Penile Fracture and Early Surgical Intervention

As odd as it may sound, a spongy and rather soft tissue like penis can also get fractured if excessive force or pressure is applied during full-blown erection phase. Penile fracture is a medical emergency and requires heroic measures to minimize the risk of hazardous complications.

Penile fracture is an uncommon injury and approximately 50% of all the cases are reported in African and Middle Eastern countries.

 

What Causes Penile Fractures?

An erect penis is engorged with blood that fills the sinuses or spongy cylinders to form a stable anatomical support in order to complete the act of physical intercourse. A sudden or forceful thrust or push on an erect penis may lead to the fracture of these cylinders (also known as corpus cavernosum) and may lead to:

• Sudden onset of severe pain usually while performing sexual intercourse
• Audible cracking sound
• Almost immediate loss of erection and stability of penis
• Onset of expanding swelling and bruising of penis due to emission/ release of blood outside of corpus cavernosa
• Hematoma formation
• Damage to the urethra that may present as passage of blood in urine, painful micturition and urinary retention/ incontinence. Urethral injury is reported in approximately 38% cases of penile fracture (2)
• Damage to the deep dorsal vein (2)

In severe cases when Buck’s fascia is also involved, patients may experience a butterfly pattern of ecchymosis (large bruise) that extends up to scrotum, perineal region and suprapubic region.

 

Penile Fracture Risk Factors

Some common causes or scenarios during which the risk of penile fracture increases significantly; are:

• Acrobatic sex (or vigorous sexual intercourse). Based on statistics, more than 2/3^rd of all penile fracture incidents are associated with sexual intercourse. The risk increases if the female is in the dominant position.
• Aggressive masturbation
• Nocturnal manipulation of penis/ genitals
• Non-sexual or spontaneous injury to erect penis

 

Early Surgical Intervention in Penile Fractures

Fracture of the shaft of penis is a surgical and medical emergency. A positive history and thorough physical examination is generally sufficient to make the diagnosis of penile fracture. Any delay seeking medical care may lead to permanent complications like:

• Erectile dysfunction (or impotency)
• Penile deformity or curvature defects due to corporal fibrosis in the setting of hematoma and inflammation
• Urinary difficulty
• Pain while performing sexual intercourse

 

Surgical Management of Penile Fracture

After assessment and confirmation of the site of injury and severity of fracture, surgeons usually perform corrective surgery under general anesthesia. Most common modalities include, end-to-end anastomosis and surgical suturing.

Study reported in Canadian Urological Association Journal (3) has summarized the surgical procedure in these words:

“The procedure included: evacuation of the hematoma, identification of the site and number of defect, closure of the defect by 4/0 Prolene non-absorbable or 4-0 vicryl absorbable sutures in continuous manner, closure of Bucks fascia in longitudinal direction by running 4/0 chromic sutures, closure of the skin by running 4/0 chromic suture and finally dressing”

Although conservative options are also available to manage penile fracture, most clinicians and investigators believe that surgical correction is the appropriate course. Early intervention is associated with higher chances of complete recovery and restoration of sexual function, as well as shorter hospital stay and minimal risk of permanent curvature deformities of penis (2).

According to a study reported in the peer-reviewed journal Urology (6), investigators reported that despite early surgical intervention, 9 of 30 patients reported some degree of erectile difficulty after the follow-up period. Other long term complications of surgical correction are:

• Voiding difficulty
• Painful micturition
• Ejaculatory difficulty
• Gangrene of penile skin (1)

The risk of complications is dependent on the intensity of initial assault, nature of surgical intervention and involvement of urethra.

 

References:

1. Mensah, J. E., Morton, B., & Kyei, M. (2010). Early surgical repair of penile fractures. Ghana medical journal, 44(3).
2. Buyukkaya, R., Buyukkaya, A., Ozturk, B., Kayıkçı, A., & Yazgan, Ö. (2014). Role of ultrasonography with color-Doppler in the emergency diagnosis of acute penile fracture: a case report. Medical ultrasonography, 16(1), 67-69.
3. Moslemi, M. K. (2013). Evaluation of epidemiology, concomitant urethral disruption and seasonal variation of penile fracture: A report of 86 cases. Canadian Urological Association Journal, 7(9-10), E572.
4. Gedik, A., Kayan, D., Yamis, S., Yilmaz, Y., & Bircan, K. (2011). The diagnosis and treatment of penile fracture: our 19-year experience. Ulus Travma Acil Cerrahi Derg, 17(1), 57-60.
5. El-Assmy, A., El-Tholoth, H. S., Abou-El-Ghar, M. E., Mohsen, T., & Ibrahiem, E. H. I. (2011). Risk factors of erectile dysfunction and penile vascular changes after surgical repair of penile fracture. International journal of impotence research, 24(1), 20-25.
6. Swanson, D. E., Polackwich, A. S., Helfand, B. T., Masson, P., Hwong, J., Dugi, D. D., … & McVary, K. T. (2014). Penile Fracture: Outcomes of Early Surgical Intervention. Urology, 84(5), 1117-1121.