Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome

Authors


Ciamack Kamdar, Department of Urology, One Brookdale Plaza, Suite 5C4, Brooklyn, NY 11212-3198, USA.
e-mail: kamdarciamack@yahoo.com

Abstract

OBJECTIVE

To review the preoperative diagnostic evaluation and surgical treatment of penile fracture, as the condition is a urological emergency that requires immediate surgical exploration and repair.

PATIENTS AND METHODS

Between January 2003 and October 2007 eight patients presented to the emergency department with penile fracture after sexual intercourse. The clinical presentation, preoperative evaluation and imaging, surgical technique, and postoperative care were assessed to determine the optimal patient outcome.

RESULTS

Seven of the eight patients were treated surgically and one refused surgical intervention. Four cases involved unilateral corporal injury, two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury. Although retrograde urethrogram were taken of all three urethral injuries, none of them revealed the injury. Diagnostic cavernosography or magnetic resonance imaging were not used in any of the patients. No complications occurred in the patients treated surgically.

CONCLUSIONS

Preoperative imaging should not delay surgical repair. If an associated urethral injury is suspected, flexible cystoscopy is recommended in the operating room, as opposed to a retrograde urethrogram. A subcoronal circumcising incision is recommended to deglove the entire penile shaft and have complete access to all three corporal bodies, as well as the neurovascular bundle. Saline mixed with indigo carmine can be injected both into the corpora cavernosum or corpus spongiosum via the glans penis, after a tourniquet is placed at the base of the penis, to evaluate the surgical repair and to determine if there are any missed injuries.

INTRODUCTION

Penile fracture is the traumatic rupture of the tunica albuginea in the tumescent state. The aetiology of this injury is usually abrupt blunt trauma by forceful bending of the erect penis; this excludes penetrating trauma and degloving or amputation injuries to the flaccid penis. Injury can involve one or both of the corporal bodies, and associated urethral injuries can also occur. The first reporting of a penile fracture was made by Abul Kasem, an Arab physician, in Cordoba, over 1000 years ago [1].

The incidence of penile fractures is under-reported because many patients do not seek medical attention due to the embarrassment of the clinical situation [2,3]. Many recently published reports have come from countries in the Middle East and the aetiology of the fracture is due to ‘Taghaandan’ or forcefully bending the erect penis to achieve detumescence [4]. Other reported causes include masturbation [3–5], falling off a bed [3,5], placing an erect penis in underwear [3,6], and ‘spontaneous fracture’ while urinating [3]. In Western societies, most penile fractures are due to sexual intercourse [3,7].

Penile fractures can be diagnosed from a history and physical examination, but there is still controversy about the need for a preoperative evaluation with cavernosography, retrograde urethrography, MRI, and cysto-urethroscopy. We reviewed the preoperative diagnostic evaluation and surgical treatment of penile fracture in patients treated at our institution.

PATIENTS AND METHODS

Between January 2003 and October 2007 eight patients (mean age 39 years, range 25–53) presented to the emergency department with painful penile swelling after sexual intercourse. On presentation all patients had a history taken and a physical examination, and were questioned about the nature of the trauma, the occurrence of gross haematuria, urinary retention, any new angulation of the penis, blood at the external meatus, and penile swelling. If patients had gross haematuria, blood at the external meatus, or urinary retention, a retrograde urethrogram was taken. Diagnostic cavernosography or MRI were not used in any patient because the diagnosis of penile fracture was evident without these imaging studies.

Corrective surgical procedures were performed by three different attending urologists, and based on the extent of the injury and the proposed surgical repair that was required, different surgical techniques were used. All patients provided informed consent and received preoperative i.v. cefazolin and gentamicin 0.5 h before surgery.

After surgery patients had their Foley catheter removed before discharge, except for patients with an associated urethral injury. If a urethral injury was repaired an indwelling Foley catheter remained for 7–10 days. All patients were discharged on a 7–14-day course of cefadroxil, 500 mg twice daily.

RESULTS

Seven patients were treated surgically within 12 h of the penile fracture; one was treated conservatively because of a delay of 10 days after the injury and his refusal to have surgery. All patients reported experiencing blunt trauma to the penis during sexual intercourse. Two patients were having sexual intercourse in the ‘missionary’ position, four patients were having rear-entry vaginal intercourse, and one with the woman in the superior position. One patient initially was reluctant to give the history but later stated that he was having same-sex rear entry anal intercourse. Seven of the eight patients stated they heard a loud characteristic ‘popping’ sound, which occurs during the tearing of the tunica albuginea. All patients had immediate detumescence, pain and penile swelling.

Two patients had urinary retention but the retrograde urethrogram showed no evidence of urinary extravasation. Both these patients had a 16 F Foley catheter placed by a urologist, with retrieval of blood-stained urine. Subsequently during exploration, both patients were found to have urethral injuries. One patient presented with blood at the external meatus, the retrograde urethrogram revealed no extravasation, and a 16 F Foley catheter was placed. This patient had a complete disruption of the corpus spongiosum and urethra. One patient presented with gross haematuria but the retrograde urethrogram showed no evidence of extravasation, a 16 F Foley catheter was placed, and on surgical exploration a urethral injury was identified.

