International Journal of Impotence Research (2008) 20, 366–369 & 2008 Nature Publishing Group All rights reserved 0955-9930/08 $30.00 www.nature.com/ijir

REVIEW Fractured : a review

SL Sawh1, MP O’Leary1, MD Ferreira1, AM Berry1 and D Maharaj2,3

1Division of , Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA and 2Department of , General Hospital, Port-of-Spain, University of the West Indies

Fracture of the penis is a well-recognized clinical entity. The ideal management has evolved and repair remains largely surgical. We present the etiology and pathophysiology of this condition and outline the therapeutic options. International Journal of Impotence Research (2008) 20, 366–369; doi:10.1038/ijir.2008.12; published online 17 April 2008

Keywords: penis; fracture;

Introduction cavernosa leaks out into the surrounding tissues producing a hematoma deep to Buck’s , which The has always been the subject of usually remains intact. When Buck’s fascia is also much interest, especially, when afflicted with a ruptured, blood may leak into the scrotum, peri- medical condition. This is particularly true of penile neum and lower abdominal wall.8,9 The site of the fractures. Discussions of this condition date as far tear is usually proximal, near the base of the penis.10 back as 1936.1 It can be defined as a rupture of Mansi and colleagues showed that in a series of 14 the of the corpus cavernosum patients, the tear is usually unilateral, transverse following blunt trauma to the erect penis.2 Owing and at the base of the penis.11 to the embarrassing nature of this condition, it Tearing of the corpus spongiosum may also remains underreported.3,4 The treatment of occur concomitantly.12,13 The incidence of this fractured penis is widely regarded to be surgical comorbid condition varies from 14 to 33% in USA in approach. In this article, we outline the epidemio- and Europe,14,15 but is almost non-existent in logy, clinical features and treatment modalities Japan.16 Rupture of the and its encasing available for management of this uncommon but spongiosum is thought to be due to stretching during important condition. tumescence. A dorsally bending, angulating force is then likely to result in urethral .17 Periurethral fibrosis or urethral strictures render the urethra more Pathophysiology and etiology rigid and thus predispose it to tearing.6 Many causes of penile fractures have been The tunica albuginea is a tough fibroelastic envelope described. The most common cause is bending during intercourse,18 with forcible thrusting but that encases the corpus cavernosum. With , 19 corpus swelling results in stretching and thinning of missing the introitus. It can occur during mastur- bation, bending the erect penis to achieve detumes- the tunica. The tunica thins out from 5 mm in the 20 flaccid state to 2 mm, when erect.5,6 A force applied cence and rolling over in bed. In the Middle East Gulf area, the most frequent cause is forceful to the erect penis, leading to angulation can cause 21 the tunica albuginea to tear.7 Blood from the corpus manipulation (65%). Classical fracture of the penis must be distin- guished from two other conditions. Firstly, tears in the tunica albuginea can occur in the flaccid penis. Correspondence: Dr SL Sawh, Division of Urology, In a review of 208 patients, this was found in 3% of Brigham and Women’s Hospital, Harvard Medical School, 16 Boston, MA, USA. the patients, due to a direct blow to the penis. The E-mail: [email protected] second condition is traumatic disruption of the 3Current address: St Clair Medical Center, #18 Elizabeth penile suspensory ligament, which does not involve Street, St Clair, Port-of-Spain, Trinidad, West Indies. the tunica albuginea at all and presents quite Published online 17 April 2008 differently from penile fractures.22 Fractured penis SL Sawh et al 367 Clinical features from extravasated contrast medium, infection and .30–32 Its use should be confined to rupture When a penile fracture is sustained, the patient of the deep dorsal vein of the penis, which can typically reports hearing a snapping or cracking be clinically indistinguishable from cavernosal sound.23 This is followed by immediate detumes- rupture.33 Alternatively, sonography of the penis cence, severe pain, penile swelling and discolora- can be performed.34,35 Sonography is noninvasive, tion. The penis can take on a bizarre shape, with carries no risk of infection and in patients managed deviation of the penile shaft, usually to the side conservatively, it is helpful in monitoring hematoma opposite the tear.5,24 resolution and has a detection rate of 86%.36 Since Buck’s fascia is usually intact, the clot Retrograde urethrography is indicated in the case within the torn tunica overlying the fracture site can of suspected urethral injury37 (Figure 2). be palpated as a firm, immobile, discrete tender swelling over which the penile skin can be gently rolled—‘rolling sign’.25 If Buck’s fascia is torn, the hematoma may be extensive, spreading to the Treatment perineum, scrotum and lower abdominal wall. Very rarely, the defect in the tunica can be palpated.19 Until the early 1980’s, the management of fractured Urethral injury is suspected when there is blood per penis was highly controversial. Many conservative urethra, difficulty to pass urine or an inability to treatments have been employed. Diethylstilbestrol pass a catheter26,27 (Figure 1). or sedatives were employed to suppress erec- tions.38,39 Others advocated the use of streptokinase and streptodornase.40 Compression bandages, ice packs and anti-inflammatory agents were also Investigations used.41 Such conservative management is associated with significant complications such as delayed The diagnosis of penile fracture, in most instances chordee and formation of a firm fibrous plaque can be made clinically without the need for similar to Peyronie’s disease, which can occur in as ancillary diagnostic tools. Accurate identification much as 30–53% of cases.14,42 This of the fracture site can usually be made on requires excision of the scar followed by primary examination by rolling the swollen skin over a repair or the use of fascial strips sutured across the fixed, smooth, rounded, tender lump (of clot), deep 41 26 fracture site. Other complications include orga- to Buck’s fascia—the rolling sign Cavernosography nized hematoma formation, cavernous fibrositis, may be used to confirm the diagnosis and 28,29 severe angulation and impotence. Hospital stay is localize the tear in difficult cases. However, also significantly longer for conservative treatment, complications include contrast reaction fibrosis when compared to surgical treatment.14 Over the last few years, there has been a move toward early surgical repair.43–47 Many surgical approaches have been described. A circumferential subcoronal incision with degloving of the penis has been employed to locate the exact site of the tear.48

