What is the ideal timeframe for performing an ultrasound to evaluate a suspected penile fracture in a patient with a history of a 'popping' sound during intercourse and penile deformity, but no visible swelling, blood, or bruising?

Ultrasound Timing for Suspected Penile Fracture

The ultrasound should be performed urgently (same-day or within hours) in this equivocal presentation, as your patient has a concerning history (popping sound and penile deformity) that warrants rapid diagnostic confirmation to determine whether immediate surgical exploration is needed. 1

Clinical Context and Diagnostic Approach

Your patient presents with an equivocal clinical picture that justifies imaging:

• Classic features present: Popping sound during intercourse and penile deformity (bent appearance at top) 1
• Classic features absent: No ecchymosis, swelling, or blood—which are the most common signs of penile fracture 1
• Preserved erectile function: Ability to have erections argues against complete tunical disruption but does not exclude partial injury 2

The AUA guidelines specifically address this scenario: ultrasound is indicated in patients with equivocal signs and symptoms of penile fracture to assist with confirmation or exclusion of the diagnosis. 1

Why Urgent Timing Matters

Surgical repair should be performed at the time of presentation to improve long-term patient outcomes, including significantly lower rates of erectile dysfunction and penile curvature compared to delayed or conservative management. 1, 3 This means:

• If ultrasound confirms penile fracture, your patient needs prompt surgical exploration and repair (ideally within hours) 1, 3, 4
• Delayed diagnosis leads to worse functional outcomes 3
• Even a 48-hour delay (as in one case report) still resulted in good outcomes with surgery, but earlier is better 4

Practical Ultrasound Considerations

Ultrasound is the preferred imaging modality for suspected penile fracture due to:

• Wide availability, low cost, and rapid examination times 1
• Ability to demonstrate the site and extent of tunica albuginea disruption 5, 6
• High diagnostic accuracy when performed by experienced operators 2

The examination should include:

• Transversal and longitudinal scanning from glans to base of penis 2
• Color-Doppler to identify vascular patterns or abnormal vascularity 2
• Looking for irregular hypoechoic or hyperechoic defects at potential rupture sites 2

Decision Algorithm After Ultrasound

If ultrasound shows tunical disruption: Proceed immediately to surgical exploration and repair 1, 3

If ultrasound is equivocal or diagnosis remains in doubt: Proceed directly to surgical exploration rather than additional imaging, as MRI would only further delay definitive management 1

If ultrasound definitively excludes penile fracture: Consider alternative diagnoses such as subtunical venous plexus injury (which may not require surgery) 2

Critical Pitfall to Avoid

Do not delay the ultrasound or adopt a "wait and see" approach—the history of a popping sound with penile deformity is concerning enough to warrant same-day evaluation, even in the absence of typical physical findings. 1, 3 The absence of swelling and ecchymosis may simply reflect early presentation before these signs develop, or a smaller injury that still requires surgical repair for optimal outcomes. 1, 2