Penile Fracture Management
Perform prompt surgical exploration and repair immediately upon presentation in any patient with clinical signs of penile fracture—this is the gold standard treatment that significantly reduces long-term complications including erectile dysfunction and penile curvature. 1
Diagnosis
Suspect penile fracture when the patient presents with:
- Penile ecchymosis and swelling (most common)
- Cracking or snapping sound during intercourse or manipulation
- Immediate detumescence (loss of erection)
- Penile pain or angulation 1
History and physical examination alone are typically diagnostic—imaging is generally unnecessary when clinical presentation is clear. 1
When to Use Imaging
- Ultrasound may be performed only in patients with equivocal signs and symptoms 1
- MRI can be considered if ultrasound is equivocal 1
- If imaging remains equivocal or diagnosis is uncertain, proceed directly to surgical exploration 1
Surgical Treatment Algorithm
Standard Repair Approach
- Timing: Perform surgery at time of presentation—immediate repair improves long-term outcomes 1
- Surgical approach: Expose the injured corpus cavernosum through either:
- Ventral midline incision, OR
- Circumcision incision 1
- Repair technique: Perform tunical repair with absorbable suture 1
Critical Pitfall: Evaluate for Urethral Injury
You must evaluate for concomitant urethral injury if the patient presents with ANY of the following 1, 2:
- Blood at urethral meatus
- Gross hematuria
- Inability to void
- Bilateral corporal body fracture (additional risk factor)
Evaluation options (neither is superior):
- Urethroscopy, OR
- Retrograde urethrogram 1
The choice depends on equipment availability and timing—this is the urologist's decision. 1
Evidence Supporting Immediate Surgery
Immediate surgical repair is associated with:
- Lower erectile dysfunction rates: 6.5-16.5% with immediate surgery vs. 42.9% with delayed surgery vs. 52.9% with conservative management 3, 4
- Reduced penile curvature and fibrotic plaques 3, 4
- Faster recovery of erectile function 5, 3
Conservative management has unacceptably high complication rates (80% in one series), including wound infection, painful erection, penile nodule, curvature, and erectile dysfunction. 3
Risk Factors for Poor Outcomes
Independent predictors of postoperative erectile dysfunction include 4:
- Age over 50 years
- Urethral injury (occurs in 10-22% of penile fractures) 1
- Bilateral corporal involvement
- Tunical defects larger than 2 cm
Postoperative Considerations
While anatomical outcomes are generally excellent with immediate repair, be aware that psychosexual complications are common but often overlooked 4:
- Up to 77.5% report persistent fear of recurrence
- Nearly 69% change sexual habits
- Performance anxiety and relationship concerns are frequent
Consider offering psychological support and sexual health counseling during follow-up, particularly for patients with risk factors for poor outcomes. 4
Special Circumstance: Extremely Proximal Fractures
For extremely proximal internal corpus cavernosum (EPICC) fractures at the penile base:
- MRI is valuable for diagnosis when clinical presentation is atypical (perineal/scrotal bruising without penile involvement)
- Midline perineal incision provides optimal exposure for repair 6