What are the treatment options for penile bruising and swelling extending into the pubis without pain or trauma?

Painless Penile Bruising and Swelling Extending to Pubis Without Trauma

This presentation requires urgent ultrasound evaluation to exclude penile fracture, despite the absence of pain or reported trauma, as patients may underreport or be unaware of inciting events. 1, 2

Immediate Diagnostic Approach

Perform duplex Doppler ultrasound of the penis as the first-line imaging study to differentiate between intracavernosal and extracavernosal hematomas and detect tunica albuginea rupture. 3 This is critical because:

• Penile fracture can present with ecchymosis and swelling even without the classic history of trauma or pain, as documented in cases where patients delayed presentation due to embarrassment or atypical presentations. 2
• Ultrasound is readily available, cost-effective, and can definitively identify tunical disruption requiring surgical intervention. 3
• The absence of pain does not exclude serious pathology—some patients present with only discoloration and swelling without significant symptoms. 2

Key Differential Diagnoses to Consider

Penile Fracture (Most Critical)

• Ecchymosis and swelling are the most common presenting symptoms, even when the classic "snap" sound and immediate detumescence are absent. 1
• Prompt surgical exploration and repair must be performed if fracture is confirmed, as this improves long-term outcomes. 1
• Patients frequently underreport the condition due to fear and embarrassment, leading to atypical presentations. 2

Penile Friction Edema

• Results from traumatic disruption of lymphatic drainage during sexual activity. 4
• Presents as local or total penile edema without infectious or obstructive causes. 4
• Diagnosis is by exclusion after ruling out more serious pathology. 4
• Treatment involves temporary abstinence from sexual intercourse, with resolution over several weeks. 4

Metastatic Crohn's Disease (Rare but Important)

• Genital swelling can precede gastrointestinal symptoms in Crohn's disease, occurring in 88% of pediatric cases before formal CD diagnosis. 5
• Consider this diagnosis if the patient has any history of gastrointestinal symptoms or if other causes are excluded. 5

Critical Management Algorithm

1. Obtain ultrasound with Doppler immediately to assess for:

   • Tunical integrity and corporal body disruption 3
   • Intracavernosal versus extracavernosal hematoma location 3
   • Vascular abnormalities 3

2. If penile fracture is confirmed or highly suspected:

   • Proceed directly to surgical exploration and repair through ventral midline or circumcision incision. 1
   • Perform tunical repair with absorbable suture at time of presentation. 1
   • Evaluate for concomitant urethral injury if any hematuria or voiding difficulty develops. 1

3. If ultrasound is equivocal:

   • Consider MRI for further characterization. 1
   • When diagnosis remains uncertain, surgical exploration should be performed rather than observation. 1

4. If imaging excludes fracture:

   • Diagnose penile friction edema by exclusion. 4
   • Recommend sexual abstinence until complete resolution. 4
   • Monitor for development of systemic symptoms suggesting inflammatory conditions. 5

Critical Pitfalls to Avoid

• Do not rely on absence of pain or trauma history to exclude penile fracture—atypical presentations are well-documented. 2
• Do not delay imaging or surgical consultation while attempting conservative management, as delayed repair of penile fracture worsens outcomes. 1
• Do not dismiss the presentation as benign edema without definitive imaging to exclude structural injury. 3, 2