Relationship between penile fracture and Peyronie's disease: a prospective study

Abstract

Peyronie's disease is postulated to be initiated by repetitive minor traumas to the fully or partially erect penis. We investigated Peyronie's disease prospectively in cases treated for penile fracture (PF) within the last 20 years. Medical records of 63 cases treated for PFs were reviewed. Subjects were required to self-assess their current penile morphologies and sexual functions. Penile nodules and Peyronie's plaques were also evaluated with physical examination, ultrasonography and magnetic resonance imaging (MRI), and penile curvatures with auto-photography, and sexual function with international erectile function index (IIEF). Of the 63 cases (mean age 37 years), 46 who had mean follow-up of 63 months were re-evaluated. The mean IIEF-5 score was 23.2±3.1. Painful erections (n=5), penile nodules (n=5) and also penile curvatures <20° (n=2) were investigated. No Peyronie's plaque was palpated in any of the cases. Ultrasound and MRI showed fibrotic nodules of 5 mm in diameter, which extended into the subtunical area in the rupture site in 54% of the cases, although any thickening and Peyronie's plaque were not found in the tunica albuginea and intracavernosal septum of the cases examined. In PF patients treated surgically, the erectile function and penile morphology were preserved. In our cases PFs did not induce the development of Peyronie's disease.

Introduction

Penile fracture (PF), defined as a rupture of the tunica albuginea of one or both corpora cavernosa caused by blunt trauma to the erect penis, is a rare urological emergency.1 Concomitant urethral injuries may occur in 10–20% of the cases.2, 3, 4 Sudden distortion of the erect penis during sexual intercourse or masturbation or violent scrubbing of the penis in the flask state or an acute penile kinking are the most commonly reported mechanisms for the penile fracture.5, 6, 7, 8

In penile fracture patients conservatively treated with cold compresses and anti-inflammatory drugs, significant complications such as infection and erectile dysfunction have been previously observed.9 Surgical treatment of penile fracture which includes the drainage of the hematoma and repair of the rupture in the tunica albuginea was first reported by Fenstrom.10 Due to faster recovery, shorter hospitalization and perfect long-term outcomes, surgical repair has become the first choice of treatment.11, 12 However, complications such as penile curvature, nodule formation in the repair region and penile numbness have been also reported.11, 12

Various factors including genetic predisposition, trauma and tissue ischemia have a role in the pathogenesis of the Peyronie's disease (PD). It is widely recognized that micro-traumas leading to the bleeding within the tunica albuginea, the accumulation of fibrin and the migration of inflammatory cells into the injured area, induce upregulation of cytokine and growth factors and excess increase in the matrix protein which in combination result in the development of a plaque.13 Jarow and Lowe14 reported that frequency of penile trauma in patients with PD is significantly higher. On the other hand, Zargooshi15 used only physical examination as a diagnostic tool and concluded that PD does not develop years after PF or with the habit of strongly bending the erected penis (called taqaandan in Iran) for detumescence.

An instantaneous strong trauma leading to the rupture of the tunica albuginea may cause occurrence of PD in the rupture site, intracavernosal septum and away from the rupture site of tunica albuginea in the long term. In recent studies, development of the Peyronie's plaque in cases with PF treated surgically was assessed using only physical examination.15, 16, 17 In this study, potential development of sequelas in tunica albuginea and intracavernosal septa of the cases treated surgically for PF within the last 20 years have been evaluated with physical examination, ultrasonography (US) and magnetic resonance imaging (MRI).

Patients and methods

Baseline medical histories, physical examination findings, diagnoses, and previous treatment methods of 63 subjects, who were treated surgically for PF between 1 March 1986 and 31 December 2006 in the Department of Urology, School of Medicine, Ondokuz Mayis University, were reviewed.

Medical treatments including oral analgesics, antibiotics, compressed dressings, cold compresses and recommendation of sexual abstinence for over a period of 1 week were prescribed for the patients who had normal erectile functions, small penile hematomas and those refusing surgical treatment.

