Treatment of Split Penis (Penile Laceration/Rupture)
Immediate surgical exploration and primary repair is the definitive treatment for a split penis, which should be performed urgently to optimize functional outcomes and prevent long-term complications including erectile dysfunction. 1
Immediate Clinical Assessment
When a patient presents with a split penis, you must determine:
- Mechanism of injury: Direct trauma during intercourse/manipulation typically causes tunical rupture with a characteristic "cracking" or "snapping" sound followed by immediate detumescence, penile swelling, and ecchymosis 1, 2
- Urethral involvement: Check for blood at the urethral meatus, gross hematuria, or inability to void—these findings mandate evaluation for concomitant urethral injury via retrograde urethrogram or urethroscopy 1, 2
- Patient stability: Ensure hemodynamic stability before proceeding to surgery 1
Surgical Management Algorithm
Primary surgical repair should be performed immediately upon presentation rather than delayed reconstruction, as acute repair provides superior outcomes. 1
Operative Technique:
- Exposure: Use either a ventral midline incision or circumcising/degloving incision to expose the injured corpus cavernosum 1
- Repair: Perform sharp débridement of devitalized tissue followed by primary closure of the tunical tear using absorbable sutures 1, 3
- Urethral repair: If urethral injury is identified intraoperatively, perform concurrent urethral repair 1
This approach results in preservation of normal erectile function, brief hospitalization (mean 3.8 days), and minimal complications. 3
When Imaging May Be Needed
If clinical presentation is equivocal (unclear history, minimal swelling, no definitive snap), ultrasound is the preferred imaging modality due to wide availability, low cost, and rapid examination. 1 MRI can be considered if ultrasound is inconclusive. 1 However, if imaging remains equivocal or diagnosis is uncertain, proceed directly to surgical exploration rather than further delaying treatment. 1
Contraindications to Immediate Repair
Primary repair should not be performed if: 1
- Patient is hemodynamically unstable
- Surgeon lacks expertise in urethral/penile surgery
- Extensive tissue destruction or loss is present requiring complex reconstruction
In these scenarios, establish urinary drainage (suprapubic tube or urethral catheter depending on severity) and arrange urgent transfer to a specialized center. 1
Critical Pitfalls to Avoid
- Never manage conservatively: Non-operative management is associated with a 29% complication rate, prolonged hospitalization (mean 14 days), and significantly worse erectile function outcomes compared to immediate surgical repair. 3
- Never delay surgical consultation: The American Urological Association emphasizes that immediate evaluation and repair at time of presentation improves long-term patient outcomes. 1, 2
- Always evaluate for urethral injury when blood is present at the meatus, gross hematuria exists, or the patient cannot void—missing a urethral injury leads to stricture formation and voiding dysfunction. 1, 2
- Do not perform immediate debridement for straddle injuries: Unlike penile fracture, crush injuries to the bulbar urethra from straddle trauma require urinary drainage only (not immediate surgical repair) because the injury border is indistinct acutely. 1