FEATURE

Penile fracture

BY PRASHANT K SINGH, CHRISTOPHER M MCLEAVY AND MARGARET LYTTLE

Traumatic rupture of the with either one or both corpora cavernosa of the penis is known as penile fracture. This may be associated with corpus spongiosum or urethral injury.

Incidence ventrolaterally. During , limbs are associated with higher incidence. Penile fracture was reported for the first the intracorporeal pressure can reach Other reported causes include vigorous time by Abul Kasem, an Arab physician, in 180mmHg, and the tunica albuginea intercourse, , falling off a bed, Cordoba, Spain more than 1000 years ago can withstand values up to 1500mmHg. placing an erect penis in underwear and [1]. It is not an uncommon condition but However, sudden flexion-based trauma spontaneously fracturing the penis while is often underreported [2]. It occurs more to an already thinned tunica albuginea urinating. In the Islamic world, instances frequently in Middle Eastern and North can result in rupture. Not unexpectedly, of penile fracture may be accidentally African countries (almost 55% of the total the most common site of rupture is self-inflicted by bending the erect penis number reported) than in the United States ventrolateral at the thinnest aspect, often in to achieve rapid detumescence, known as or Europe (almost 30% of those reported). the midshaft. taghaandan. Annual incidence in the USA is estimated The passes through the corpus Injury can involve one or both of at 500–600 cases, responsible for one spongiosum. This is very elastic relative the corporal bodies and associated in every 175,000 emergency admissions to tunica albuginea, allowing expansion simultaneous urethral injuries may also [3]. Concomitant urethral injury has been of the corpus spongiosum for passage occur. Penile fracture can be diagnosed reported as high as 38% of cases, although of the ejaculate and urine through the clinically with history and physical the largest USA series suggests a lower rate urethra. Blood to the corpora cavernosa examination. If there is doubt about the of 23% [4]. is supplied by paired deep arteries of the diagnosis adjuncts such as imaging may be penis (cavernosal arteries), which run in the used. Anatomy of penis centre of each corpora cavernosa. All three The penile shaft is made up of three erectile cavernosa and spongiosa are surrounded by Clinical features tissues: the two corpora cavernosa and Bucks fascia, dartos fascia, and the penile Typically the history includes a sexual a corpus spongiosum. Each corpora is skin. encounter involving trauma to the erect covered by fascial layers containing nerves, penis with an audible ‘pop’ or ‘cracking’ lymphatics, and blood vessels. Externally, Aetiology sound, pain, and rapid detumescence. these are all covered by skin. Both corpora Penile fractures are usually due to The penis may become tense, swollen, cavernosa are surrounded by the tunica trauma during intercourse but can also and darkly discoloured (the ‘aubergine albuginea, which displays outer longitudinal occur secondary to non-sexual causes. deformity’ – Figure 1) and penile deviation and the inner circular fibres. Proximally, at They usually result from an abrupt blunt towards the side opposite to the injury. On the base of the penis, these form the crura, trauma by forceful bending of the erect palpation focal tenderness and a palpable which are attached to the ischiopubic rami. penis. Typically it occurs during vigorous defect in the tunica albuginea may help in The tunica albuginea encasing the corpora heterosexual coitus, whereby a failed diagnosing the fracture site. There is often cavernosa is 2mm thick when the penis is attempt at vaginal insertion of the erect a clot lying over or near the fracture site flaccid. penis results in collision with the pubic that corresponds to the site of cavernosal In the erect state, the tunica albuginea bone or perineum. Sexual positions like rupture (Figure 2). thins to 0.25–0.50mm and is thinnest the female partner on top or on all four Difficulty with urination or blood at the

Figure 1. Aubergine sign. Figure 2. Subcutaneous haematoma.

