The objective of this study was to compare the long-term clinical outcomes from longitudinal incisions and subcoronal circumferential degloving incisions in the surgical treatment of penile fractures. From July 2001 to July 2014, 23 patients were identified with penile fractures. Fourteen patients underwent longitudinal incisions after ultrasound localization; nine patients underwent subcoronal circumferential degloving incisions. Sexual function was evaluated preoperatively and postoperatively using an abridged International Index of Erectile Function (IIEF) questionnaire. The mean (±s.d.) operative time was 19.1 (±3.9) min in the longitudinal incision group and was 45.1 (±6.5) min in the subcoronal circumferential degloving incision group (P<0.05). The mean (±s.d.) times required to recover sexual function were 35.6 (±6.0) days in the longitudinal incision group and 54.0 (±5.8) days in the circumferential incision group (P<0.05). Six months postoperatively, the erectile functions of all cases were comparable to the level preoperatively except three patients. One patient from each group reported symptoms associated with mild ED, but they experienced satisfying sexual orgasms after psychotherapy for 2 months. Another patient’s score on the IIEF-5 declined from 25 to 24 points in the circumferential incision group 10 months postoperatively, and this was associated with maintaining an erection after vaginal penetration. In conclusion, the longitudinal incision may allow quicker return to sexual function but not necessarily improved the long-term clinical outcomes. Furthermore, postoperative psychosocial nursing and psychotherapy should receive more attention.
Penile fracture is a rare urological emergency, and it is defined as the primary rupture of the tunica albuginea of the penile corpora cavernosa that occurs during an erection.1 When an erect penis is struck by a blunt force, the intracavernous pressure increases suddenly, which may cause transverse damage to the vascular bed and the tunica albuginea associated with the corpora cavernosa, and it may rupture the tunica albuginea. The compression of the subsequent hematoma and the ensuing inflammatory changes may aggravate the injuries within the cavernous tissues and small vessels.2, 3
The clinical presentation of penile fracture is distinctive, and it includes reports of audible cracking or tearing sounds accompanied by immediate pain, rapid detumescence, swelling and ecchymosis, and the penis deviates toward the side that is opposite to the fracture.4 In the past, the management of penile fractures mainly involved conservative treatment with ice packs and anti-inflammatory medication,5 but this approach was associated with a high incidence of complications, including curvature, palpable nodules and ED, in up to 50% of patients.6 The immediate surgical repair of penile fractures, which was accompanied by drainage of the hematomas and suturing of the ruptured tunica albuginea, was first described by Fernstrom7 in 1957, and it gradually became the new standard for treatment because of its excellent long-term outcomes.8, 9, 10 A variety of surgical incisions have been proposed for the repair of penile fractures.4, 11, 12 This study aimed to compare the long-term clinical outcomes associated with longitudinal incisions and subcoronal circumferential degloving incisions used in the surgical treatment of penile fractures. We also report on our 13 years of experience in diagnosing and therapeutically managing penile fractures and investigate the mechanisms that predispose people to penile fractures.
This was a retrospective study of adult male patients aged between 28 and 56 years who presented to the emergency department at Shanghai Ninth People’s Hospital, which is affiliated with Shanghai Jiao Tong University School of Medicine. Written informed consent was obtained from all patients within this study and all patient information was dealt with confidentiality and used only for the purpose of the study; no third party was involved. The study design was approved by the institutional review board of Shanghai Jiao Tong University School of Medicine.
Study setting and population
From July 2001 to July 2014, 23 cases of penile fracture presented to the Shanghai Ninth People’s Hospital. Patients had a mean age of 35.3 years (range=28–56 years). The mean time interval from injury to presentation was 11.8 h (range=4 h to 4 days).
Acquisition of patients’ clinical data
All of the patients’ clinical data were collected from the patients’ records that were held at the Shanghai Ninth People’s Hospital. The data collected comprised the patients’ detailed histories, which included the symptoms, the mechanisms underlying the trauma and the sexual position, when appropriate; the clinical findings disclosed during the physical examinations; the imaging results; the presence of urethral injuries; the outcomes; the operative times; the sexual function recovery times and postoperative complications relating to sexual function and voiding. Postoperative erectile function was assessed using the abridged International Index of Erectile Function (IIEF-5) questionnaire, which comprised five questions with a maximum score of 25 that focused on erectile function and satisfaction with regard to sexual intercourse, and it diagnosed the presence and severity of ED.13 Preoperative erectile function was also assessed by the IIEF-5 questionnaire 1 day postoperatively according to patients’ memory.
