What is the management and treatment of a penile fracture?

Management and Investigation of Penile Fracture

Immediate Clinical Diagnosis

Suspect penile fracture based on clinical presentation alone—history and physical examination are typically diagnostic without requiring imaging in most cases. 1

Classic Presentation

• Cracking or snapping sound during intercourse or manipulation, followed by immediate detumescence 1, 2
• Penile ecchymosis and swelling are the most common physical findings 1
• Penile pain and angulation may also be present 2
• The clinical picture is typically so characteristic that no further investigation is needed for diagnosis 3

Diagnostic Imaging (When Needed)

Reserve imaging for equivocal cases only—do not delay surgery for imaging when clinical diagnosis is clear. 1, 2

Imaging Indications

• Ultrasound is the first-line imaging modality when signs and symptoms are equivocal, due to wide availability, low cost, and rapid examination 1, 2
• MRI can be considered if ultrasound results are equivocal 1
• If imaging remains equivocal or diagnosis uncertain, proceed directly to surgical exploration rather than pursuing additional studies 1, 2

Evaluation for Urethral Injury

Always evaluate for concomitant urethral injury when warning signs are present—this occurs in 10-22% of penile fracture cases. 2, 4

Indications for Urethral Evaluation

• Blood at the urethral meatus 1, 2
• Gross hematuria 1, 2
• Inability to void 1, 2
• Bilateral corporal body fracture (additional risk factor) 1, 2

Diagnostic Methods

• Perform either retrograde urethrogram or urethroscopy—neither method is superior 1, 2
• Choice depends on equipment availability and timing of the procedure 1, 2
• One study found urethral injury in 38% of their cases, including complete and partial disruptions 4

Surgical Management

Perform prompt surgical exploration and repair at the time of presentation—this is the standard of care and significantly improves long-term outcomes. 1, 2

Surgical Approach

• Expose the injured corpus cavernosum through either a ventral midline incision or circumcision (degloving) incision 1
• The midline ventral incision provides direct access to both corpora cavernosa and the anterior urethra with minimal skin incision 5
• Repair the tunical tear with absorbable suture 1, 2
• If urethral injury is present, perform concurrent repair 4

Timing Considerations

• Immediate repair (within hours) provides the best outcomes, including lower rates of erectile dysfunction and penile curvature compared to conservative management 2, 6
• Even delayed cases benefit from surgical intervention over conservative management 2
• Studies show successful outcomes with preservation of sexual function and minimal curvature when surgery is performed promptly 4, 3, 5

Common Pitfalls to Avoid

Critical Errors

• Do not delay surgical repair: Conservative management is associated with significantly higher complication rates 2, 6
• Do not miss urethral injury: Always evaluate when warning signs are present, as this occurs in up to 22% of cases and requires concurrent repair 2, 4
• Do not pursue extensive imaging when clinical diagnosis is clear: History and physical examination alone are often diagnostic, and imaging should not delay definitive surgical treatment 1, 3

Expected Outcomes

• Immediate surgical repair offers complete recovery in most cases, with preservation of erectile function and normal voiding 4, 3
• Minor penile curvature may occur in some patients but typically does not hinder intercourse 3, 5
• Patients with urethral injuries report normal voiding without need for additional procedures when repaired concurrently 4