Current Treatment Options for Penile Fractures

Treatment Review

TREATMENT REVIEW Current Treatment Options for Penile Fractures Gregory S. Jack, MD, Isla Garraway, MD, PhD, Richard Reznichek, MD, Jacob Rajfer, MD Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Los Angeles, CA The diagnosis of “penile fracture” describes the traumatic rupture of the tunica albuginea of an erect penis. Penile fractures typically occur when the engorged penile corpora are forced to buckle and literally “pop” under the pressure of a blunt sexual trauma. Patients typically describe immediate detumescence, severe pain, and swelling as a result of the injury. 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. [Rev Urol. 2004;6(3):114-120] © 2004 MedReviews, LLC Key words: Penile fracture • Corpora rupture • Cavernosography • Urethrography • Trauma enile fracture typically occurs when the engorged penile corpora are forced to buckle and literally “pop” under the pressure of a blunt sexual trauma. Here, we present a sample case, review the current literature, and discuss the diagnostic and surgical dilemmas posed by this relatively common trauma. P 114 VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY Current Treatment Options for Penile Fractures Incidence and Pathophysiology The diagnosis of “penile fracture” specifically refers to a rupture of the corpus cavernosum induced by blunt trauma to the erect penis. Although similar cavernosal lacerations to the flaccid penis have been reported as the result of gunshot traumas and sporting injuries, it is accepted that injuries to the flaccid penis should not be regarded as “fractures,” owing to the different nature of the injury.1,2 Anatomically, the flaccid penis lacks onto an erect penis.8 A majority of the cases in Mediterranean countries are the result of patients kneading and snapping their penis during erection to achieve detumescence.6 In Iran, only 8% of the cases were attributed to sexual intercourse; the remaining cases were due to selfmanipulation and potentially fabricated events, such as a donkey bite to the erect penis, a man falling from a mountain onto his erect penis, and a brick falling onto an erect penis.6 The firmly engorged corpora under the strain of buckling can generate pressures in excess of 1500 mm Hg and exceed the limit of the thinned tunica. a fulcrum for snapping and contains relatively thick tunica albuginea, protecting it from internal rupture under strain. In contrast, the tunica of the erect penis thins to approximately 0.25 mm on expansion, and the firmly engorged corpora under the strain of buckling can generate pressures in excess of 1500 mm Hg and exceed the limit of the thinned tunica.3 The first case of a penile fracture was described in the literature in 1924.4 Although initially regarded as a relatively rare injury, fracture of the penis is an increasingly reported genitourinary trauma. A review by one investigator identified more than 1600 cases in the world literature, with more than half of those cases originating from Muslim countries.5 The largest single series to date describes 172 cases over 9 years in a single province of Iran.6 In the United States, the majority of cases are the result of traumatic coitus, usually from thrusting an erect penis against the symphysis pubis or perineum.7 In Japan, only 19% of cases are attributed to sexual intercourse, with the majority of cases reported as the result of masturbation and rolling over in bed Other rare reports in the world literature include cases resulting from banging an erect penis against a toilet, masturbating into a cocktail shaker, and placing an erect penis into tight pants.7,9,10 Case Presentation A 29-year-old, healthy AfricanAmerican man presented to the emergency room for acute scrotal pain and swelling lasting 12 hours after traumatic intercourse. His injury occurred when his penis ination, and there was no blood at the meatus. The penile shaft lacked a palpable defect, rolling sign, or hematoma, but the scrotum was markedly ecchymotic and tender. His urinalysis was normal, without evidence of microscopic hematuria. Ultrasound of the testicles was normal. A retrograde urethrogram did not demonstrate any urethral injury. On the basis of his clinical presentation, the patient was taken to the operating room urgently for exploration and repair of an acute penile fracture. Clinical Presentation Penile fractures are commonly diagnosed from their stereotypical clinical presentation.11 Patients commonly report hearing a “pop” or cracking sound from the erect penis at the moment of injury.12 Some patients have likened the sound to the snapping of a corn stalk or glass rod.5 Detumescence occurs rapidly, and acute swelling, pain, and penile deformity follow. The pain can vary from minimal to severe and is not proportional to the degree of injury.13 Cases that lack the popping sound or in which there is gradual detumescence have a higher rate of false- Some patients have likened the sound at injury to the snapping of a corn stalk or glass rod. slipped from the vagina and was forcefully thrust against his partner’s perineum. Upon injury, he heard a “pop” from his penis, and rapidly experienced acute penile pain and detumescence. He rapidly developed swelling of his scrotum and significant pain in his penoscrotal region. Upon presentation to the emergency department, he was voiding well and denied gross hematuria. His penis was symmetrically swollen on exam- positive diagnosis14 and might benefit from additional preoperative workup. 