Twenty-three cases underwent emergency surgery at the time of diagnosis under general or spinal anesthesia. Circumferential incisions proximal to the corona (Figure 1) were undertaken on nine cases. Fourteen cases whose ultrasound examinations had identified the exact locations of the ruptures (Figure 2a) underwent longitudinal incisions (2 cm) (Figures 2b and c) that were made directly above the lump on the side of the penis. The typical operation involved the catheterization of the urethra, the subsequent evacuation of the hematoma and an examination of the tears in the corporal bodies. Tears in the corpora cavernosa that measured 2–25 mm were found in all cases. The corpora cavernosa ruptures were repaired and closed using running silk or 4–0 polypropylene sutures and the knots were inverted. The catheters were in place for 2 weeks in order to avoid secondary injury of urethra. Parenteral antibiotics were used for 5–7 days postoperatively. Diethylstilbestrol was given orally to prevent postoperative erections for 3 days in all cases. All cases were discharged on the second postoperative day, and they were advised to abstain from sexual intercourse for 1 month. The assessment of the 'return of sexual function' was begun 1 month postoperatively, and the time when they could perform sexual intercourse successfully was viewed as the return of sexual function. Cavernosography and urethrography were not performed on any of the cases.
The data were analyzed and are expressed as absolute numbers, ranges, percentages and the means and s.d. All of the statistical analyses were performed using the IBM SPSS software version 19.0 (IBM Corporation, Armonk, NY, USA). The significance of the differences was assessed using a one-way analysis of variance followed by a t-test, and values were considered statistically significant when the P-values were <0.05.
This study involved adult male patients aged between 28 and 56 years who presented with penile fractures. Most of the penile fractures (65.2%) occurred during vaginal intercourse (15 of the 23 patients). Other reasons that led to penile fractures in 34.8% of the patients included masturbation in 26.1% (6 of the 23 patients) of the patients and blunt injuries in 8.7% (2 of the 23 patients) of the patients, of these, one penis was fractured after it was bumped against the side of a bathtub and one was injured when the patient fell onto the floor after rolling off a bed. With regard to the sexual positions that were reported by the patients who were in heterosexual relationships (n=15), 'woman on top' was the position most commonly associated with the penile fractures, which corresponded to 66.7% (10 out of the 15 patients) of the cases, followed by 'rear entry coital position' in 33.3% (5 out of the 15 patients) of the cases. The 'man on top' sexual position was not identified among the patients with penile fractures.
Clinical manifestations at presentation
Most of the patients had felt a sudden sharp pain and heard a cracking sound when the erect penis was forcibly pushed. These patients presented with severe pain, rapid detumescence, local swelling, ecchymosis of the skin and deformations of their penises. Table 1 summarizes the information regarding the clinical manifestations, causes and postoperative outcomes of the penile fractures. The physical findings included varying degrees of hematoma, local swelling and angulations of the penile shaft. The rupture sites could be located by the characteristic rolling sign in 17 cases. Large hematomas and ecchymosis of the scrotal and infrapubic regions were found in cases where there was severe bleeding and in whom the rolling sign was less clear. Microscopic hematuria was not found in any patient.
Preoperative ultrasound examinations were performed in all 14 patients in the longitudinal incision group, which enabled the exact locations of the ruptures within the corpora cavernosa to be identified with a positive predictive value of 100%.
Outcomes and follow-up
The mean (±s.d.) operative time for the approach that used a longitudinal incision was 19.1 (±3.9) min (range, 15–26 min), while the mean (±s.d.) operative time for the approach that used a subcoronal circumferential degloving incision was 45.1 (±6.5) min (range, 34–56 min) (P<0.05). A tear was solitary in all cases. The defect was in the distal shaft in 5 cases (21.7%) and was proximal in 18 (78.3%). The defect was located dorsally in 3 cases (13.0%) and was located laterally in 20 (87.0%). The number of tears in left side of the corpora cavernosa was 10 (43.5%), and a right-side lesion of corpora cavernosa was found in 13 patients (56.6%). The tunical tear length was 16.3±4.6 mm in the longitudinal incision group and was 15.6±4.3 mm in the subcoronal circumferential degloving incision group (P>0.05).
