What is the treatment for penile fracture?

Treatment of Penile Fracture

Perform immediate surgical exploration and repair at the time of presentation—this is the definitive treatment that provides the best outcomes with significantly lower rates of erectile dysfunction and penile curvature compared to conservative management. 1

Diagnosis and Clinical Presentation

Suspect penile fracture when the patient reports:

• A cracking or snapping sound during intercourse or penile manipulation, followed by immediate loss of erection 1
• Penile swelling and ecchymosis (the classic "eggplant deformity") 1, 2
• Penile pain and angulation 1

If imaging remains equivocal or diagnosis is uncertain, proceed directly to surgical exploration rather than delaying treatment. 1 History and physical examination are typically sufficient for diagnosis, and diagnostic tests like ultrasonography or MRI are generally not required. 3

Surgical Management Algorithm

Immediate Surgical Repair

Perform prompt surgical exploration and repair at the time of presentation. 1 This approach is supported by multiple studies showing:

• Lower complication rates compared to conservative management 3
• Only 10.8% complication rate (primarily painful erection) with surgery versus 80% complication rate with conservative treatment 3
• Good outcomes for erectile function, micturition, and sexual intercourse with minimal complications 2

Surgical Technique

• Repair the tunical tear with absorbable suture 1
• Perform primary repair of corpus cavernosum ruptures 2
• Use intraoperative exploration to identify all injuries, including bilateral corpus cavernosum rupture and Buck's fascia tears 2
• Evacuate and drain scrotal hematomas if present to prevent persistent collections 2

Timing Considerations

Do not delay surgical repair—immediate repair within hours provides the best outcomes. 1 However, even significantly delayed presentations (up to 23 days) can be successfully managed surgically and should always be offered surgical treatment. 4 There are no "lost" cases when it comes to penile fracture. 4

Evaluation for Urethral Injury

Evaluate for urethral injury in any patient presenting with: 1

• Blood at the urethral meatus 1, 5
• Gross hematuria 1, 5
• Inability to void 1, 5
• Bilateral corporal body fracture (additional risk factor) 1

Urethral injury occurs in 10-22% of penile fracture cases and is typically localized at the same level as the corpus cavernosum tear. 1, 6 The injury is partial in most cases (approximately 79%) and complete in fewer cases (approximately 21%). 6

Diagnostic Approach for Urethral Injury

Perform either urethroscopy or retrograde urethrogram—neither method is superior, and the choice depends on equipment availability and timing. 1

Urethral Repair Technique

• Perform immediate surgical repair of both urethral and corporal ruptures 6
• Use end-to-end anastomosis for complete urethral ruptures 2
• This approach results in no harmful long-term sequelae on urethral and erectile function in most patients 6
• Normal urinary flow is maintained in the vast majority of cases, with only rare instances requiring temporary urethral dilation 6

Expected Outcomes

With immediate surgical management:

• Mean follow-up at 90 months shows 33% with no complications 6
• Painful erection in 8%, erectile dysfunction in 17%, and palpable fibrous nodule in 47% 6
• Minor penile deviation may occur but typically does not interfere with function 2
• Normal voiding and ability to have intercourse are preserved in most cases 2

Critical Pitfalls to Avoid

Do not delay surgical repair: Immediate repair provides the best outcomes, though even delayed cases benefit from surgery over conservative management. 1, 4

Do not miss urethral injury: Always evaluate for urethral involvement when warning signs are present, as this occurs in up to 22% of cases and requires concurrent repair. 1, 6

Do not choose conservative management: Conservative treatment results in 80% complication rates including wound infection, painful erection, penile nodule and curvature, and erectile dysfunction—far worse than the 10.8% complication rate with surgical repair. 3