Figure 1 Gross picture post injury. Figure 2 Ultrasound showing expanding hematoma.

International Journal of Impotence Research Fractured penis SL Sawh et al 368 The complication rate with this approach has been should be performed to define the urethral injury. reported to approach 25% in at least one source18 Whether the urethra should be managed conserva- and includes subcoronal skin necrosis, infections tively or operated on remains controversial. Both and abscess formation. Use of this distal incision methods have been tried with equally good with degloving, to treat a proximal pathology, leads results.26 The authors believe that based on the to unnecessary trauma and bloody dissection. mechanics of the injury the rupture of the urethra is Re-gloving after the procedure may lead to transient likely to be partial, since the cavernosum is more edema as a minor complication but this, as rigid than the spongiosum and the force is angulated mentioned, is thought to be self-limiting. Others causing a tear on one side of the urethra. This can be advocate the use of an inguinal scrotal incision to managed successfully by performing a temporary expose the fracture site.49 This approach also diverting cystostomy alone,12 or in combination appears to involve extensive dissection, however, with direct repair of the partially torn urethra51 complication rates and late outcomes have not With total rupture, however, end-to-end anastomo- documented. sis should be performed with a suprapubic Alternatively, a small longitudinal skin incision cystostomy.26 Urethral strictures and corpo-urethral can be placed directly over the fracture site allowing fistulae can follow this condition.52 evacuation of the clot and primary repair of the tear Patients should be advised to avoid intercourse in the tunica.50 The documented complication rate for at least 6 weeks to allow for healing of the tear. for this procedure is nil but this may be a misleading This period should be increased, if the fracture is figure as some studies may have less stringent managed conservatively. Some advocate the use of follow-up making side effects difficult to assess diazepam or other sedatives to prevent premature accurately. . The tear in the tunica should be repaired using an Patients who complain of suboptimal erections absorbable suture. The use of nonabsorbable suture should be objectively assessed using intracavernosal material can leave knots that may be palpable and injection of paparverine and phentolamine. Patients painful for the patient and his partner (Figures 3 and 4). may be afraid to have intercourse again should the A concomitant urethral injury complicates man- condition recur. Psychotherapy and self-injections agement. When suspected, retrograde urethrography with papaverine may prove useful in such cases.11

Conclusions

Although fractured penis has been recognized and treated for a considerable time, there is no universal agreement on the manner in which it should be treated. Surgical management is thought to be the general treatment modality employed when the condition is encountered. The most widely prac- tised technique of degloving the penis has a high complication rate and other more recently described alternatives should be considered and examined critically, if we have to improve outcomes in this uncommon but important condition. Figure 3 Fracture at the base of penis. Acknowledgments

Dr Marcos Ferreira has a Post Doctoral Research Fellowship grant partially supported by Porto Alegre City Council, Brazil. Dr Michael O’Leary receives funding from the NIH.

Disclaimer

The funding bodies had no role in study design, data collection, data analysis, data interpretation or writing of the report. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for Figure 4 Repair. publication.

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