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urethral meatus should raise suspicion In reality it is often difficult to obtain tolerated due to pain and can only identify of associated urethral trauma, although images of diagnostic quality with ultrasound urethral injury and not the defect in the difficulty in voiding can also be secondary to as pressure needs to be applied to the tunica albuginea. This is no longer used in compression of the urethra by haematoma. penis and this is not well tolerated due to the acute phase but does still have a role Urethral injury is observed in around pain. Also if there is a large haematoma postoperatively in assessing for strictures or one third of cases and is usually a partial present it can be difficult to view the tunica fistulae [9]. disruption of urethra. Penile rupture can albuginea in its entirety making it difficult to Another historical imaging tool occur anywhere but is commonly localised confidently exclude fracture. was cavernosography. This involves at the base of the penis, just proximal to The quality of ultrasound is dependent on percutaneous injection of contrast into the penoscrotal junction. Often single the skill of the operator. As penile fracture is the corpus cavernosum under fluoroscopic corporal body is injured, but both corpora an uncommon presentation there are very guidance. This is an invasive procedure and the corpus spongiosum may be injured few sonographers or radiologists who have which requires an interventional radiologist depending upon the severity of the injury. experience performing this examination, to perform and was not well tolerated by A haematoma within the perineum, therefore you may encounter difficulties in patients due to pain. It is no longer routinely scrotum, or lower abdominal wall indicates finding an appropriately trained member of performed. rupture of Buck’s fascia: the extravasation of the radiology team to perform the scan. haematoma spreads along the Colles fascia MRI is becoming more widely used as it Management of penile fracture and ecchymosis extends like a ‘butterfly’ can demonstrate penile fractures in detail, Blunt trauma to the flaccid penis rarely over the perineum, scrotum, and lower identify urethral involvement, identify results in significant injury and may only abdomen. It is important to recognise that alternative diagnosis (such as suspensory produce a subcutaneous haematoma. penile fracture can exist in the absence of Usually no surgical intervention is needed classic findings and a high index of suspicion ligament injury) and should be less painful and only analgesics and ice packs are is required. The main differential diagnoses for the patient. MRI is therefore the most required for treatment of these cases. In are ruptured superficial dorsal vein of penis accurate modality in the diagnosis or cases of penile fracture, emergency surgical or suspensory ligament injury. exclusion of penile fracture. For the best quality diagnostic images exploration with closure of the tunica Use of imaging in diagnosis of a penile coil should be used with multi- albuginea is the treatment of choice. penile fracture planar T1, T2 and post contrast T1 images Early (36 to 48 hours) [10] also results in significantly fewer complications Penile fracture is predominately a clinical acquired [8]. In reality there are very few MRI vs. delayed surgery especially for penile diagnosis, therefore imaging should not be departments who will have a specific penile curvature [11]. routinely considered as it is likely to lead coil as it is not a common examination. In our unit, we use a pelvic / abdominal to unnecessary delays in diagnosis and Conservative management increased morbidity [5]. This is particularly coil with the penis taped up to the lower Conservative management is not advised for important out-of-hours as modern day abdomen. Small field of view sequences are penile fracture as it is associated with poor radiology on-calls usually involve remote then acquired with multi-planar T1, T2 and long-term outcomes [12]. However, should reporting or outsourcing to external axial T1 post contrast (30s) images acquired. a fully informed and competent patient companies so it is rare to find a radiologist The tunica albuginea is normally a low adamantly refuse surgical intervention, on site overnight. There are rare cases in signal band on both T1 and T2. In the case of they may be offered cold compressions which imaging may be of benefit. Imaging fracture there will be a high T2 signal defect and pharmacologic interventions to limit should be considered in patients with a in this band with surrounding oedema and and advised to abstain from sexual delayed presentation or if the history and haematoma. activity for up to six weeks [11]. examination are equivocal leading to an The disadvantage of MRI is that it is costly, Non-surgical management predisposes uncertain diagnosis. more time consuming than ultrasound the patient to the development of penile The main aim of imaging is to confirm and not routinely available out-of-hours. curvature, , and pain or exclude the presence of penile fracture. Therefore reliance on MRI to confirm a with intercourse in up to 60% of cases [13]. The location of the defect can be identified breach in the tunica may lead to delays in Additionally, failure to diagnose urethral and thus the surgical incision can be made diagnosis. injury may result in subsequent stricture or directly over the site of the defect to avoid Penile angiography has a role in the urethrocutaneous fistula. the need for complete de-gloving of the diagnosis and management of only a small penis [6]. minority of penile fractures. This is mainly Surgical management Ultrasound should be the first-line used in cases of post-traumatic investigation for penile fracture according to identify the source of bleeding and Catheterisation embolise the vessel responsible. It cannot to the current literature [7]. This is a fast, Urethral catheterisation should be done inexpensive and readily available test which identify the defect in the tunica albuginea. before surgery (if urethral injury has been in experienced hands can provide a definitive This is an invasive procedure and is only excluded by history and examination or diagnosis of penile fracture. The penis is best available at specialist centres with vascular imaging). If there is clinical or radiological imaged in long section. The tunica albuginea interventional radiologists. suspicion of a concurrent urethral injury, it normally appears as a hyperechoic structure Historically the assessment of urethral is our practice to view the urethra directly surrounding the hypoechoic corpus involvement was done using retrograde with flexible cystoscopy. However, we cavernosum and spongiosum. In the case of urethrograms. This involves catheterising are aware that some colleagues feel a fracture there will be a hypoechoic break in the terminal portion of the urethra and cystoscopy is unnecessary as they will view the tunica albuginea, often with associated injecting contrast under fluoroscopic the urethra directly when they deglove the haematoma or oedema. control. As you can imagine this is not well penis and identify the corporal defect. If