Of the seven patients treated surgically, three had right corporal injuries, one had a left corporal injury, one had a right corporal injury with a concomitant urethral injury, one had a left corporal injury with a concomitant urethral injury, and one had bilateral corporal injuries with complete transection of the urethra. All urethral injuries occurred at the same level as the corporal injuries. The patient who was not treated surgically had a palpable corporal defect over his proximal right corpus cavernosum. This patient presented 10 days after the injury and refused any type of surgery. He was treated conservatively with analgesics, anti-inflammatory medication, and other supportive measures.

Three patients were explored by a midline incision made along the penoscrotal median raphe. The choice of incision and surgical technique were made by the surgeon’s personal preference and the site of the suspected injury. The subsequent evacuation of haematoma, repair of tunica albuginea of the corpora cavernosa and corpus spongiosum, along with the urethra, were completed as needed (Figs 1,2). The tunica albuginea was repaired with 2-0 synthetic absorbable suture in an interrupted or running locked fashion, making sure the repair was watertight. The urethra was repaired with 4-0 chromic cat gut, and 4-0 synthetic absorbable suture was used for the corpus spongiosum.

Figure 1.

Right corpora cavernosum injury.

Figure 2.

Right corpora cavernosum injury repaired in a running locked manner.

Three patients had a subcoronal degloving incision. The rest of the surgical procedures, as outlined above, were then completed. The patient with the bilateral corporal injuries and complete transection of the urethra had a subcoronal degloving incision. The skin of the penile shaft could not be retracted secondary to the massive tissue oedema, and therefore a penoscrotal incision was made and the tunica albuginea and urethra were repaired as outlined above (Fig. 3). The repair of corpora cavernosa and corpus spongiosum was further enhanced by interposition of a sub-dartos flap to prevent fistula formation (Figs 4,5).

Figure 3.

Bilateral corporal and urethral injuries with the Foley catheter in the urethra.

Figure 4.

Bilateral corporal repair.

Figure 5.

Urethral repair with interposition of sub-dartos flap between the corpora cavernosum and corpus spongiosum to prevent fistula formation.

In the short-term follow-up, all patients were able to obtain and maintain an erection adequate for sexual intercourse. The patient treated conservatively was also able to obtain an erection with no penile curvature. He had mild pain during intercourse. No surgical patient had a late complication such as urethral diverticula, fistula, urethral stricture, or high-flow priapism.

DISCUSSION

Injuries to the flaccid penis are uncommon due to its protected location and relative mobility. However, in the tumescent state the corpora cavernosa become engorged with blood and the tunica albuginea thins from 2 mm to 0.25–0.5 mm [8]. This thinning of the tunica albuginea makes it more susceptible to traumatic injury. The normal pressure inside the erect penis is the mean arterial pressure, at ≈100 mmHg. The intracorporal pressure that is needed to rupture the tunica, or overcome its tensile strength, is 1500 mmHg [9]. In Western societies, vaginal intercourse is the main cause of penile fracture [3,7], and usually occurs secondary to the woman being in the superior position, when her entire body weight lands on the erect penis or when the erect penis is pushed against her perineum during rear-entry vaginal intercourse.

Previously there has been debate about whether to use immediate surgical exploration and repair, or proceed with conservative management, which included cold compresses, anti-inflammatory agents, instructions to abstain from sexual intercourse, and antiandrogens or sedatives to suppress erections. However, the current standard of care is immediate surgical repair, due to the decreased incidence of subsequent morbidity. Immediate surgical exploration and repair results in >90% of patients having normal sexual intercourse after surgery [10].

Penile fracture remains a clinical diagnosis; in our experience all patients were diagnosed based on a physical examination and history. Patients present with swelling of the penile shaft, or ‘eggplant deformity’, discoloration, and deviation of the penile shaft. If the haematoma is contained within Buck’s fascia, many times the ‘rolling sign’, a palpable clot felt directly over the tear in the tunica albuginea, can determine the site of the injury [4]. If Buck’s fascia is disrupted, blood will extravasate into the subcutaneous plane of the scrotum, perineum, or pubic areas, resulting in significant swelling.

Concomitant urethral injuries have been reported in 0–3% of cases in Japan and the Middle East, and up to 20–38% in the USA and Europe [11]. This discrepancy is most likely due to the differing mechanisms of injury leading to penile fracture, with sexual intercourse being the usual aetiology in the USA and Europe. In the present study, three of seven patients repaired surgically had an associated urethral injury, and all injuries were due to sexual intercourse. Most authors advocate a retrograde urethrogram if patients present with blood at the external meatus, gross haematuria, or urinary retention, to exclude urethral injury. However, false-negative results can occur due to an overlying blood clot, small tunical tear with mucosa alone intact, or inadequate amount of contrast medium injected during the study. All urethral injuries in the current study had non-diagnostic retrograde urethrograms. Thus, we recommend that if there is a high suspicion of urethral injury, flexible cystoscopy should be used in the operating room before inserting the Foley catheter. This will allow a visual examination of the urethral mucosa and the extent of injury before placing the catheter.

