Management of Acute Penile Fracture
Perform immediate surgical exploration and repair through a circumferential subcoronal incision with degloving of the penis, exposing the injured corpus cavernosum and repairing the tunical tear with absorbable suture. 1, 2
Diagnosis and Clinical Recognition
Suspect penile fracture when the patient presents with the following classic triad: 1, 2
- Cracking or snapping sound during intercourse or manipulation followed by immediate detumescence
- Penile swelling and ecchymosis (most common symptoms)
- Penile pain and possible angulation
History and physical examination alone are typically diagnostic in patients with these presenting symptoms, and no further imaging is required when the diagnosis is clinically obvious. 1, 2
When to Use Imaging
Perform ultrasound only in patients with equivocal signs and symptoms to confirm or exclude the diagnosis. 1, 2
- Ultrasound is preferred due to wide availability, low cost, and rapid examination times 1, 2
- Timing is critical: perform ultrasound urgently on the same day or within hours, as delayed diagnosis leads to worse functional outcomes including higher rates of erectile dysfunction and penile curvature 2
- If ultrasound remains equivocal or diagnosis is uncertain, proceed directly to surgical exploration 1, 2
Surgical Management Algorithm
Timing of Surgery
Perform prompt surgical exploration and repair at the time of presentation—ideally within hours. 1, 2 This approach is associated with significantly lower rates of erectile dysfunction and penile curvature compared to delayed or conservative management. 2, 3, 4, 5
Surgical Technique
- Make a circumferential coronal incision under the glans (also called subcoronal incision) 3, 5
- Deglove the penis to allow thorough exploration of both corpora cavernosa 5
- Identify and repair the tunical tear with absorbable suture 1, 3, 4
- Most cases involve unilateral corporal rupture 3
Alternative approach: A ventral midline incision can also be used to expose the injured corpus cavernosum. 1
Evaluation for Urethral Injury
You must evaluate for concomitant urethral injury in all patients with penile fracture who present with: 1, 2
- Blood at the urethral meatus
- Gross hematuria
- Inability to void
Urethral Injury Prevalence and Risk Factors
- Urethral injury occurs in 10-22% of penile fracture cases 2
- Bilateral corporal body fracture is an additional risk factor for urethral injury 2
- In one series, 38% of patients had concomitant urethral injury (3 of 8 cases) 4
Diagnostic Method for Urethral Injury
Perform either urethroscopy or retrograde urethrogram—neither method is superior, and the choice depends on equipment availability and timing. 2 If urethral injury is confirmed, repair it during the same surgical exploration. 4
Expected Outcomes
When immediate surgical repair is performed: 3, 4, 5
- Preservation of sexual function with adequate erection for intercourse in the vast majority of patients
- No significant erectile or voiding dysfunction in most cases
- Minimal penile curvature (when present, typically mild and does not hinder intercourse)
- Normal voiding even in patients with repaired urethral injuries, without need for additional procedures 4
Critical Pitfalls to Avoid
Do not delay surgical repair: Immediate repair within hours provides the best outcomes, though even delayed cases benefit from surgery over conservative management. 2, 6 Delayed diagnosis and treatment lead to higher rates of erectile dysfunction, penile curvature, and other complications. 2
Do not miss urethral injury: Always evaluate for urethral involvement when warning signs (blood at meatus, hematuria, inability to void) are present, as this occurs in up to 22% of cases. 2 Missing urethral injury can lead to stricture formation and voiding complications.
Do not rely on imaging when diagnosis is clinically obvious: When the classic triad is present (snapping sound, immediate detumescence, swelling/ecchymosis), proceed directly to surgery without delay for imaging studies. 1, 2