Surgical repair was performed after intravenous injection of the first generation cephalosporins. Surgery comprised of a subcoronal circumferential degloving incision, evacuation of the hematoma, identification of the site and number of the defect(s) and closure of the defect(s) by interrupted absorbable, inverted-knot sutures. Urethral rupture (if any) was repaired on a urethral catheter using interrupted 4/0 polyglactin sutures and urethral catheter was removed after 7 days, postoperatively. The presence of extravasation on the rupture site and penile curvature were checked intraoperatively by creating artificial erection with intra-cavernosal saline injection. After recommended sexual abstinence for 6 weeks, the cases were examined for penile pain, curvature, loss of tactile sense and erectile dysfunction at least twice, on 45 days and at 3 and 6 months, and first year postoperatively.

To determine postoperative penile morphology and sexual function, all cases were re-invited to the clinic between January 2006 and March 2008. Their current histories were obtained, and the complaints on erection and urination were questioned. Sexual functions were evaluated with the validated Turkish version of the International Erectile Function Index-5 (erectile function domains) (IIEF-5). Penile nodules and Peyronie's plaques were sought with physical examination, and the degree of penile curvatures was evaluated using auto photographic images from two different angles at erect position. Monitoring schedule was shown at Table 1.

Table 1 Monitoring schedule of the patients

Tunica albuginea and cavernosal morphologies of the cases who gave informed consent were examined with US (General Electric Logiq Pro 5, Seoul, South Korea) and MRI (1.5T Siemens, Magnetom Symphony, Erlangen, Germany). Radiological examinations were performed by a radiologist (EG), who was blind to the operational findings. MRI was performed in the supine position using body coil while the penis was in the natural position and T1- (time to repeat (TR): 738 msec, time to echo (TE): 13 msec) and T2-weighted (TR: 5060 mec, TE: 100 msec) images with section thickness of 3 mm, matrix volume of 256x256 pixels and FOV of 100 cm on the axial and sagittal planes were obtained and interpreted. Penile ultrasonographic examination was performed in the supine position by the same radiologist using 10 MHz linear array transducer in the Mode B.

Erect and non-erect penile US and MRI images of the patients and five randomly selected healthy cases without any penile abnormalities and/or history of trauma (control group) were compared.

Results

The mean patient age at the time of injury was 37±11.75 years (range 16–63). Time from the incident to initial presentation ranged from 2 h to 6 days (median 6 h, mean 16.7±24.16 h). The causes of the fracture were shown in Table 2. In the physical examination, although hematoma, ecchymosis and swelling along the penile shaft were observed in all cases, scrotal ecchymosis and swelling were noted only in nine (14%) cases (Figure 1). In four (6%) cases with urethrorrhagia, penile urethral rupture was detected using retrograde urethrography. Tunical extravasation was not observed in three cases who underwent cavernosography. Surgical repair was performed in 56 (88.8%) cases. Among seven cases, one who refused the surgical repair, three patients without any extravasation detected in the cavernosography and three cases with local hematomas and ruptures measuring less than 1 cm in length as noted in the MRI received medical treatments.

Table 2 Etiology of the penile fracture
Figure 1
figure1

(a) Penile and scrotal ecchymosis and swelling due to penile fracture. (b) Urethral rupture (urethral catheter is seen) in same patient.

Locations of tunical ruptures determined intraoperatively were shown in Table 3. The majority (85.7%) of tunical ruptures occurred in the ventral aspect of penises with a transverse orientation. The length of tunical ruptures ranged from 1 to 4 cm (mean 2.3±0.74). One of the cases who underwent surgical treatment had superficial dorsal vein rupture with an intact tunica. Urethral rupture was also observed in four (6%) cases.

Table 3 Surgical findings (n: 56)

Urinary infection occurred in one case in the early postoperative period. Hospitalization period ranged from 1 to 11 days (mean 2.5±1.14 days).

We have got in touch with 46 (73%) cases who had undergone surgical (n=44) or medical (n=2) treatment whose follow-up periods varied between 3 months and 158 months (mean 63±17.25 months). During physical examination, no Peyronie's plaque was palpated in any of the cases. A penile curvature of 20 degrees deviating towards the ruptured side was found in two cases by means of autophotography.

