatic coitus, violent penile manipulation, masturbation or rolling over in bed onto an erect penis. Among these causes, sexual intercourse leads the most to urethral rupture, given the high violence of the trauma in this situation.¹

Symptoms and signs of penile fracture are characteristic. They associate cracking sound and acute pain of the erect penis rapidly followed by detumescence. Inspection usually notes a localized hematoma and deviation of the penis toward the opposite side of the fracture, thus giving the appearance of the classic 'Eggplant Deformity'. The hematoma can reach the perineo-scrotal region and even the anterior abdominal wall in case Buck's fascia is torn.⁵ If the patient presents rapidly after injury, palpation of the penis will often allow detecting the site of the corporal tear.⁴

Voiding complaints and, mainly, bloody urethral discharge are very suggestive of a potential-associated urethral injury, but are not specific.^{4, 10, 11} Microscopic hematuria is also an indicative sign of urethral injury but its positive predictive value is only 50%.⁴ In such cases, when urethral injury is suspected, we avoid urethral catheterization because we believe that it might worsen a partial urethral tear, although we are aware of no clinical or research evidence in which this has actually happened. Therefore, we preferred to drain urines by placement of a suprapubic cystostomy. In our experience, everyone with urethral injury had blood at the meatus. We also noticed that penile hematoma was not important in 60% of the cases. We suggest that when there is a urethral tear, penile hematoma is often absent, because the blood leaks out the urethra.

Most of the authors consider that urethrography is compulsory if the diagnosis of urethral rupture is suspected.^{4, 12, 13} Others, however, consider that routine urethrography is unnecessary,⁹ as well as magnetic resonance imaging, which has been shown to be accurate in diagnosing urethral lesions.¹⁴ In our series, we directly adopted an interventional approach since urethral rupture is often located at the same level as corporal tear.^{5, 15}

Standard treatment is surgical. Immediate surgical exploration is recommended by most of the authors to avoid infectious short- as well as long-term complications including urethral stricture, urethrocavernous fistula and erectile dysfunction.^{1, 5, 10, 16} The most commonly used incision is the circumferential coronal incision under the gland. This esthetic incision allows a wide exposure to the corpora cavernosa and spongiosum. However, it is associated with an increased risk of complications including infection, skin necrosis and sensitive sequelae.^{9, 10, 12} Thereby, hemi-circumferential elective incision is preferred whenever the site of the corporal tear could be suspected on physical examination.

Urethral injuries in penile fractures are most often partial, such as in all our patients. Complete urethral rupture is very uncommon and is usually associated with rupture of both corpora cavernosa.¹⁷ Only three cases involving complete urethral rupture and disruption of both corpora have been reported.¹⁸ In case of complete urethral rupture, the treatment consists in extra-mucosal tension-free termino-terminal urethrorraphy, after sufficient dissection of the urethra at both sides of the tear and after placement of a transurethral catheter. In case of partial rupture, one can choose between urethral sutures with catheterization and a simple supra-pubic cystostomy, with good results reported in both cases.^{4, 8, 10} We advocate immediate surgical repair, which is the recent tendency, since the patient will obviously undergo a surgery for the corpora cavernosa fracture.

Postoperative antibiotics (anti-Gram-negative bacilli), compressive bandage (the gland must be visible to visualize any ischemic problem) and erection inhibitors are surgeon-dependent. It is our preference to use postoperative benzodiazepine to decrease erections, although we are aware of no research which specifically proves the necessity of its use.

The duration of urethral catheterization depends on the severity of observed lesions. It usually ranges between 7 and 14 days and can even reach 6 weeks in case of complete rupture.^{1, 5}

Clinical follow-up is necessary. Given the risks of strictures, urethrocutaneous or urethrocavernous fistula, the presence of any sign suggesting these complications should prompt the performance of urethrocystography. Isolated corpora fracture complications should also be suspected although immediate surgery has been shown to reduce them. These sequelae have been reported to reach 25% of patients; post-traumatic penile curvature remains the most common long-term complaint.⁴

Conclusion

Urethral rupture must be suspected in any case of penile fracture presenting with bloody urethral discharge. The urethral injury is often partial and localized at the level of the corpora tear. Standard treatment consists in immediate surgical repair of both urethral and corporal ruptures. Follow-up is recommended to search postoperative urethral strictures and erectile sequelae.

Notes

Competing interest

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this study.

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