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.12,13 Manual examination of the penis can often detect the site of the corporal tear by palpation of the overlaying hematoma. The “rolling sign” VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY 115 Current Treatment Options for Penile Fractures continued Table 1 Assessment of Urethral Injuries in the Setting of Penile Fracture Series (Reference) Penile Fractures (n)* Urethral Injury (n) Microscopic Hematuria (n) Positive RUG (n) Hematuria PPV† n (%) RUG Sensitivity‡ n (%) Beysel et al (23) 21 2 4 2 2/4 (50) 2/2 (100) Mydlo (25) 29 4 6 2 2/6 (33) 2/4 (50) Mydlo et al (48) 7 3 4 2 2/4 (50) 2/3 (66) Fergany et al (13) 8 3 3 3/3 (100) RUG, retrograde urethrography. *Number of patients assessed for urethral injury. † Positive predictive value = number (percent) of patients with microscopic hematuria who had a true urethral injury (true positive/predicted positive). ‡ Sensitivity = number (percent) of patients for whom RUG detected a urethral injury (true positive/predicted positive). is used to describe a firm, immobile hematoma, which is palpable as the penile skin is rolled over it.15 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.16 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. Urethral Injury and Urethrography Retrograde urethrography is advocated in any case of suspected penile fracture that presents with voiding difficulty, hematuria, or blood at the meatus. The incidence of urethral injury ranges from 0% to 3% in Asia and the Middle East to 20% to 38% in the United States and Europe.6,8,13,17,18 Although hematuria, blood at the meatus, and voiding symptoms often signal a urethral injury, the absence of these features does not exclude the possibility of a urethral injury (Table 1).19 Evidence of bilateral corporal rupture should also prompt investigation for a potential urethral injury, because bilateral injuries have a higher rate of urethral disruption compared with unilateral fractures.13,20 Considering that the urethrogram is quick, inexpensive, and poses little risk, Miller and McAninch12 recommend that “only in the setting of an unremarkable urinalysis and the complete lack of voiding complaints . . . should one forego urethrography. This should be considered the exception rather than standard practice.” Table 2 Evaluation of Penile Fractures with Cavernosography Series (Reference) Penile Fractures (n)* Cavernosogram Positive (n) Sensitivity† n (%) Specificity‡ n (%) PPV§ n (%) Mydlo (25) 15 11 11/15 (68) Beysel et al (23) 27 21

11/11 (100) 21/21 (100) Karadeniz et al (22) 21 19 19/19 (100) 2/2 (100) 19/19 (100) *Number of patients who underwent cavernosography. † Sensitivity = true positive/true positive + false negative. ‡ Specificity = true negative/false positive + true negative. § Positive predictive value = true positive/predicted positive.
Sensitivity and specificity n/a because only patients with a positive cavernosogram were explored surgically. 116 VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY Current Treatment Options for Penile Fractures However, not all authors agree with this statement: Zargooshi21 concludes on the basis of his series of 172 patients that routine urethrography is unnecessary. Role of Cavernosography Although some authors recommend routine cavernosography on all patients with suspected penile fracture,22,23 most reserve it for unusual cases, such as those with delayed presentation24 or discrepancies in clinical findings.12 Proper technique for cavernosography includes injection of 15 to 70 mL of half- to quarterstrength nonionic contrast dye (we recommend diatrizoate meglumine and diatrizoate sodium) directly into the uninvolved corpora under live fluoroscopy. Injection is continued until both corpora are filled and tumescent changes are observed. Anteroposterior and oblique radiographs should be obtained over several time intervals. Early films are reviewed for filling defects and extravasation at the suspected hematoma site; 10-minute-delayed films should ascertain for delayed extravasation.12,23,25 Intraoperative cavernosography can be performed on the operating room table in an identical manner.25 Primary limitations to cavernosography include the time, expertise, and equipment required to perform the study. Other investigators cite the potential for delay in treatment and the potential of falsenegative results (Table 2).6,16,25 Reported complications of cavernosography include allergic reaction, corporal fibrosis, and priapism.26 Additional Radiographic Modalities Ultrasonography has been reported as a cheap and noninvasive modality27; however, it is limited by examiner expertise and difficulty in interpretation.28 Theoretically, ultrasound might be advantageous in the pediatric setting because of its noninvasive nature compared with more invasive