Mean IIEF-5 score of the cases who underwent surgical treatment was found to be 23.2±3.1. There were two cases (5.4%) with ED. One of these cases was 62 years old who was examined 5 years after the surgical repair. His ED which became apparent 3 years after the surgical repair (IIEF-5 score: 14) was attributed to his worsening hyperlipidemia and atherosclerosis. The second case was 58 years old who was examined 11 years after the repair (IIEF-5 score: 6). His ED was attributed to severe chronic obstructive pulmonary disease and coronary artery disease he was suffering.

Median IIEF-5 score (22.65) of 17 patients who were operated more than 24 h after the PF, was lower than that of 39 patients (23.78) who were managed surgically within 24 h of the incident, without any statistically significance difference between two groups.

Two patients who initially received medical treatment were re-evaluated and ED, penile curvature or nodule was not observed.

Radiological findings

Penile morphologies of 46 patients were re-evaluated by means of US (n=37) or MRI (n=12), and their findings were compared with those of five healthy subjects. Patients who had received medical treatment refused any radiological examination.

At 3 months postoperative, MRI or penile US was performed for 3 and 10 cases, respectively. In the ultrasonographic examination, irregular thickening and increased echogenity were found in the repair site (Figure 2c). In the T1- and T2-weighted series of MRI, increased signal intensity and fusiform thickening in the repair region and intracavernosal nodular appearance with low signal intensity were observed in all of the cases (Figures 2a and b). None of the cases had intra-cavernosal hematoma. Thickness of tunical albuginea of the repaired site was similar to that of the control group.

Figure 2
figure2

(a) Sagittal T1 magnetic resonance imaging (MRI), arrows indicate tunical irregularities on fracture lines. MRI at the third month. (b) Sagittal T2 MRI, arrows indicate tunical irregularities and thinning. MRI at the third month. (c) Axial ultrasound, arrows indicate echogenities of posterior shadow belonging to operative material. Ultrasound at the third month.

At 1 year postoperative, MRI or penile US was performed for 3 and 10 cases, respectively. In the ultrasonographic examination, irregular thickening in the repair site and nodular scar tissue appearance with heterogeneous echogenity, extending from tunica into the cavernous body with irregular borders and tiny hypoechoic halo were found (Figures 3a and b). In the MRI, T1- and T2-weighted series of repair site revealed fusiform thickening in the tunica albuginea accompanied by increased signal intensity and intracavernosal nodular appearance caused by scar tissue with low signal intensity (Figures 4a–c). None of these cases had Peyronie's plaque.

Figure 3
figure3

(a) Sagittal ultrasound, the arrow shows the nodule. Ultrasound at the first year. (b) Axial ultrasound, the arrows show the nodule. Ultrasonography at the first year.

Figure 4
figure4

(a) Sagittal T2 magnetic resonance imaging (MRI), the arrow shows fracture repair region in the tunica, the signal increase, irregularity and thickening in the tunica. MRI at the first year. (b) Axial T1 MRI, the arrow shows the hypointense nodule. MRI at the first year. (c) Axial T2 MRI, the arrow shows fracture repair region in the tunica, the singnal increase, irregularity and thickening in the tunica. MRI at the first year.

At 2 years postoperative, MRI or penile US was performed for 3 and 7 cases, respectively. In the ultrasonographic examination, mild thinning in the tunica albuginea of the fracture site, heterogeneous hyperechoic nodular appearance with small calcifications, and tiny hypoechoic areas and irregular intracavernosal borders, and penile curvatures deviating towards extra-tunical field in the penis were detected (Figures 5a and b). In concordance with ultrasonographic findings, MRI revealed narrowing and curvature in the tunica and irregular intracavernosal nodular appearances with hypointense areas in the center manifesting increased signal intensities in two, whereas tunical irregularities and increased signal intensities in one cases, respectively (Figures 5c and d). Thickness and appearance of tunica albuginea outside the repair site were similar to those of the control group.

Figure 5
figure5

(a) Sagittal ultrasound, tiny (in mm) echogenities of calcifications and posterior shadows are seen. Ultrasonography (US) at the second year. (b) Sagittal US, the nodule-causing resilience in the tunica on penile shaft is seen. Ultrasound at the second year. (c) Sagittal T1 magnetic resonance imaging (MRI), tunical irregularity on the penile shaft and slightly hypointense nodule related with the tunica. MRI at the second year. (d) Sagittal T2 MRI, slightly hypointense nodule in the tunica on penile shaft. MRI at the second year.

