Penile fracture is an uncommon condition that results from the abrupt bending of the erect penis. The classic scenario involves a couple having sexual relations with the female on top. The penis accidentally comes out of the vagina and the female exerts her body weight downwards onto the penis. Other mechanisms that have been described include aggressive masturbation and rolling over onto an erect penis during sleep. These forces result in a tear in the tunica albuginea (the lining of the erectile bodies). This results in the instantaneous loss of erection. If an instant loss of erection has not occurred, then it is unlikely that a penile fracture has occurred.
It is not unusual for the patient to delay (up to several days) presenting to his physician or emergency department. Accompanying the pain associated with this event is profuse bleeding leading to the development of massive penile shaft and scrotal bruising and swelling. In extreme cases, a tear in the urethra (urine channel) can also occur. The hallmarks of this are the presence of blood in the urine (gross or microscopic) or the inability to pass urine.
When the patient presents it is essential that an urgent urologic consultation be sought. Failure to repair the tunical rupture is associated with the development of delayed penile curvature and possibly erectile dysfunction (ED). A sensitive but thorough history should be taken from the patient. The patient should be asked to void. A urinalysis should be performed on this specimen. If blood is present in the specimen an X-ray of the urethra (retrograde urethrogram) should be performed to identify the site and degree of the urethral tear. This is important in planning of the surgical procedure that is required to repair the tear. If a urethral injury is found, it is our recommendation that a catheter be placed in the operating room using direct vision (cytoscopy).
Much has been written about radiologic imaging of the fractured penis. The bottom line is that it generally offers little information, as the tunical tear is usually easily identified during the operation. Historically, cavernosography was used to identify the site of the tear. This investigation has recently been replaced by MRI. We reserve this imaging modality for those cases where either the history or physical findings are not fully consistent with penile fracture, in an effort to spare the patient a visit to the operating room.
It is our policy to operate on the patient within the first 24 hours of rupture if he has presented in an early fashion. We have operated on men up to 5 days following injury, although the operation is technically more difficult at this time. Patients are counseled regarding the 2 major consequences of non-operative management, penile angulation and ED. Following the completion of informed consent, the patient is brought directly to the Operating Room. The procedure is usually relatively simple and involves drainage of the accumulated blood and repair of the tear(s). A urethral catheter is left in place. If there is no urethral injury the catheter can be removed the following day. If a urethral injury has occurred, it is our policy to leave the catheter in place for 7 days and perform a peri-catheter urethrogram prior to removing the catheter. No sexual relations are permitted for a full 4 weeks post-injury and repair. Based on our experience, this management approach results in excellent preservation of both penile anatomy and function.
- Uygur MC et al:. 13 years' experience of penile fracture. Scandinavian Journal of Urology & Nephrology. 31(3):265-6, 1997.
- Saporta L et al: Penile fractures and our treatment policy. International Urology & Nephrology. 29(1):85-9, 1997.
- Karadeniz T et al: Penile fracture: differential diagnosis, management and outcome. British Journal of Urology. 77(2):279-81, 1996.
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