The mean (±s.d.) follow-up duration for the cases who underwent operations was 49.4 months (range=10–125 months), and all of the cases who underwent surgical treatment for penile trauma showed excellent recoveries. The mean (±s.d.) times required to recover sexual function were 35.6 (±6.0) days in the longitudinal incision group and 54.0 (±5.8) days in the circumferential incision group (P<0.05). Six months postoperatively, the erectile function of all cases were comparable to the level preoperatively except three patients. One patient from each group reported symptoms associated with mild ED. Their IIEF-5 scores were between 17 and 21, and these declines were mainly associated with reductions in sexual satisfaction, which were associated with worrying about further penile fractures occurring during sexual intercourse. Following 2 months of psychotherapy, which involved teaching the patients about the anatomy of the penis, advising the patients to avoid the riskiest sexual position and encouraging them to relax during sexual intercourse, all patients recovered and achieved satisfying sexual orgasms. Within the circumferential incision group, one patient’s score on the IIEF-5 declined from 25 to 24 points, and this was associated with maintaining an erection after vaginal penetration. Except this patient, all cases recovered their preoperative IIEF-5 scores 10 months postoperatively.
A minor penile nodule was found in one patient in the circumferential incision group. Additionally, one patient in the circumferential incision group presented with a minimal penile curvature, and this was characterized as a minor curvature that did not impair penetration, and it was usually <20°. None of the patients had urethral strictures, voiding deterioration or pain during follow-up.
In westernized countries, vigorous sexual intercourse accompanied by a blow from the partner’s pubis or perineum is the main cause of penile fracture,14 and this was reflected in our patient series. Interestingly, in the Middle East, particularly in Iran, injuries mainly result from penile manipulations during masturbation.15 Blunt injuries were found in our study that had been caused by bumping the penis against the side of a bathtub and falling onto the floor after rolling off a bed. As the patients who suffered these injuries were older compared with the other patients, the injuries may have been a consequence of reductions in the coordination of movements that are associated with aging. Penile fractures caused by Mondor’s disease16 and injecting drugs into the penis17 were not found in our study.
The tunica albuginea will become much thinner when the penis is erect.18 If there is a local developmental defect, the tunica albuginea will rupture if the penis is subjected to a sudden and blunt force; hence, the incidence of penile fracture correlates directly with the frenzied and forceful actions that occur during sexual intercourse, especially sexual intercourse that occurs in stressful situations.19 It has also been demonstrated that ‘woman on top’ is the sexual position that is most frequently associated with penile fractures in westernized societies,20 and the results from our study concur with this finding. When a woman assumes the ‘on top’ position, she usually controls the movement and her entire body weight lands on the erect penis, and the man might be unaware of his penis penetrating the woman in the wrong direction, especially when the couple are moving quickly.
Penile fractures can be diagnosed based on the clinical findings associated with the ruptures in most cases. The use of urethrography or cavernosography as diagnostic methods is controversial.21, 22, 23, 24 Although magnetic resonance imaging may have a role in the differential diagnosis of a rupture of the circumflex or dorsal vein of the penis or when the tunical rupture is not associated with a tear of the overlying Buck’s fascia,25 it is expensive and not readily available in the acute setting. Ultrasound examinations appear to be the optimal diagnostic method, because they can locate the position of the tears, which facilitates surgery and reduces the risk of further damage or complications.26, 27 However, the accuracy of ultrasonography depends on the skill of the observer, the size of the tear in the tunica albuginea and whether the tear is filled with a blood clot.14 In our study, ultrasound was not just a diagnostic tool, it was a necessary step in the method of making longitudinal incisions, as it was used to detect the position of the tunical tear. Comparably, it is easy to find the position of the tunical tear under direct vision in the process of making subcoronal circumferential degloving incisions. By degloving, we can find the fractured position, and the injuries to additional blood vessels and nerves are obvious; thus there was no need to use ultrasound to detect the fractured position in the subcoronal circumferential degloving incision group. Moreover, to our knowledge, there is no obvious effect of ultrasound on the long-term clinical outcomes. Thus this is the reason why the ultrasound was employed in longitudinal incisions and not in subcoronal circumferential degloving incisions. In the current study, 14 patients underwent penile side incisions to repair their penises after the parameters of the rupture sites had been determined using ultrasound scanning, and none of the ultrasound findings were inaccurate. In our study, the level of accuracy in relation to the ultrasound findings was higher than that reported in the literature, which was probably because the tears in the corpora cavernosa exceeded 2 mm, and this was confirmed during the operations.
