Penile fracture

Penile fracture is a traumatic tear of the tunica albuginea over the erect corpora cavernosa, caused by non-physiologic bending of the shaft. The injury may or may not involve the corpus spongiosum and urethra. It is relatively uncommon - on the order of one in 175,000 emergency visits - and many additional cases never present to hospital because of embarrassment or fear of seeking care.

The inciting event is trauma to the erect penis. The most frequent mechanism is sexual intercourse when the penis slips out of the vagina and strikes the perineum or pubic symphysis. Other causes include masturbation, forced bending to achieve detumescence, direct blows to the erect penis, and other erect-state injuries.

The tunica albuginea surrounds the corpora cavernosa and is critical for erection rigidity. With erection it thins from roughly 2 mm to about 0.25-0.5 mm, stiffens, and becomes less compliant. Sudden bending or direct trauma can tear the tunica - usually in a transverse direction, less often obliquely or irregularly. One corpus is typically fractured; both are involved only rarely. Associated urethral or spongiosal injury must be sought and repaired when present.

Urethral involvement occurs in roughly 10-30% of penile fractures. Clues include blood at the meatus, hematuria, dysuria, or urinary retention. Some urethral injuries are asymptomatic and can be missed without deliberate evaluation.

Rupture of the deep dorsal vein can mimic penile fracture clinically. Surgical exploration may be required to distinguish the two. Swelling and ecchymosis occur without the classic snap or pop or rapid loss of erection in the same pattern as tunica rupture.

Patients often describe a snap or pop, followed by sharp pain and rapid detumescence. Deformity, swelling, and ecchymosis develop from hematoma within the penile fascia. History and examination secure the diagnosis in most cases. Imaging is reserved for atypical presentations; options include retrograde urethrography, cavernosography, or MRI when the diagnosis is unclear.

Conservative management (historical)

Non-operative care (cold compresses, pressure dressings, anti-inflammatory drugs, fibrinolytics, anti-androgens, sedatives) was once common but leads to complications in roughly 29-53% of cases, including missed urethral injury, abscess, permanent curvature, palpable fibrotic nodules, arteriovenous or corporourethral fistulas, painful erection, and erectile dysfunction.

Surgical repair

Early operative repair is the standard of care. Goals are restoration of penile anatomy, prevention of deformity and erectile dysfunction, preservation of length when possible, and restoration of normal voiding when the urethra is injured.

Principles include:

• Optimize exposure - for example:
  • direct incision over the defect
  • circumscribing (degloving) incision
  • inguinal or inguinoscrotal approach when indicated
• Evacuate the hematoma
• Identify all injuries (tunica, spongiosum, urethra)
• Close the tunica albuginea with durable suture
• Repair urethral injury when present, with appropriate drainage and follow-up