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flexible cystoscopy is performed, pass a foley this serves to avoid lymphoedema of corpora cavernosa and corpus spongiosum, catheter urethrally following this. the distal shaft skin, which can occur to prevent fistula formation. The Foley The catheter allows identification of the after degloving incisions and can be catheter should also be left indwelling for urethra and reduces the risk of inadvertent cosmetically unacceptable to some patients. 10–14 days after surgery. injury while dissecting the corporal bodies, Alternatively, a vertical or transverse After surgical repair, penile tumescence as well as providing a scaffold for the repair incision can be made directly over the defect should be induced to check the stability of any associated urethral injury. The Foley when the fracture is palpable or localised on of the repair and for any missed corpora catheter can be removed immediately after imaging preoperatively. cavernosal injuries (Figure 6 shows a leak surgery unless a urethral injury was repaired, prior to repair, Figure 7 shows the same in which case it should be left in place for Technique area after repair). This is done by placing a 10-14 days. Adequate exposure and delineation of Penrose drain around the base of the penis the site, size and any associated urethral / with a clamp to act as a tourniquet. After the Choice of incision corpus spongiosum injury is essential. application of tourniquet, saline or saline Multiple incision sites have been proposed, A single dose of antibiotics is given at mixed with indigo carmine is injected with including a circumcising degloving incision, induction. a 22G needle in the corporal body on the midline penoscrotal, inguinoscrotal, and During exploration the haematoma is lateral aspect. This creates tumescence and lateral incision. Each incision has its benefits evacuated with debridement of dead tissue allows a clear evaluation of the repair and but in most cases a degloving circumcising and primary repair of the defect performed. identification of any other corporal injuries. incision is recommended. This allows an Surgical exploration is traditionally done To exclude a corpus spongiosum injury, a evaluation of all three corporal bodies via a subcoronal circumferential incision 22G needle is placed in the glans penis and and the ability to repair injuries anywhere (Figure 3), and penile skin degloved the corpus spongiosum is engorged with along the course of the shaft, as well as proximally up to the base. Usually the saline mixed with indigo carmine. This allows repair or separation of the neurovascular fracture site presents as a transverse a visual inspection of the engorged corpus bundle and repair of the urethra if needed. laceration, between 0.5 and 2.0cm long, in spongiosum and helps to identify any injury. However, this approach carries a risk of the tunica albuginea (Figure 4). The edges neurovascular insult with subsequent of the opened tunica are only trimmed if Postoperative management detriment to penile sensation and erectile deemed necessary. Absorbable sutures like Postoperatively anti-inflammatory function. In uncircumcised patients, polyglactin or polydioxanone 3-0 or 2-0 agents are recommended for analgesia. historically circumcision was considered round body are used for closure of the tunica Penile tumescence after surgery has due to possibility of postoperative , albuginea tear [11] (Figure 5). been reported to cause dehiscence of the however there is no conclusive data to Corpus spongiosum injuries almost always corporal repair .The decision to use anti support this practice in all patients. occur at the same level as the corpora androgen or sedatives is controversial as A midline penoscrotal incision can be done cavernosal injury. If the corpus spongiosum pain after surgery normally prevents fully if a degloving incision is difficult due to and urethra are injured, a two-layer closure rigid erections. Patients can be discharged tissue oedema and haematoma or if the is recommended with 4-0 synthetic after 24-48 hours of surgery and sexual main haematoma / suspected site of injury absorbable suture. These type of injuries activity can be restarted after six weeks is in the penoscrotal region. Additionally, require a sub-dartos flap between the [11]. In patients with urethral repair, a Foley

Figure 3. Degloving of penile shaft. Figure 5. Repair of tunica albuginea defect.