Although successful repairs have been reported after delays of 7–9 days28, 29 and non-operative treatment is reportedly successful,30 penile fractures should be treated using active surgical exploration.31, 32 However, a variety of surgical incisions have been proposed for the repair of penile fractures.4, 11, 12, 25 The incidence rate of ED in the long term after surgical management was 0–17% according to the literature,3, 6, 28, 33 but a higher incidence rate was reported by Hatzichristodoulou et al.34 The present study compared the long-term clinical outcomes from longitudinal incisions with those from subcoronal circumferential degloving incisions, and the findings are reported for the first time. The longitudinal incision was associated with shorter times before the recovery of sexual function and fewer penile deformities than the subcoronal circumferential degloving incision, and the reasons that may underlie these advantages are described next. First, the longitudinal incision is associated with a shorter wound exposure time, which reduces the likelihood of postoperative infection. The subcoronal circumferential degloving incision injures more blood vessels and nerves and it traumatizes more tissue than a small longitudinal incision that is directly over the fracture site, and this is detrimental to the recovery of sexual function. Moreover, longitudinal incisions are particularly useful when operating on circumcised men who may have sparse amounts of coronary sulcus skin, which are not conducive to wound healing. However, degloving the penis with a circumferential incision might be advantageous in cases who present with significant penile swelling or extensive hematomas and for those in whom the location of the tunical rupture cannot be determined either clinically or by ultrasonography.35
The incidence of urethral injury ranges from 0% to 3% in Japan and the Persian Gulf, from 20% to 38% in Europe and the United States and it is 1.1% in Iran.8, 36 Urethral ruptures were not found in this study. Long-term complications that can follow the repair of penile fractures include urethral strictures, painful erections, painful intercourse, skin necrosis, penile deviations and priapisms.37 Our study demonstrated excellent postoperative outcomes in terms of voiding functions during the mean follow-up period of 46.2 months (range=10–125 months). The IIEF-5 was used to evaluate erectile function, and two cases were unable to attain their previous levels of sexual satisfaction, but they experienced satisfying sexual orgasms after psychotherapy for 2 months. Studies have also reported that some patients may show normal color duplex findings besides a pathological IIEF-5 score in the context of a psychogenic cause of ED.33, 38 These patients reported that they had an extreme fear of recurrence, which consequently led to a restricted sexual life besides normal erections.38 We consider that postoperative psychosocial nursing and psychotherapy should receive more attention. One patient who was in the circumferential incision group showed a decline in his IIEF-5 score from 25 points to 24 points that was associated with his ability to maintain an erection when his penis had penetrated a vagina, but he did not require further treatment.
This study was limited by the small number of patients compared with other series from the Middle East or Mediterranean regions,29, 38 which is a consequence of penile fracture being a rare injury in China. Furthermore, data regarding the patients’ voiding functions were obtained from self-reported responses to a single question and not by quantifying the urinary flow rate. We will continue to enlarge the sample size and improve the quality of the data. Additionally, this study was a single-institution retrospective series with the potential of selection bias, and recall bias of preoperative IIEF score and other points existed. The prospective study will be conducted in the future to overcome the shortage.
‘Woman on top’ was the sexual position associated with the greatest risk of penile fracture. Emergency surgical treatment is crucial for defect repair, preserving erectile function and reducing complication rates. The longitudinal incision may allow quicker return to sexual function but not necessarily improved the long-term clinical outcomes Postoperative psychosocial nursing and psychotherapy should be given more attention.
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This work was supported by the General Programs of the National Natural Science Foundation of China (Nos. 81370860 and 81070605), Pudong Health Bureau of Shanghai (PW2013D-3), Key Disciplines Group Construction Project of Pudong Bureau of Shanghai (PWZxq2014-11) and the Biomedical Engineering Research Fund of Shanghai Jiao Tong University (No. YG2011MS14). We sincerely thank Dr Selcuk Yucel for his excellent technical assistance during this work.
The authors declare no conflict of interest.
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Xu, M., Zhou, Z., Yao, H. et al. Comparison of different approaches to the surgical treatment of penile fractures: quicker return to sexual function with longitudinal incisions. Int J Impot Res 28, 155–159 (2016). https://doi.org/10.1038/ijir.2016.13