Fractured penis: a review

Abstract

Fracture of the penis is a well-recognized clinical entity. The ideal management has evolved and repair remains largely surgical. We present the etiology and pathophysiology of this condition and outline the therapeutic options.

Introduction

The human penis has always been the subject of much interest, especially, when afflicted with a medical condition. This is particularly true of penile fractures. Discussions of this condition date as far back as 1936.1 It can be defined as a rupture of the tunica albuginea of the corpus cavernosum following blunt trauma to the erect penis.2 Owing to the embarrassing nature of this condition, it remains underreported.3, 4 The treatment of fractured penis is widely regarded to be surgical in approach. In this article, we outline the epidemiology, clinical features and treatment modalities available for management of this uncommon but important condition.

Pathophysiology and etiology

The tunica albuginea is a tough fibroelastic envelope that encases the corpus cavernosum. With erection, corpus swelling results in stretching and thinning of the tunica. The tunica thins out from 5 mm in the flaccid state to 2 mm, when erect.5, 6 A force applied to the erect penis, leading to angulation can cause the tunica albuginea to tear.7 Blood from the corpus cavernosa leaks out into the surrounding tissues producing a hematoma deep to Buck's fascia, which usually remains intact. When Buck's fascia is also ruptured, blood may leak into the scrotum, perineum and lower abdominal wall.8, 9 The site of the tear is usually proximal, near the base of the penis.10 Mansi and colleagues showed that in a series of 14 patients, the tear is usually unilateral, transverse and at the base of the penis.11

Tearing of the corpus spongiosum may also occur concomitantly.12, 13 The incidence of this comorbid condition varies from 14 to 33% in USA and Europe,14, 15 but is almost non-existent in Japan.16 Rupture of the urethra and its encasing spongiosum is thought to be due to stretching during tumescence. A dorsally bending, angulating force is then likely to result in urethral injury.17 Periurethral fibrosis or urethral strictures render the urethra more rigid and thus predispose it to tearing.6

Many causes of penile fractures have been described. The most common cause is bending during intercourse,18 with forcible thrusting but missing the introitus.19 It can occur during masturbation, bending the erect penis to achieve detumescence and rolling over in bed.20 In the Middle East Gulf area, the most frequent cause is forceful manipulation (65%).21

Classical fracture of the penis must be distinguished from two other conditions. Firstly, tears in the tunica albuginea can occur in the flaccid penis. In a review of 208 patients, this was found in 3% of the patients, due to a direct blow to the penis.16 The second condition is traumatic disruption of the penile suspensory ligament, which does not involve the tunica albuginea at all and presents quite differently from penile fractures.22

Clinical features

When a penile fracture is sustained, the patient typically reports hearing a snapping or cracking sound.23 This is followed by immediate detumescence, severe pain, penile swelling and discoloration. The penis can take on a bizarre shape, with deviation of the penile shaft, usually to the side opposite the tear.5, 24

Since Buck's fascia is usually intact, the clot within the torn tunica overlying the fracture site can be palpated as a firm, immobile, discrete tender swelling over which the penile skin can be gently rolled—‘rolling sign’.25 If Buck's fascia is torn, the hematoma may be extensive, spreading to the perineum, scrotum and lower abdominal wall. Very rarely, the defect in the tunica can be palpated.19 Urethral injury is suspected when there is blood per urethra, difficulty to pass urine or an inability to pass a catheter26, 27 (Figure 1).

Figure 1
figure1

Gross picture post injury.

Investigations

The diagnosis of penile fracture, in most instances can be made clinically without the need for ancillary diagnostic tools. Accurate identification of the fracture site can usually be made on examination by rolling the swollen skin over a fixed, smooth, rounded, tender lump (of clot), deep to Buck's fascia—the rolling sign26 Cavernosography may be used to confirm the diagnosis and localize the tear in difficult cases.28, 29 However, complications include contrast reaction fibrosis from extravasated contrast medium, infection and priapism.30, 31, 32 Its use should be confined to rupture of the deep dorsal vein of the penis, which can be clinically indistinguishable from cavernosal rupture.33 Alternatively, sonography of the penis can be performed.34, 35 Sonography is noninvasive, carries no risk of infection and in patients managed conservatively, it is helpful in monitoring hematoma resolution and has a detection rate of 86%.36 Retrograde urethrography is indicated in the case of suspected urethral injury37 (Figure 2).