Cavernosography and MRI have also been used for diagnosing penile fracture; no patient had cavernosography or MRI in the current study. Both these costly imaging methods should not delay surgical exploration in the acute setting. We recommend their use only when the clinical diagnosis is in question, i.e. vascular injuries in Mondor’s disease, rupture of the deep dorsal vein, or laceration of the suspensory ligament of the penis producing penile swelling.

Multiple incision sites have been proposed, including a circumcising degloving incision, midline penoscrotal, inguinoscrotal, and lateral incision. Each incision has its benefits but in most cases we recommend a degloving circumcising incision. This allows an evaluation of all three corporal bodies and the ability to repair injuries anywhere along the course of the shaft, as well as repair or separation of the neurovascular bundle if needed. We also recommend circumcision at the end of the procedure if the patient is uncircumcised, due to the possibility of phimosis after surgery due to the massive penile swelling. If tissue oedema and haematoma do not allow a degloving incision then a midline penoscrotal incision is recommended to evacuate the haematoma and repair the corpora. If the main haematoma is in the penoscrotal area and the suspected site of injury is deeper, then also a penoscrotal incision might be preferred.

If the corpus spongiosum and urethra are injured, a two-layer closure is recommended with 4-0 synthetic absorbable suture. In these cases, the corpus spongiosum injury almost always occurs at the same level of the corpora cavernosal injury. These types of injuries require a sub-dartos flap between the corpora cavernosa and corpus spongiosum, to prevent fistula formation. The Foley catheter should also be left indwelling for 7–10 days after surgery.

After surgical repair, if there is doubt about the stability of the repair or missed corpora cavernosal injuries, penile tumescence should be induced. We recommend doing this by placing a Penrose drain around the base of the penis with a clamp to act as a tourniquet. A 22 G butterfly needle is then placed laterally in one corporal body and saline mixed with indigo carmine is injected into the corpora. This creates tumescence and allows a clear evaluation of the repair and identification of any other corporal injuries. If a corpus spongiosum injury is present it almost always occurs at the same level as the corpora cavernosal injury. However, after exploration and cystoscopy, if suspicion is still high, a 22 G butterfly needle is placed in the glans penis and the corpus spongiosum is engorged with saline mixed with indigo carmine. This will allow a visual inspection of the engorged corpus spongiosum and help to identify any injury.

The need for intraoperative catheterization is also debated. We always recommend catheterization either before surgery or in the operating room once the flexible cystoscopy is completed. The Foley catheter will allow identification of the urethra and prevent inadvertent injury while dissecting the corporal bodies, as well as allowing a scaffolding to the repair of any associated urethral injury. The Foley catheter can be removed immediately after surgery unless a urethral injury was repaired, in which case it should be left in place for 7–10 days.

Penile tumescence after surgery is also an area of concern; it was reported to lead to dehiscence of the corporal repair [10]. Thus some authors advocate an antiandrogen or sedative to prevent erections; we do not recommend any of these agents. Pain after surgery normally prevents extremely rigid erections. In our experience a dehiscence has never occurred due to a postoperative erection.

In conclusion, penile fracture is a urological emergency that is best treated with immediate surgical exploration and repair. Preoperative imaging evaluation should not delay surgical repair. If an associated urethral injury is suspected, flexible cystoscopy is recommended in the operating room, as opposed to a retrograde urethrogram. A subcoronal circumcising incision is recommended to deglove the entire penile shaft and have complete access to all three corporal bodies and the neurovascular bundle. If a concomitant urethral injury has been repaired, a sub-dartos flap should be created and placed between the repairs of the corpora cavernosa and corpus spongiosum, to prevent future fistula formation. Saline mixed with indigo carmine can be injected both into the corpora cavernosa directly, or corpus spongiosum via the glans penis, after a tourniquet is placed at the base of the penis, to evaluate the surgical repair and locate any missed injuries.

CONFLICT OF INTEREST

None declared.

EDITORIAL COMMENT

Penile fractures in Western societies are relatively uncommon, but any urologist might be unexpectedly called upon to evaluate and treat a man with this injury. This paper shows that preoperative retrograde urethrography frequently fails to disclose associated urethral injuries. Three of their eight patients had associated urethral injuries that were encountered only during surgical exploration. One of their eight patients refused surgery, and the others had surgery within 12 h of the injury. Early surgery is beneficial in my opinion because it speeds recovery and results in a smaller scar of the tunica albuginea, lessening the chance of subsequent erectile deformity (curvature toward the scarred side). An additional benefit is that urethral injuries will ordinarily be recognized during early surgical exploration, and their repair should avoid the early morbidity and later urethral stricture formation often associated with non-operative care of these injuries.

Drogo K. Montague,

Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

Ancillary