Ouch! A fractured Penis?

A penile fracture is a severe form of bending injury to the erect penis that occurs when a membrane called the tunica albuginea tears. The tunica albuginea surrounds the corpora cavernosa, specialized spongy tissue in the core of the penis that fills up with blood during an erection. When the tunica albuginea tears, the blood that is normally confined to this space leaks out into other tissues. Patients typically describe having heard a “pop”/”crack” from their penis, immediate detumescence, severe pain, bruising and swelling as a result of the injury.

Any situation during intercourse when there is thrusting and when the penis, instead of penetrating its normal location, hits some solid structure, like plunging deeply into a partner with a great deal of vigor and railing against the pubic bone, leads to a fracture. Usually this occurs during regular vaginal sex with the woman on top, but it can happen in the missionary position or during sexual acrobatics. It may also occur as a result of masturbation and rolling over in bed onto an erect penis.

Fractures of the penis are an increasingly reported genitourinary trauma with one or two cases reported per month. Incidence is high in young men in their 20s and 30s, who tend to be more engaged in vigorous sexual activity, but we do see it in men in their 40s and 50s. The latter's lower risk might be because older men have decreased frequency and vigor of sexual activity and the tissue in their penises tends not to get quite as rigid.

A penile fracture requires urgent medical attention. It can usually be diagnosed on physical exam.

Presentation

The gross appearance of a fractured penis is often summarized as an “eggplant deformity,” which refers to the combination of localized penile swelling, discoloration, and deviation toward the opposite side of the fracture.

Manual examination of the penis can often detect the site of the corporal tear by palpation of the overlaying hematoma. The “rolling sign” is used to describe a firm, immobile hematoma, which is palpable as the penile skin is rolled over it. Less commonly, penile fractures can present with swelling within the scrotum, suprapubic region, and perineum secondary to the hematoma extravasation outside of Buck’s fascia.

Voiding symptoms, including dysuria, urinary retention, and gross hematuria are uncommon but warrant investigation because they are indicative of a potential urethral injury. Analysis of the urine should be performed to evaluate for microscopic hematuria, which can be indicative of a nonapparent urethral injury.

Work-up and Management

Left untreated, a penis fracture may result in deformity of the penis or the inability to have or maintain an erection.

Prompt surgical exploration and corporal repair is the most efficacious therapy. Although a majority of cases can be diagnosed from the history and physical examination alone. Radiographic studies, including retrograde urethrography and corporal cavernosography can aid in the diagnosis of unusual cases.

Surgery entails evacuation of the hematoma, identification of the tunica injury, local corpora debridement, closure of the tunica lacerations, and ligation of any disrupted vasculature.

Treatment options for partial urethral tears include urethral catheterization, primary closure with nonabsorbable suture, or suprapubic cystostomy tube. The operation usually takes an hour or so depending on the severity and the patient can resume sexual activities after a month.

Long-term complaints after penile fracture repair include penile deviation, painful intercourse, painful erection, erectile dysfunction, priapism, skin necrosis, arteriovenous fistula, urethrocavernous fistula, and urethral stricture.