Figure 4. Site of rupture. Figure 6. Saline injection in corpora cavernosa to confirm site of rupture.

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catheter should be continued for two weeks following which a voiding cystourethrogram is done to confirm healing.

Postoperative complications Postoperatively, superficial wound infection in 9% and erectile dysfunction in 1.3% have been reported [14]. Erectile dysfunction is usually self-limiting and resolves in three to four months.

Conclusion Figure 7. Saline injection to confirm adequacy of repair. Penile fracture is a urological emergency. It is usually a clinical diagnosis and although preoperative imaging is not mandatory, TAKE HOME MESSAGE it can be used in equivocal clinical cases AUTHORS provided it does not delay surgical repair. Have a high index of suspicion for • Surgeons should perform prompt Prashant K Singh, surgical exploration and repair associated urethral injury and if suspected Trust Grade in Urology, Mid we would recommend flexible cystoscopy in patients with acute signs and Cheshire Hospitals to assess the injury prior to definitive symptoms of penile fracture. NHS Foundation Trust, Crewe. repair. Conservative management places • Imaging may be used as an the patient at increased risk for erectile adjunct to clinical diagnosis dysfunction and penile curvature, whereas provided this does not unduly prompt surgical repair is associated with delay surgery. favourable long-term functional and • Clinicians may perform cosmetic outcomes. ultrasound in patients with Christopher M equivocal of McLeavy, penile fracture. Specialist Registrar in References • MRI could be considered as Radiology, Mid Cheshire 1. Taha SA, Sharayah A, Kamal BA, et al. Fracture of the an alternative to ultrasound Hospitals NHS Foundation penis: surgical management. Int Surg 1988;73:63-4. Trust, Crewe. 2. Eke N. Fracture of the penis. Br J Surg 2002;89:555-65. or in cases when ultrasound is 3. Pariser JJ, Pearce SM, Patel SG, et al. National patterns of equivocal. urethral evaluation and risk factors for urethral injury in • If imaging is equivocal or patients with penile fracture. Urology 2015;86(1):181-5. diagnosis remains in doubt, 4. Amit A, Arun K, Bharat B, et al. Penile fracture and surgical exploration should be Margaret Lyttle, associated urethral injury: experience at a tertiary care hospital. Can Urol Assoc J 2013;7(3-4):168-70. performed. Consultant in Urology, Mid 5. Masarani M, Dinneen M. Penile fracture: diagnosis and • Clinicians must perform Cheshire Hospitals NHS Foundation Trust, Crewe. management. Trends in Urology Gyneacology & Sexual evaluation for concomitant E: Margaret.Lyttle Health 2007;Sep/Oct:20-22. urethral injury in patients with 6. Harbiyeli M, Abol-Enein H, Johansen TEB. Diagnosis @mcht.nhs.uk and treatment of penile fractures: a single centre series. penile fracture or penetrating Open Journal of Urology 2017;7:31-9. trauma who present with blood 7. Nicola R, Carson N, Dogra VS. Imaging of traumatic at the urethral meatus, gross injuries to the scrotum and penis. American Journal of haematuria or inability to void. Roentgenology 2014;202(6):512-20. Declaration of competing interests: None declared. 8. Choi MH, Kim B, Ryu JA, et al. Imaging of acute penile fracture. Radiographics 2000;20:1397-405. 9. Pompili G, Munari A, Campari A, et al. Traumatic penile fracture: what radiologist should know. European Society of Radiology 2014; Poster C-0695. 10. De Luca F, Garaffa G, Falcone M, et al. Functional outcomes following immediate repair of penile fracture: a tertiary referral centre experience with 76 consecutive patients. Scand J Urol 2017;51:170-5. 11. Vilson F, Macdonald S, Terlecki R. Contemporary management of penile fracture: a urologist’s guide. Curr Sex Health Rep 2016;8(2):91-6. 12. Swanson DE, Polackwich AS, Helfand BT, et al. Penile fracture: outcomes of early surgical intervention. Urology 2014;84(5):1117-21. 13. Ozorak A, Hoscan MB, Oksay T, et al. Management and outcomes of penile fracture: 10 years’ experience from a tertiary care center. Int Urol Nephrol 2014;46(3):519-22. 14. Orvis BR, McAninch JW. Penile rupture. Urol Clin North Am 1989;16:369.

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