Penile US or MRI was performed at 5 years postoperative for 5 and 2 cases, respectively; at 10 years postoperative for 5 and 1 cases, respectively. Mild thinning in the tunical albuginea within rupture site and nodular appearances with irregular intracavernosal borders, fine hypoechoic halo, penile curvatures deviating towards extra-tunical field, mild tunical irregularities with increased echogenity were observed. None of the cases had Peyronie's plaque.

Sizes of the penile nodules as determined by MRI are shown in Table 4.

Table 4 The thickness of tunica albuginea in MRI (non-erected penis)

Discussion

The main cause of PF is blunt trauma or sudden increase in intracorporeal pressure due to accidental or intentional bending of the erect penis.12, 14 PF occurs mainly (33–60%) during sexual intercourse.5, 6, 7, 8, 18 However, manual bending of the erect penis for ensuring detumescence particularly in the Middle East countries (called ‘taqaandan’ in Iran) is the other most frequently encountered regional etiologic factor.19, 20 Zargooshi21 reported the results of 172 cases in Iran with PF, and stated that the cause in 69.1% of the cases was ‘taqaandan’. In our series, sexual intercourse was the etiologic factor in 41% of the cases.

Older publications on the management of PF had supported the conservative treatment methods involving local cold compresses, compressed dressings, antibiotics, anti-inflammatory and fibrinolytic medications.13, 14, 19 However, in long-term follow-up studies, the incidence of complications such as fibrotic nodules, penile curvatures, painful erections, arteriovenous fistulas and erectile dysfunction were found to be higher (10–53%) in cases who received conservative treatment.18, 19, 22 On the contrary, early- and long-term results of immediate surgical repair are highly satisfactory. Erectile functions of the patients who have applied to the clinics within the first 24 h following the fracture are preserved better when compared with the findings of late-comers and/or the patients who have been followed with conservative measures. Complications such as penile curvature, fibrotic plaque formation and painful erection are largely prevented, sexual functions are preserved and hospitalization period is substantially shortened with the early (within 24 h after the penile fracture) surgical repair.18, 19, 21 Although early surgical repair has promising outcomes, complications such as penile nodules, curvatures and sensory loss may be observed in some cases. In our series, the incidence of palpable penile nodules was determined as 5% and both penile curvature and temporary penile skin sensory loss was observed in 2% of the cases.

Trauma to the erect and non-erect penis is thought to be an important etiologic factor for PD. Experimentally induced surgical trauma (incision and suture repair) on rat tunica albuginea can induce histological changes similar to the acute phase of PD but not the overt picture of the chronic phase of PD.23 It can also result in an early but transient up-regulation of TGF-B1 protein expression in the rat penis.23 During PF, tunical ruptures at the site exposed to maximal shearing forces. Furthermore, tunica albuginea just across the rupture site may also be traumatized at a lesser degree during bending of the penis. Although it is possible to close the tunical defect by surgical repair, whether or not tunical trauma in the non-ruptured regions might lead to the development of PD is an issue of concern. For this purpose, the use of ultrasonography and penile MRI in addition to physical examination has been considered satisfactorily effective in determining the long-term alterations in the tunica albuginea and cavernosal tissue associated with the trauma related to the fracture and also its repair process.

Zargooshi15 could not determine PD with physical examination in 193 PF patients who underwent surgical treatment, and followed for a mean duration of 85 months. The same researcher palpated nodules within the repair site in 93.7% of 352 patients with PF, who had undergone surgical treatment and monitored for 93.6 months without any physical examination evidence of Peyronie's plaque.16 Similarly, in another study, no Peyronie's plaque could be found in 37 cases who were surgically treated for PF and followed for about 18 months.17 On the other hand, in two separate controlled studies including 82 and 134 patients with PD, respectively, none of the cases had PF history.24, 25 Similarly, no history of PF was reported in a retrospective study on 307 patients with PD.26 In all of these clinical studies, Peyronie's plaque was diagnosed with medical history and physical examination. In contrast, in our study, penis morphologies of the patients were evaluated by physical examination, US and MRI imaging methods in more detail after surgical treatment. Nodules detected in rupture site in the physical examination were intracavernosal nodules in US and MRI and were differently imaged from Peyronie's plaques. In our series, physical examination revealed no plaque in 44 patients who were treated surgically and followed-up for a mean duration of 63 months. The findings were verified with US and MRI.