cavernosography.12 Magnetic resonance imaging has been shown to be extremely accurate in diagnosing and localizing corporal injuries, but the modality is severely limited by Surgical Repair and Timing of Repair Surgical repair of penile fractures was popularized in the 1980s after several studies demonstrated that long-term complications were reduced from 30% to 4% in surgically treated patients.7,30,31 Thus, the current litera- Primary limitations to cavernosography include the time, expertise, and equipment required to perform the study; reported complications include allergic reaction, corporal fibrosis, and priapism. the time and significant expense of the study.28 Angiography is not recommended in the setting of acute penile fracture.5 Nonoperative Treatment of Penile Fractures Ice packs, Foley catheterization, and anti-inflammatory medicines were initially regarded as the standard of care for penile fractures,29 and the condition was associated with a relatively high morbidity rate. 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; however, the long-term complication rates remained approximately 30% ture generally advocates immediate surgical repair upon presentation to the hospital. In the event of a delayed presentation (48 hours after injury), immediate repair is still advocated, although it is associated with increased risk of long-term sequelae.8,16,32 In 1 patient, delayed treatment was performed as late as 30 days after the injury.8 In another series of 3 patients, investigators reported successful outcomes after intentionally delaying the repair for 7 to 12 days, though this practice is not universally recommended.15 Surgical Technique Proper surgical repair of penile fractures requires evacuation of the hematoma, identification of the tuni- Instead of conservative therapy, current recommendations are for immediate surgical exploration and repair. or higher despite all of the above.7 Commonly reported complications included painful erections, severe penile angulation, arterial–venous fistulas, infected hematomas, abscess formation, and impotence.7,30 As a result, instead of conservative therapy, current recommendations are for immediate surgical exploration and repair. ca injury, local corpora debridement, closure of the tunica lacerations, and ligation of any disrupted vasculature.5 The type and location of the incision is operator dependent, although we use and recommend a distal circumferential degloving incision, as advocated by McAninch and others.6,12,25 In addition to being the most cosmetic incision, distal deglov- VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY 117 Current Treatment Options for Penile Fractures continued Table 3 Locations of Corpora Injuries Series (Reference) Penile Fractures (n)* Distal Corpora n (%) Mid-Corpora n (%) Proximal Corpora n (%) Prominent Side (%) Fergany et al (13) 8 1 (12.5) 1 (12.5) 6 (75) n/a Ishikawa et al (8) 8 0 0 8 (100) Right (75) Zargooshi (6) 91 n/a (<10) n/a (<10) 83 (91.2) Right (71) *Number of patients with documented location. ing readily allows exposure to the entire tunica bilaterally, facilitating diagnosis and repair of coexisting urethral and contralateral injuries.33 Some surgeons argue that the degloving is associated with increased neurovascular injury and skin necrosis,34,35 and they advocate a less invasive lateral incision directly over the hematoma site.36 Still others prefer the selective use of each incision based on the clinical presentation and severity of injury.8,35 Suprapubic, inguinal–scrotal, and perineal incisions have also been reported to have excellent functional and cosmetic results.37,38 Regardless of the incision site, proper dissection must be carried down until the hematoma within Buck’s fascia is exposed and evacuated. The underlying laceration in the tunica albuginea usually runs transverse in direction5,39 and lies ventral and lateral in location.5 Most commonly, the proximal corpora is the source of the rupture, but the injury can occur anywhere (Table 3).5,8,13 Extremely proximal corporal injuries have also been reported, sometimes necessitating a perineal approach for repair.16 For an unknown reason, significantly more lesions occur to the Intracorporeal saline injection and simulated erection, referred to as a Gittes test,40 might help localize a nonapparent or incompletely repaired tunica laceration.25 Corporal injection with indigo carmine is a similar alternative, and might be beneficial in the evaluation of an otherwise negative exploration. The decision to Regardless of the incision site, proper dissection must be carried down until the hematoma within Buck’s fascia is exposed and evacuated. right corpora,5,8 with the right-side incidence as high as 75% (Table 3). Closure of the tunica laceration is best performed with running or interrupted absorbable sutures15; however, similar results have been reported with the use of nonabsorbable suture with inverted knots.6 place a Foley catheter is operator dependent. McAninch7,41 and Mydlo25 routinely catheterized their patients overnight in their series, whereas Zargooshi6 advocates use of a urethral catheter only when injuries are close to the urethra. Postoperative