At a glance......
Penile fracture is defined as the traumatic rupture of the tunica albuginea of the corpora cavernosum. Traumatic rupture of the penis is relatively uncommon and is considered a urologic emergency [rx]. The tunica albuginea is a bilaminar structure (inner circular, outer longitudinal) composed of collagen and elastin. Penile fracture has typical clinical signs reported as trauma to the penis, audible clicking sound, post erection detumescence with hematoma, and swelling. Structural anomalies could alter the mechanical properties of the tunica albuginea, representing a weakening factor of the corpora cavernosa and thus a predisposing factor for traumatic rupture of the penis.[rx] The need for immediate surgery is emphasized, in order to avoid erectile failure and curvature, which are typical complications of conservative treatment.[rx] Many conditions can simulate fracture penis as dorsal vein tears in the penis may mimic penile fracture.[rx]
Penile fracture is a rupture of one or both of the tunica albuginea, the fibrous coverings that envelop the penis’s corpora cavernosa. It is caused by rapid blunt force to an erect penis, usually during Sexual intercourse, or aggressive masturbation.[rx] It sometimes also involves partial or complete rupture of the urethra or injury to the dorsal nerves, veins, and arteries.[rx]
Anatomy of Penile Fracture
Fracture of the penis is a relatively uncommon form of urologic trauma. It is a disruption of the tunica albuginea of one or both corpus cavernosum due to blunt trauma to the erect penis [rx]. It can be accompanied by partial or complete urethral rupture or by injury of the dorsal nerve and vessels [rx].
Tunica albuginea is one of the strongest fasciae in the human body. One reason for the increased risk of penile fracture is that the tunica albuginea stretches and thins significantly during erection: in the flaccid state it is up to 2.4 mm thick; during erection, it becomes as thin as 0.25 to 0.5 mm. Bitsch et al. and De Rose et al. proposed that an intracorporal pressure of 1500 mmHg or more during erection can tear the tunica albuginea [rx,rx].
Causes of Penile Fracture
- Vigorous sexual intercourse is the main cause of penile fracture in the Western world.
- Trauma during sexual intercourse was the most common cause of the penile fracture.
- Because of high energy trauma, urethral rupture is associated in up to 38% of penile fractures [rx].
- Fracture of the penis is a urological emergency resulting from a tear in the tunica albuginea of the penis often due to forceful manipulation, vigorous vaginal or anal intercourse or masturbation, gunshot wounds, or any other mechanical trauma that causes forcible bending of an erect penis.
- Less common etiologies include turning over in bed, a direct blow, forced bending, or hastily removing or applying to clothe when the penis is erect [rx].
- Most commonly, it involves one of the corpora cavernosa. It may also affect both corpora cavernous, corpus spongiosum or urethra [rx].
- During an erection, the thickness of the tunica albuginea decreases from 2 mm in the flaccid state to 0.25–0.5 mm. Therefore the penis is more vulnerable to traumatic injury [rx].
- The most common mechanism of injury is when the penis slips out of the vagina and strikes against the symphysis pubis or perineum.
Symptoms of Penile Fracture
- A popping or cracking sound, significant pain, swelling, immediate loss of erection leading to flaccidity, and skin hematoma of various sizes are commonly associated with the sexual event.[rx][rx]
- Acute onset of pain, swelling, and ecchymosis of the penis during sexual intercourse indicate a penile fracture until proven otherwise.[rx]
- Detumescence voiding difficulties and penile swelling and deviation may accompany.
- Swelling and ecchymosis spreads to perineum, scrotum, and lower abdominal wall within the Colles fascia if the buck’s fascia gives way and produces typical butterfly-pattern ecchymosis.
- Rolling sign can be demonstrated in fracture penis which is the movement of penile skin over the organized hematoma at the site of rupture of tunica albuginea.
- Audible snapping or popping sound
- Sudden loss of your erection
- Severe pain following the injury
- Dark bruising above the injured area
- Bent penis
- Blood leaking from penis
- Difficult urination
Diagnosis of Penile Fracture
A doctor can typically diagnose a penile fracture by asking questions about how the fracture occurred and inspecting the penis.
Imaging studies for penile injuries include
- X-ray – can be used to map out an injury to the penis that is thought to be a penile fracture. These techniques can be used to detect whether the urethra has been torn or damaged. They can also be used to identify other concerns such as injury to the arteries and veins of the penis.
- Ultrasound – Tunica albuginea is usually seen as a hyperechoic linear band in the penis covering two corpora cavernosa and the corpora spongiosa. A hypoechoic breach in this band may be seen especially along the longitudinal axis of the penis. The associated collection is also seen along with the breach.
- MRI – Tunica albuginea is a hypointense band on all sequences. A tear can be seen as a T2 hyperintense breach in this band. MRI can accurately determine if the fracture is transversely or longitudinally oriented. Also, it can accurately depict the depth and extent of tear. Magnetic resonance imaging (MRI) with a scanner that uses a magnetic field and radio-energy pulses to create detailed images of the inside of the penis.
- Cavernosography – It is an interventional procedure and usually avoided, however, may depict the tear in corpora cavernosa.
- Retrograde urethrography – Urethral rupture or post-traumatic stricture can be depicted by this imaging.
Treatment of Penile Fracture
- Attempts to minimize the long-term complications of penile fractures involved the use of compression bandages, erection- inhibiting estrogens, penis splints, antibiotics, and fibrinolytic agents
- Early conservative treatment with cold applications – pressure dressings, catheterization, anti-inflammatory drugs, antibiotics and erection suppressing drugs is now replaced with immediate surgical repair.
- A broad-spectrum antibiotic – low molecular heparin (dalteparin) were given during the hospital stay. Nocturnal erections recovered on the third postoperative day and they were mitigated with diazepam. On day 12 the catheter was removed and on day 13 the patient was released home. The antibiotic was continued at home for the next 10 days.
- Penile fracture is a medical emergency – and emergency surgical repair is the usual treatment. Delay in seeking treatment increases the complication rate. Non-surgical approaches result in 10–50% complication rates including erectile dysfunction, permanent penile curvature, damage to the urethra and pain during sexual intercourse, while operatively treated patients experience an 11% complication rate.[rx][rx] In some cases, retrograde urethrogram may be performed to rule out concurrent urethral injury.
- Recovery time varies significantly – depending on the type of fracture and the specific surgical procedure. Men may be in the hospital for anywhere between one day and three weeks.
- Fortunately – only a small fraction of men with penile fractures experience significant complications after surgery. Found that fewer than 2 percent of men who had surgery for penile fracture experienced long-term erectile dysfunction.
- In addition – less than 3 percent experienced permanent curvature of the penis. Those numbers were significantly higher for men whose penile fractures were managed more conservatively.