What is the emergent management of a penile fracture without urethral involvement?

Emergent Management of Penile Fracture Without Urethral Involvement

Perform prompt surgical exploration and repair at the time of presentation—this is the standard of care and significantly reduces the risk of erectile dysfunction and penile curvature compared to conservative management. 1, 2

Clinical Diagnosis

The diagnosis of penile fracture is primarily clinical and should be suspected when the patient presents with: 1, 2

• Cracking or snapping sound during intercourse or penile manipulation 1, 2
• Immediate detumescence following the audible sound 1, 2
• Penile swelling and ecchymosis (most common physical findings) 1, 2
• Penile pain and angulation may also be present 1, 2

History and physical examination alone are often diagnostic in patients with these presenting symptoms, and no imaging is required when the clinical picture is clear. 1

Role of Imaging

Imaging should only be used in equivocal cases and should not delay surgical intervention. 1, 2

• Ultrasound is the most commonly used imaging modality due to wide availability, low cost, and rapid examination times 1
• MRI can be considered when ultrasound is equivocal 1
• If imaging remains equivocal or diagnosis is uncertain, proceed directly to surgical exploration 1, 2

Surgical Management

Immediate surgical repair is the standard of care and must be performed promptly: 1

• Expose the injured corpus cavernosum through either a ventral midline or circumcision incision 1
• Perform tunical repair with absorbable suture 1, 2
• Surgery should be performed at the time of presentation to improve long-term patient outcomes 1

The evidence strongly supports immediate repair over conservative management. Surgical exploration and repair is associated with lower risk of erectile dysfunction and penile curvature compared to non-operative treatment. 1, 3 While some studies suggest conservative management can work in selected uncomplicated cases, immediate surgery yields superior results overall, with success rates of 92% versus 59% for conservative therapy. 3

Confirming Absence of Urethral Injury

Since the question specifies no urethral involvement, it is critical to confirm this clinically:

• Absence of blood at the urethral meatus 1, 2
• No gross hematuria 2
• Ability to void normally 1, 2

If any of these warning signs are present, urethral injury must be evaluated with either urethroscopy or retrograde urethrogram before proceeding with corporal repair, as urethral injury occurs in 10-22% of penile fracture cases. 1, 2

Common Pitfalls to Avoid

• Do not delay surgical repair: Immediate repair (within hours) provides the best outcomes 2, 4
• Do not pursue conservative management in the acute setting when surgical expertise is available, as this leads to higher rates of complications including erectile dysfunction, penile curvature, and pain 1, 3
• Do not miss concomitant urethral injury: Always assess for blood at the meatus, hematuria, or voiding difficulty 1, 2

Expected Outcomes

With immediate surgical repair, patients can expect: 5

• Preservation of sexual function 5
• Minimal to no penile curvature 5
• Return to sexual activity typically 4-6 weeks after repair 6
• Excellent overall outcomes in the vast majority of cases 5, 3