FEATURE Penile fracture BY PRASHANT K SINGH, CHRISTOPHER M MCLEAVY AND MARGARET LYTTLE Traumatic rupture of the tunica albuginea 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 sexual intercourse, 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, masturbation, 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 urethra 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. urology news | MAY/JUNE 2018 | VOL 22 NO 4 | www.urologynews.uk.com FEATURE 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 surgery (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 erections 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, erectile dysfunction, 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 priapism investigation for penile fracture according to identify the source of bleeding and Catheterisation embolise the vessel responsible.