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ORIGINAL ARTICLE
Year : 2021 | Volume
: 13
| Issue : 4 | Page : 351-355
Penile fracture: Institutional experience of 14 cases
Rajendra K Shimpi, Pranay J Patel, Suraj T Bhondave
Department of Urology, Ruby Hall Clinic, Pune, Maharashtra, India
Correspondence Address:
Dr. Suraj T Bhondave
Department of Urology, Ruby Hall Clinic, Pune - 411 001, Maharashtra
India
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DOI: 10.4103/UA.UA_27_20
Abstract
Background: Penile fracture due to various causes is urological emergency condition, which can be diagnosed on history and clinical examination of the patient. Appropriate management in each case prevents patients from future physical and psychological consequences.
Materials and Methods: Fourteen patients were included in the study. The study was carried out at Ruby Hall Clinic, Pune, India, between January 1, 2016, and December 31, 2019. All patients were evaluated by history and clinical examination and radiographic investigation in suspected urethral injury.
Results: Fourteen patients with penile fracture, between 20 and 50 years, were in the study. The most common mechanism of injury was abnormal positional coital activity. About 85.71% of patients were diagnosed with a history and clinical examination. Ninety-three percent of patients were treated surgically and had a successful outcome. One patient had associated urethral injury. All patients had good sexual function posttreatment except one who later recovered well on medical management.
Conclusion: Early diagnosis and treatment of patients with penile fracture depend on the history and clinical examination with less role of radiological investigations. The appropriate treatment gives a good outcome.
Keywords: Penile fracture, retrograde urethrography, tunica albuginea
Introduction 
Fracture penis is a rare injury due to rupture of the corpora cavernosal tunica albuginea that is commonly seen with tumescence. During abnormal positional sexual intercourse, rolling over the bed, masturbation, or fall onto the erect penis are usual causes which cause abrupt bending of the erect penis by blunt trauma.[1],[2] Audible “cracking” sound, immediate detumescence, pain, and swelling are the classic triad present in penile fracture, which makes diagnosis easy. History and clinical examination reveal the typical symptoms and signs of penile fracture, which helps in early diagnosis.[3],[4] However, fear and embarrassment for a patient cause delay in the requirement of medical treatment, which may result in poor outcomes in terms of his voiding and sexual function.[5]
Fracture penis results in “eggplant deformity” of the penis due to hematoma, bruising, and deformity.[1],[2] Fair number of patients have associated urethral injuries.[2],[6],[7] When there is difficulty in diagnosing such cases, imaging techniques like ultrasonography with Doppler, retrograde urethrography (RGU) help to confirm diagnosis.[8],[9],[10] Cases of penile fracture if not managed properly may have severe physical and functional complications.[11] The current standard protocol for the treatment of fracture penis includes immediate surgical exploration of penis involving degloving of the penis, hematoma evacuation, and suturing of rent in tunica albuginea with nonabsorbable suture. Associated urethral injury can be managed conservatively or surgically, depending on the situation.[7],[12],[13] Complications of penile fracture include penile curvature related to late treatment of the condition, feeling of nodular swelling, urethral stricture, and urethral cutaneous fistula.[7],[14]
We present our experience in the management of 14 cases of penile fracture, including their presentation, causes, treatment, and complications.
Materials and Methods This was prospective study. Between January 1, 2016, and December 31, 2019, 14 patients with blunt trauma to the erect penis were included in the study after prior informed consent. Each patient underwent thorough evaluation, including history taking, examination, RGU (retrograde urethrography) for suspected urethral injury and cavernosography in doubt. A standard operative management technique was adopted for all patients, including careful examination of all the three corpora and urethra through a subcoronal degloving incision, thorough wound toilet, and corporal and tunical repair with interrupted inverted nonabsorbable sutures. Foley's catheterization was done in all patients. It was removed on the 2nd postoperative day except in one patient who underwent urethral repair catheter was removed on the 7th postoperative day. All patients were followed up after 1, 3, 6, and 12 months for postoperative complications like wound-related complications, penile curvature, nodule, as well as for voiding and sexual function status.
Results The study included 14 patients who were prospectively evaluated over a period of 3 years. Age distribution of patients, Youngest patient in the present series was 23 years old and oldest was 46 years of age. The maximum number of patients was in the age group of 31–40 years. The mean age was 33 years [Table 1].
Etiology of fracture penis
Out of 14 patients 2 were unmarried and 12 were married. The etiology of fracture was coital activity in 8 (57.14%) cases, masturbation in 3 (21.43%) cases and rolling over erect penis during sleep in 3 (21.43%) cases [Table 2]. The time between occurrence of fracture and presentation varied between 2 h and 48 h (an average of 8 h) [Figure 1]. Thirteen (92.9%) patients had a typical history of popping sound followed by pain, rapid detumescence, and development of swelling and discoloration. One (7.1%) patient had bleeding per-urethra, deviation of the penis to the opposite side of the fracture and palpable swelling. Urethral bleeding and blood at meatus were recorded in 2 (14.29%) cases [Figure 2] and [Figure 3].
Twelve (85.71%) patients underwent surgical exploration depending on the basis of clinical diagnosis. One patient was conservatively managed with Foley's catheter and perineal tight dressing. Co-existing corpora-spongiosal and the urethral injury was reported in one case with the help of RGU, which was also conservatively managed. All patients managed surgically were explored through circumcoronal degloving incision [Figure 4]. Tunical tear was found in the right corpus in 8 (57%) patients and the left corpus in 6 (43%) patients [Figure 5] and [Figure 6]. The site of tear was proximal in 8 (57%) patients and midshaft in 6 (57%) patients. One patient had both corporeal fracture with urethral rupture [Table 3].
