Penile fracture is a rare but serious genitourinary emergency caused by the rupture of the fibrous cover of the erectile tissue, during an erection. This condition requires immediate medical attention to prevent long-term complications.
What is the Incidence of Penile Fracture?
The incidence of penile fracture varies globally:
- In the United States, it is reported at 0.57 per 100,000 emergency admissions.
- In Iran, the incidence is significantly higher, ranging from 1.14 to 10.48 per 100,000. This higher rate is attributed to the practice of taqaandan (manual bending of an erect penis), common in some provinces of Iran.
What Are the Risk Factors for Penile Fracture?
Several factors increase the risk of penile fracture, including:
- Age 30-50 years.
- Aggressive sexual intercourse, especially with the female partner on top.
- Aggressive masturbation.
- Chronic urethritis (inflammation of the urethra).
- Fibrosclerosis of the tunica albuginea (thickening and hardening of the tissue).
- Taqaandan (manual bending of the erect penis to produce rapid detumescence).
Approximately 5% of patients may experience penile fracture following intralesional injection of collagenase Clostridium histolyticum for Peyronie's disease (a condition causing penile curvature).
What Conditions are Associated with Penile Fracture?
Penile fractures can be complicated by partial or complete urethral injury in 10%-25% of cases, more commonly associated with sexual intercourse than masturbation. Urethral fistula formation is linked to tunical tears near the urethra and the absence of graft use during urethral injury repair.
How is Penile Fracture Evaluated?
Penile fracture should be suspected in patients presenting with penile swelling, bruising, and a history of a cracking or snapping sound during sexual intercourse or manipulation followed by immediate detumescence (loss of erection). A physical examination often reveals:
- Swollen, bruised, and flaccid penis deviated away from the fracture site (eggplant deformity).
- Bruising extending to the scrotum, perineum, and lower abdominal wall if Buck's fascia is torn.
Imaging studies like ultrasound or MRI can confirm the diagnosis and locate the site of tunical rupture but should not delay surgery.
- Ultrasound: Commonly used for its rapid diagnostic capabilities.
- MRI: Considered superior by the European Association of Urology (EAU) for diagnosing penile fracture.
Urethral diagnostic testing (retrograde urethrogram or urethroscopy) is necessary for patients with gross hematuria (blood in urine), blood at the urethral meatus (opening), or inability to void.
How is Penile Fracture Managed?
Surgical Management
Prompt surgical exploration and repair are essential for patients with acute signs of penile fracture. Early surgical intervention (within 24 hours) reduces the risk of complications such as Peyronie's disease and erectile dysfunction.
- Preoperative care: Broad-spectrum antibiotics.
- Surgical technique: The location of incisions varies depending on the fracture site. Hematomas are evacuated, and the tunica albuginea is repaired using absorbable sutures.
- Postoperative care: Foley catheter insertion for patients without urethral injury and a 14-day catheter for those with urethral injury.
Patients are advised to follow up after two weeks and refrain from sexual intercourse for six weeks.
Conservative Management
For patients unable or unwilling to undergo surgery, conservative treatments include:
- Ice packs.
- Catheterization.
- Compressive bandages and/or splints.
- Anti-inflammatory drugs.
- Fibrinolytic drugs.
- Antibiotics.
- Erection-inhibiting estrogens.
However, conservative management carries a higher risk of complications compared to surgical repair.
What are the Potential Complications of Penile Fracture?
Even with prompt surgical repair, complications can occur:
- Erectile dysfunction: Reported in up to 62% of untreated cases.
- Peyronie's disease: Fibrous scarring causing penile curvature, reported in up to 35% of cases.
- Painful erections.
- Urethral stenosis (narrowing).
- Penile abscess.
- Chronic hematoma.
Erectile dysfunction may be treated with medications, intracavernosal or intraurethral prostaglandin injections, creams, and penile prosthesis for severe cases. Management of penile curvature involves treatments similar to those for Peyronie's disease, including medications, injections, topical therapies, or surgery in chronic cases.
Words of Wisdom from a Urology Consultant
Penile fracture is a medical emergency that demands immediate attention. Quick diagnosis and prompt surgical intervention are crucial to prevent long-term complications like erectile dysfunction and Peyronie's disease. Understanding the risk factors and early symptoms can help in seeking timely medical help. Remember, preserving your sexual health is an essential aspect of your overall well-being.