Figure 2
figure2

Ultrasound showing expanding hematoma.

Treatment

Until the early 1980's, the management of fractured penis was highly controversial. Many conservative treatments have been employed. Diethylstilbestrol or sedatives were employed to suppress erections.38, 39 Others advocated the use of streptokinase and streptodornase.40 Compression bandages, ice packs and anti-inflammatory agents were also used.41 Such conservative management is associated with significant complications such as delayed chordee and formation of a firm fibrous plaque similar to Peyronie's disease, which can occur in as much as 30–53% of cases.14, 42 This complication requires excision of the scar followed by primary repair or the use of fascial strips sutured across the fracture site.41 Other complications include organized hematoma formation, cavernous fibrositis, severe angulation and impotence. Hospital stay is also significantly longer for conservative treatment, when compared to surgical treatment.14

Over the last few years, there has been a move toward early surgical repair.43, 44, 45, 46, 47 Many surgical approaches have been described. A circumferential subcoronal incision with degloving of the penis has been employed to locate the exact site of the tear.48 The complication rate with this approach has been reported to approach 25% in at least one source18 and includes subcoronal skin necrosis, infections and abscess formation. Use of this distal incision with degloving, to treat a proximal pathology, leads to unnecessary trauma and bloody dissection. Re-gloving after the procedure may lead to transient edema as a minor complication but this, as mentioned, is thought to be self-limiting. Others advocate the use of an inguinal scrotal incision to expose the fracture site.49 This approach also appears to involve extensive dissection, however, complication rates and late outcomes have not documented.

Alternatively, a small longitudinal skin incision can be placed directly over the fracture site allowing evacuation of the clot and primary repair of the tear in the tunica.50 The documented complication rate for this procedure is nil but this may be a misleading figure as some studies may have less stringent follow-up making side effects difficult to assess accurately.

The tear in the tunica should be repaired using an absorbable suture. The use of nonabsorbable suture material can leave knots that may be palpable and painful for the patient and his partner (Figures 3 and 4).

Figure 3
figure3

Fracture at the base of penis.

Figure 4
figure4

Repair.

A concomitant urethral injury complicates management. When suspected, retrograde urethrography should be performed to define the urethral injury. Whether the urethra should be managed conservatively or operated on remains controversial. Both methods have been tried with equally good results.26 The authors believe that based on the mechanics of the injury the rupture of the urethra is likely to be partial, since the cavernosum is more rigid than the spongiosum and the force is angulated causing a tear on one side of the urethra. This can be managed successfully by performing a temporary diverting cystostomy alone,12 or in combination with direct repair of the partially torn urethra51 With total rupture, however, end-to-end anastomosis should be performed with a suprapubic cystostomy.26 Urethral strictures and corpo-urethral fistulae can follow this condition.52

Patients should be advised to avoid intercourse for at least 6 weeks to allow for healing of the tear. This period should be increased, if the fracture is managed conservatively. Some advocate the use of diazepam or other sedatives to prevent premature erections.

Patients who complain of suboptimal erections should be objectively assessed using intracavernosal injection of paparverine and phentolamine. Patients may be afraid to have intercourse again should the condition recur. Psychotherapy and self-injections with papaverine may prove useful in such cases.11

Conclusions

Although fractured penis has been recognized and treated for a considerable time, there is no universal agreement on the manner in which it should be treated. Surgical management is thought to be the general treatment modality employed when the condition is encountered. The most widely practised technique of degloving the penis has a high complication rate and other more recently described alternatives should be considered and examined critically, if we have to improve outcomes in this uncommon but important condition.

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Acknowledgements

Dr Marcos Ferreira has a Post Doctoral Research Fellowship grant partially supported by Porto Alegre City Council, Brazil. Dr Michael O'Leary receives funding from the NIH.

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Correspondence to S L Sawh.

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The funding bodies had no role in study design, data collection, data analysis, data interpretation or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

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Sawh, S., O'Leary, M., Ferreira, M. et al. Fractured penis: a review. Int J Impot Res 20, 366–369 (2008). https://doi.org/10.1038/ijir.2008.12

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Keywords

  • penis
  • fracture
  • penile fracture

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