Dr. Debasis Maity

Remember:

• Penile fracture is the disruption of the tunica albuginea with rupture of the corpus cavernosum. Fracture typically occurs during vigorous sexual intercourse, when the rigid penis slips out of the vagina and strikes the perineum or pubic bone,producing a buckling injury.
• The tunica albuginea is a bilaminar structure (inner circular, outer longitudinal) composed of collagen and elastin. The outer layer determines the strength and thickness of the tunica and is thinnest ventrolaterally.
• The tensile strength of the tunica albuginea is remarkable, resisting rupture until intracavernous pressures rise to more than 1500 mm Hg.
• When the erect penis bends abnormally, the abrupt increase in intracavernosal pressure exceeds the tensile strength of the tunica albuginea, and a transverse laceration of the proximal shaft usually results.
• Whereas penile fracture has been reported most commonly (94%) with sexual intercourse, it has also been described with masturbation, rolling over or falling onto the erect penis.
• In the Middle East, self-inflicted fractures predominate; the erect penis is forcibly bent during masturbation or as a means to achieve rapid detumescence, the practice of taghaandan.
• The tunical tear is usually transverse and 1 to2 cm in length. The injury is usually unilateral.
• Although the site of rupture can occur anywhere along the penile shaft, most fractures are distal to the suspensory ligament.
• Injuries associated with coitus are usually ventral or lateral, where the tunica albuginea is the thinnest.

Diagnosis and Imaging:

• The diagnosis can be made reliably by history and physical examination.
• Patients usually describe a cracking or popping sound as the tunica tears, followed by pain, rapid detumescence, and discoloration and swelling of the penile shaft.
• If the Buck fascia remains intact, the penile hematoma remains contained between the skin and tunica, resulting in a typical eggplant deformity.
• If the Buck fascia is disrupted, hematoma can extend to the scrotum, perineum, and suprapubic regions. The swollen, ecchymotic phallus often deviates to the side opposite the tunical tear because of hematoma and mass effect.
• The fracture line in the tunica albuginea may be palpable.
• The incidence of urethral injury is significantly higher in the United States and Europe (20%) than in Asia, the Middle East, and the Mediterranean region (3%), probably owing to the different etiology— intercourse trauma versus self-inflicted injury.
• Most urethral injuries are associated with gross hematuria, blood at the meatus or inability to void, although the absence of these findings does not definitively rule out urethral injury.
• Intraoperative flexible cystoscopy is now performed routinely just before catheter placement at the time of penile exploration when urethral injury is suspected.
• Ultrasonography, although noninvasive and easy to perform, has also been associated with significant false-negative studies.
• Magnetic resonance imaging (MRI) is a noninvasive and accurate means of demonstrating disruption of the tunica albuginea.
• False fracture = has been reported in patients who present with penile swelling and ecchymosis, and some even describe the classic “snap-pop” or rapid detumescence typically associated with fracture.
• Physical examination may not be adequate for definitive diagnosis of a corporeal tear in these circumstances. Surgical exploration or evaluation with MRI should be considered.
• Another condition that may mimic penile fracture is rupture of the dorsal penile artery or vein during sexual intercourse.

Management:

• Suspected penile fractures should be promptly explored and surgically repaired.
• Distal circumcoronal incision is appropriate in most cases, providing exposure to all three penile compartments.
• Closure of the tunical defect with interrupted 2-0 or 3-0 absorbable (Vicryl ) sutures is recommended.
• Deep corporeal vascular ligation or excessive debridement of the delicate underlying erectile tissue must be avoided.
• Induction of an artificial erection with saline or colored dye may aid in locating the corporeal laceration.
• Partial urethral injuries should be oversewn with fine absorbable suture over a urethral catheter. Complete urethral injuries should be debrided, mobilized and repaired in a tension-free fashion over a catheter.
• Therapy with broad-spectrum antibiotics and 1 month of sexual abstinence are recommended.

Outcome and Complications:

• Immediate surgical reconstruction results in faster recovery, decreased morbidity, lower complication rates, and lower incidence of long-term penile curvature (less than 5% of patients ).
• Conservative management of penile fracture has been associated with penile curvature in more than 10% of patients, abscess or debilitating plaques in 25% to 30%, and significantly longer hospitalization times and recovery.
• Surgical management of penile fractures resulted in erectile function comparable to that of a control population.
• Timing of surgery may also influence long-term success— those undergoing repair within 8 hours of injury had significantly better long-term results than did those having surgery delayed 36 hours after the fracture occurred.