antibiotics, compressive bandages, Table 4 Incidence of Bilateral and Urethral Injuries in Acute Penile Fractures Series (Reference) Penile Fractures (n) Unilateral Corpora Tear n (%) Bilateral Corpora Tear n (%) Urethral Injury n (%) No Fracture Identified n (%) Fergany et al (13) 8 5 (63) 3 (27) 3 (27) 0 Beysel et al (23) 34 29 (85) 3 (9) 3 (9) 2 (6) Mydlo (25) 29 26 (90) 3 (10) 4 (14) 0 Zargooshi (6) 91 91 (100) 0 2 (2) 0 Hinev (32) 25 24 (96) 1 (4) 3 (12) 0 118 VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY Current Treatment Options for Penile Fractures Table 5 Complaints After Penile Fracture Repair Series (Reference) Country Fractures With Long-Term Follow-Up (n) Karadeniz et al (22) Turkey 21 Most Common Complication, % Curvature, 14 Mydlo (25) United States 31 Curvature, 6 Ghanem (11) Egypt 27 Skin necrosis, 11 Fergany et al (13) United States 8 Sensory loss, 25 Asgari et al (17) Iran 68 Dysparunia, 9 Benchekroun et al (49) France 50 Painful erection, 22 and erection inhibitors are highly surgeon dependent. Urethral Injury Management of urethral injuries is highly variable between series. Treatment options for partial urethral tears include urethral catheterization, primary closure with nonabsorbable suture, or suprapubic cystostomy tube. All possible combinations of the above have also been used. McAninch41 advocates percutaneous suprapubic cystostomy for the majority of partial tears. Other investigators report excellent results after primary repair.13,42 Partial tears managed strictly with Foley catheterization did equally well.25 Complete urethral injuries can be managed with primary reanastamosis, graft interposition, or stenting over a urethral catheter.43 Mimicking Injuries of the Erect Penis Despite the stereotypical history and Other Common Complication, % Reoperation, 3 Voiding difficulty, 12 Curvature, 18 reliable examination of most penile fractures, negative findings are occasionally encountered at the time of penile fracture exploration.23 Presumed penile fractures unaccompanied by rapid detumescence or that lack the classic “snap” sound are more likely to have negative explorations.14 Rupture of the dorsal artery44 and veins45 are the most common mimics, and they are usually indiscernible from corporal rupture except by cavernosography. Dorsal vein ruptures Main Points • The diagnosis of “penile fracture” specifically refers to a rupture of the corpus cavernosum induced by blunt trauma to the erect penis; in the US, the majority of cases are the result of traumatic coitus, usually from thrusting an erect penis against the symphysis pubis or perineum. • Penile fractures are commonly diagnosed from their stereotypical clinical presentation: a “popping” or cracking sound from the erect penis at the moment of injury, rapidly followed by detumescence and acute swelling, pain, and penile deformity. • Voiding symptoms 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. • Retrograde urethrography is advocated in any case of suspected penile fracture that presents with voiding difficulty, hematuria, or blood at the meatus. • Current treatment recommendations for penile fractures are for immediate surgical exploration and repair; proper surgical repair requires 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. • Reported 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. VOL. 6 NO. 3 2004 REVIEWS IN UROLOGY 119 Current Treatment Options for Penile Fractures continued should be ligated when encountered intraoperatively but can be managed conservatively if diagnosed clinically.23,25 Rupture of the suspensory ligament of the penis might present in the emergency room with a similar history of traumatic intercourse, but the injury should be identifiable based on physical presentation of the floppy penis.46 Other negative explorations have been attributed to nonspecific bleeding, isolated urethral injury,47 and proximal shaft injury inaccessible by the standard incisions.16 sibility of false-negative results. Immediate surgery reduces longterm complications; posttraumatic penile curvature remains the most common long-term complaint. 1. 2. 3. 4. 5. 7. Although surgery has been shown to reduce the incidence of penile fracture complications, 6% to 25% of patients still experience long-term sequelae after surgery (Table 5). Reported longterm complaints after penile fracture repair include: penile deviation, painful intercourse, painful erection, erectile dysfunction, priapism, skin necrosis, arteriovenous fistula, urethrocavernous fistula, and urethral stricture.5 The incidence of the most common postsurgical complaints in several modern series is listed in Table 5. 8. 9. 10. 11. 12. 13. 14. 15. 16. Conclusions The diagnosis of penile fracture is mostly a clinical one. Prompt surgical exploration and repair are advocated in almost all cases. Most commonly, the rupture occurs on the lateral side of the proximal corpora, but it can occur anywhere along the corpora and produce a variety of swelling patterns. Hematuria and voiding symptoms are not specific to a urethral injury. Their presence should prompt the performance of retrograde urethrography. 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