Penile Fracture: Mechanism and Management
Penile fracture occurs due to a rupture of the tunica albuginea of the penis as a result of forceful bending of the erect penis, most commonly during sexual intercourse in the United States. 1
Mechanism of Injury
Penile fracture results from trauma to the erect penis when:
- The tunica albuginea (the tough fibrous covering of the corpora cavernosa) thins during erection from 2mm to 0.25mm, making it vulnerable to rupture 2
- Forceful bending causes the engorged penile corpora to buckle and "pop" under pressure 3
- The injury typically occurs during:
- Sexual intercourse (most common cause in the US and Europe)
- Self-manipulation (more common in Middle Eastern regions) 4
Clinical Presentation
The classic presentation includes:
- An audible "pop" or "snap" sound at the time of injury
- Immediate detumescence (loss of erection)
- Rapid penile swelling and ecchymosis (the "eggplant deformity")
- Penile pain and possible angulation 1, 5
Diagnosis
Diagnosis is primarily clinical based on:
- History of forceful bending of the erect penis
- Characteristic physical findings (swelling, ecchymosis, deviation)
- In equivocal cases, ultrasound is recommended as the first-line imaging modality 5
- MRI may be considered when ultrasound results are inconclusive 5
Associated Injuries
Important associated conditions to evaluate:
- Urethral injury occurs in 10-22% of penile fracture cases 1
- Signs of urethral injury include:
- Blood at the urethral meatus
- Gross hematuria
- Inability to void 5
Management
Surgeons should perform prompt surgical exploration and repair in patients with acute signs and symptoms of penile fracture to minimize complications. 1, 5
The surgical approach includes:
- Exposure of the injured corpus cavernosum through either a ventral midline or circumcision incision
- Tunical repair with absorbable suture at the time of presentation 1
- Evaluation and repair of any concomitant urethral injury if present 5
Complications of Delayed Treatment
Delaying surgical intervention increases the risk of:
- Erectile dysfunction
- Penile curvature
- Painful erections
- Tunical scar formation 6
Key Points for Clinicians
- Even in delayed presentations, surgical treatment should be offered as there are no "lost" cases 6
- Non-surgical management is associated with higher complication rates and should be avoided 5
- Follow-up care is essential to monitor for complications such as erectile dysfunction, penile curvature, or urethral stricture 5
Pitfalls to Avoid
- Failing to evaluate for urethral injury when blood is present at the meatus or the patient cannot void
- Delaying surgical intervention, which significantly worsens outcomes
- Missing bilateral corpus cavernosum injuries, which are associated with higher rates of urethral injury 7
- Relying solely on conservative management, which leads to poorer functional outcomes