Tunical defect was repaired in a single layer, interrupted, inverted with nonabsorbable suture ethylon 4-0. Intraoperative complications were not reported. All patients were catheterized with 14 Fr foley's catheter. One patient who had tunical tear with urethral transection, the urethra repaired with vicryl 4-0 interrupted suture over a 14 Fr Foley's catheter [Figure 7]. All patients had catheter removed on the 2nd postoperative day except the one who underwent urethral repair in whom catheter was removed on the 7th postoperative day [Figure 8]. Only one patient had immediate wound infection, which healed by secondary intention. All patients were discharged on the post-operative day 3 except one who had wound infection he was discharged on the postoperative day 5. All patients were followed up after 4 weeks. Clinically 1 (7.1%) patient was found to have small nodule, while 4 (29%) patients had minimal penile deviation. Sexual function was evaluated with the IIEF-5 questionnaire. 13 (93%) patients were satisfied with their sexual life with erection sufficient for intercourse. One patient who was conservatively managed had erectile dysfunction (ED), was given medical treatment in the form of tadalafil and he recovered well.
Discussion The first patient of penile fracture was described by Malis and Zur in 1924 in the modern medical literature.[15] Arab physician Abu-al-Qasim al-Zahrawi documented the first report of penile fracture >1000 years of age in Cordoba.[16] The usual mechanism of penile fracture is related to specific sexual activities that an individual engages in, masturbation, and socio-cultural customs.
In a study by Kumar et al., 45% of patients were in the age group of 30–40 years of age.[16] In a study by Mahapatra et al., 40% of patients of penile fracture were in the age group of 21–30 years of age.[14] In our study also, 50% of patients were in the age group of 31–40 years of age.
Coital activity is found to be the most common cause of the penile fracture. In a study by Kumar et al. 90% of the patients cause of penile fracture was coital trauma.[16] In Mahapatra et al. 50% of patients had penile fracture due to vaginal intercourse, 25% due to masturbation and 25% due to rolling over erect penis during sleep.[14] In our study, 57% of patients had penile fracture due to coital activity, while rest of the patients, it was due to masturbation and rolling over the erect penis during sleep.
Many a times, only patients' history and physical examination are all that is required to make a correct diagnosis of penile fracture. In a study by Mahapatra et al., 95% of cases were diagnosed through proper history and physical examination.[14] In a study by Kumar et al., 85% of patients had undergone immediate surgical exploration depending on history and examination findings.[16] In our study, 92.9% of patients were clinically diagnosed of penile fracture, depending on history and clinical examination.
The time of presentation of patients with penile fracture plays an important role in postmanagement morbidity. In Kumar et al. mean time of presentation was 28.9 h (range 2 h to 7 days).[16] In Mahapatra et al. time interval from injury to the presentation was 6 h to 156 h (37.6 h).[14] In our study, the time occurrence of fracture and presentation to hospital was between 2 h and 48 h (average 8 h).
In Kumar et al. penile fracture associated with urethral injury was found in 15% of patients.[16] In Mahapatra et al. 10% of patients had associated urethral injury with penile fracture.[14] In our study, 7% of patients had urethral injury associated with penile fracture detected by retrograde urethrogram (RGU).
Penile fracture most commonly occurs on venterolateral aspect of the proximal part of the penis and on the right side. In Kumar et al. most of the tear involved the proximal part of the penis. About 5% of patients have associated urethral transection along with tunical tear.[16] In Mahapatra et al., 60% of patients had tear in the proximal third of the penis.[14] In our study, 57% of patients had tear in the proximal part of the penis and on the right side.
Felter and Gartmen in 1936 first described the surgical repair of penile fracture. In surgically treated patients, studies showed that the complication rate was reduced from 30% to 4%. Surgical and conservative treatments were compared by Muentener et al. and found a success rate of 92% and 59%, respectively.[11] Yapanoglu et al.[17] and Gamal et al.[18] also found that immediate surgical repair resulted in good outcomes and was superior to conservative management. In Kumar et al., 90% of patients were explored immediately who had good outcomes.[16] In Mahapatra et al., 95% of patients underwent surgical management and recovered well.[14] In our study, 93% of patients underwent immediate surgical exploration and had successful outcome.
Postoperative outcomes have been different in various case series. In Mahapatra et al., 10% of patients had mild skin infections and 10% of patients had distal skin necrosis. 10% of patients had nontender palpable nodule, which disappeared later on.[14] In Kumar et al., 11% of patients had short-term postoperative complications.[16] In this study, 7% of patients had small nodule, which regressed later, while 29% of patients had minimal penile deviation. About 7% of patients had ED, which had improved on medical treatment.
Surgical treatment should be offered in most of the patients with penile fracture, as early intervention gives good outcomes in such patients. Inappropriately selected patients, conservative management should be reserved.
Conclusion To conclude, early diagnosis and treatment of patients of the penile fracture depends on the history and clinical examination with less role of radiological investigations. Appropriate treatment gives a good outcome. Still, it deserves a large-scale study and longer follow-up to determine the consequences of penile fracture.
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Conflicts of interest
There are no conflicts of interest.
References 
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