In the ultrasonographic examination, tunica albuginea is observed as a homogenous and regularly surfaced structure, which is mildly hypoechoic compared with the cavernous body. In the penile ultrasonographic examination of 37 cases within the postoperative 3 months and 10 years, non-palpable intracavernosal nodules, and specifically, millimetric calcifications were observed in 20 cases. In the late term, tunical irregularities, bending and intracavernosal nodules in rupture site of tunica albuginea were observed. Intracavernosal nodules with sizes ranging from 2 to 9 mm can be considered as patches of fibrotic scar tissue during the healing process. In the ultrasonographic examination, these nodules can be evaluated as tunica albuginea-related heterogeneous structures having millimetric calcifications, a thin hypoechoic halo with slightly increased echogenicity compared with the cavernous body. On the other hand, Peyronie's plaque is observed as a hyperechogenic diffuse thickening in the tunica albuginea in US images. However the plaque is visualized as a hyperechogenic area without a single acoustic shadow in the acute phase, but with multiple acoustic shadows in the intermediate phase and a more intense hyperechogenic plaque-like lesion with acoustic shadows in the chronic phase.27

PD is best viewed in T2-weighted images of MRI. Following the administration of intravenous gadolinium, formation of contrast on plaques indicates an active inflammation.28 In the T1- and T2-weighted sections of the MRI, tunica albuginea appears as a homogenous, regular-surfaced structure with low signal intensity, which surrounds the cavernous bodies.28 Although cavernous and spongious bodies are iso-intense with muscular tissue (moderately intense) in T1-weighted series, they are hyperintense compared with the muscular tissue in T2-weighed series.28 In T1- and T2-weighted images, Peyronie's plaques are observed as irregularly-thickened, low signal intensity areas of tunica albuginea. In MRI, we observed curvature and thinning in the tunica albuginea within repair region and irregular intracavernosal nodular appearance with hypointense central areas, which cause increase in signal intensity in cases with PF treated surgically. MRI and US findings were similar in all cases. As US is readily accessible, cheap, tolerable and easy to apply imaging modality, it should be preferred in examining late-term penile deformities of patients treated for penile fractures.

The finding that all intracavernosal nodules detected in US and MRI were in the rupture site suggests nodular development secondary to the surgery. Moreover, tunical structures away from the rupture area were found normal. According to the widely accepted view, pathophysiology of PD is related to chronic micro-traumas. Delamination may occur and small hemorrhages may develop in the tunica albuginea as a result of acute and/or chronic bending of the penis during sexual intercourse and of exposing to the traumas such as distension. Fibrosis occurring in the long term may lead to decreased elasticity, less efficient wound healing and collagen storage. Calcifications, which are typical for PD, may develop in collagen-rich lesions.

As a conclusion, in the PF, instantaneous and acute trauma causes the rupture of the tunica albuginea. Thickening of the tunica albuginea and the resultant calcified nodules extending from the rupture site into the cavernous tissue, which developed some time after early surgical repair, might have been attributed to the suture material and a scar tissue as a result of healing process. In the US and MRI examinations, no thickening or plaque development was observed in the close proximity of the rupture line, in the tunica albuginea symmetrically across the rupture site, in the intracavernosal septum and in the other tunica albuginea regions. As surgical treatment of PF is associated with lower incidence of early- and long-term complications, shorter hospitalization period and patient satisfaction in terms of cosmetic appearance of the penis as well as better preservation of sexual functions in the long term, it should be the preferred treatment modality for cases with PF.

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Acikgoz, A., Gokce, E., Asci, R. et al. Relationship between penile fracture and Peyronie's disease: a prospective study. Int J Impot Res 23, 165–172 (2011). https://doi.org/10.1038/ijir.2011.24

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Keywords

  • Peyronie's disease of tunica albuginea (penile and clitoral)
  • blunt trauma and sexual dysfunction
  • diagnostic testing
  • history
  • physical examination

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