What type of incision is recommended for penile fracture repair?

Incision Selection for Penile Fracture Repair

A subcoronal circumferential degloving incision is the standard approach for penile fracture repair, providing optimal exposure to evaluate both corpora cavernosa and the urethra, though a local longitudinal incision directly over the fracture site may be used in select cases when the injury location is precisely identified and urethral injury is definitively excluded. 1, 2

Primary Surgical Approach: Degloving Incision

The subcoronal circumferential degloving incision remains the gold standard because it:

• Provides complete exposure of both corpora cavernosa to identify all injuries, including bilateral ruptures that occur in approximately 10% of cases 1, 2
• Allows thorough evaluation of the urethra, which is injured in 10-22% of penile fractures 3, 1
• Enables intraoperative saline injection to identify additional occult injuries and assess repair integrity 1, 2
• Permits comprehensive exploration when the exact fracture location is uncertain 2

Technical Considerations for Degloving Approach

• Place a urethral catheter before making the incision to provide proper orientation and facilitate urethral evaluation 2
• Make the circumferential incision just proximal to the coronal sulcus 4
• Evacuate all hematoma and inspect the entire length of both corpora 4
• Repair tunical tears with absorbable suture in interrupted or figure-of-eight pattern 3, 1

Expected Complications with Degloving Incision

• Postoperative foreskin edema occurs in approximately 87% of cases (14 of 16 patients in one series) but resolves spontaneously 5
• This temporary edema does not affect long-term outcomes 5

Alternative Approach: Local Longitudinal Incision

A local longitudinal incision directly over the fracture site may be considered only when:

• High-quality ultrasound has precisely localized a unilateral tunical rupture 5
• There are no signs of urethral injury (no blood at meatus, no gross hematuria, normal voiding) 3, 6
• The injury is not bilateral 5

Advantages of Local Incision

• Minimal tissue trauma and preserved blood supply 5
• Lower rate of postoperative complications, with no foreskin edema reported in one series of 30 patients 5
• Shorter operative time when the diagnosis is certain 5

Critical Limitations

• This approach is contraindicated when urethral exploration is necessary, which requires circumferential degloving access 5
• Risk of missing additional injuries if preoperative imaging is inadequate 1
• Cannot be used when bilateral corporal injury is suspected 5

Mandatory Urethral Evaluation Protocol

Before selecting your incision, you must evaluate for urethral injury if any of these findings are present:

• Blood at the urethral meatus 7, 3
• Gross hematuria 7, 3
• Inability to void 7, 3
• Bilateral corporal body fracture 7, 3

Perform either urethroscopy or retrograde urethrogram—neither is superior, and the choice depends on equipment availability 7, 3. If urethral injury is confirmed or suspected, you must use the degloving approach 5.

Critical Pitfalls to Avoid

• Never use a local incision without high-quality preoperative imaging that definitively localizes the injury and excludes bilateral involvement 5
• Do not blindly catheterize if urethral injury is suspected, as this can convert a partial injury to complete disruption 6
• Do not rely on urinalysis alone—microscopic hematuria (5-10 RBCs) may be present even with significant urethral injury, and false-negative urethrograms occur 2
• Always perform intraoperative saline injection through the corporotomy to identify additional tears and confirm repair integrity, regardless of incision type 1, 2

Surgical Timing

• Perform immediate surgical exploration and repair at presentation—this approach yields significantly lower rates of erectile dysfunction and penile curvature compared to delayed or conservative management 3
• Optimal timing is within hours of injury 3