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Management of a Penile Fracture with Urethral Injury at the HUEH: Case Study and
Literature Review

Authors: Axler Jean Paul1*; Jean Ronald Exume2, PGY 3 Urology; Mirtho Etienne1; Peterson
Fenelon2, PGY 2 Urology; Elysée Joseph1; Jean Nelson Cajuste2, PGY 1 Urology; Claudy

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Lacarte2, PGY 4 Chief resident Urology
*
Corresponding Author
jeanpaulaxler@hotmail.com
79, Impasse Dady, Juvénat, Pétion-ville, Haiti
+509 37349648/ +509 43776900

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1) State University of Haiti; State University Hospital of Haiti

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2) State University Hospital of Haiti, Urology resident

Abstract

Introduction:
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Penile fracture with rupture of the urethra is a rare and underreported case in Urology. We present
this case received at the Emergency Department of Urology at the State University Hospital of
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Haiti.

Case Study:
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A 49 years old man was seen with a 6 hours history of urethrorrhagia with pain and deformation
of the penis. The symptoms occurred following sexual intercourse with use of a stimulant in a
doggy style position. The patient was taken to the OR 12 hours after presentation, a circular
incision was initiated through the balanopreputial groove to deglove it to the root. A wound of the
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corpus cavernosum at 2.5 cm from the meatus was noted with a partial anterior urethral injury
about 3 cm in length.
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Conclusion:
The diagnosis of penile fracture is essentially clinical and does not require imaging. Urgent
surgical management is necessary to reduce the risk of long-term complications.
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Keywords: Penile fracture; Urethral rupture; Urology in Haiti; Management.

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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
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Background

Penile fracture is a surgical emergency in Urology. 1,2 Considered a rare and underreported trauma 3–6, its
incidence ranges from 0.29 to 1.36 per 100,000 people. 1 The main is trauma during coitus, representing
a third of all trauma. In rare cases, it is accompanied by rupture of the urethra with an incidence varying

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around the globe from 1% to 38% of cases. 1,2,7,8 We present a patient with penile fracture and urethral
injury received in the Emergency Department of Urology at the State University Hospital of Haiti (HUEH).

Case study

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Patient is a 49-year-old man with no known medical history, who was seen in the emergency department
of Urology with a 6-hour history of urethrorrhagia and difficulty retracting the glans. Symptomatology

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followed sexual intercourse after having taken stimulants. They were in a “doggy style” position. The
patient reported hearing a cracking noise in the penis after coming into contact with the perineum of his
partner. Then passed blood through the meatus, and later developed pain and edema in the penis. He
decided to come to the HUEH Urology Emergency Department for treatment. Initial clinical examination
was unremarkable except for the affected area, where a leftward deformity of the penis was noted, most
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marked in the upper third (Figure 1), and passage of blood through the urethral meatus. The diagnosis of
penile corpus cavernosum fracture was made and the patient was prepared for surgery.

In the operation room, the frenulum artery was tied off and circular incision was made through the
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balanopreputial groove to deglove it to the root (Figure 2). A tourniquet was placed for less than 30
minutes and exploration of the penis was initiated. Clots were identified, hematoma was drained and the
wound was washed with normal saline. Exploration of the penis revealed an injury in the corpus
cavernosum on the right side, approximately 2.5 cm distal to the urethral meatus. This was repaired with
Vicryl 0, followed by a sealing test using normal saline prior to removal of the tourniquet (Figure 3). Next,
the urethra was explored using a Nelaton 16 Fr revealed a longitudinal anterior urethral injury,
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approximately 3 cm in length located 5 cm proximal to the urinary meatus. Following placement of a Foley
16 Fr urethral catheter, the urethra was dissected and repaired injury with Vicryl 4.0. The erection test
with normal saline was positive. Then, the tunica albuginea was repaired with Vicryl 2.0. A second circular
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incision was made 5 cm from the first one proximally, the skin was repaired to the mucosa with chromic
2.0, followed by the repair of the frenulum. Patient was followed postoperatively for 2 days and
administered an antibiotic regimen of ceftriaxone 2 grams IV stat, and 1 gram 12 hourly. He was followed
regularly at 3-day intervals for fatty bandage with neomycin during the first 15 days. Foley catheter was
removed after one month and satisfactory urination was achieved. The patient was advised to resume
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sexual intercourse after 2 months.

Discussion
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Penile fracture is the traumatic rupture of the tunica albuginea attached to the corpus spongiosum. 1,3,9
This structure has a bi-layer of collagen, which generates a significant tensile force that resists the intra-
cavernous pressure of about 1500 mmHg. This tensile strength is provided by the outer layer of the tunica
albuginea, which during erection decreases considerably in width (2 mm to 0.2-1.5 mm) and thus weakens
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the corpus cavernosum. 6,8

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
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Diagnosis of penile fracture is essentially clinical 5,10,11, and is based mainly on the history. Generally there
is a history of trauma, and more a third of cases trauma occurs during coitus. 1,2,12 Other causes of trauma
include fall from bed whilst asleep, direct shocks, and projectiles 1,2. It is uncommon to see penile fractures
with urethral rupture. The reported prevalence of urethral rupture varies by region of the world. It is 3%

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in Asian and African countries, while it is around 38% in Western countries 6,7. The patient may also
mention certain sexual positions in which penile fractures are most likely to occur; the “doggy style” and
the “woman on top” positions are those most frequently associated with penile fractures. 13–16

The most consistent clinical sign of penile fracture with urethral rupture is hematuria, followed by
urethrorrhagia, dysuria, and urinary retention. 5,17–19 However, absence of these signs does not exclude a
penile fracture with urethral injury. 19,20 In addition, there are classic signs of penile fracture such as pain,

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edema, ecchymosis, and the "eggplant" deformity. 4,5,10,19 Imaging can be used in specific circumstances;
modalities include sonography and cavernosography, retrograde urethrography, MRI, and

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cystourethroscopy.11 These are not recommended in emergencies situations where the clinic is usually
sufficient to make the diagnosis and initiate emergency surgery. 21

Since 1980, emergency surgery has been recommended in all cases of penile fractures. The British
Association of Urological Surgeons recommends surgery within the first 24 hours13 to reduce the risk of
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long-term complications. Naouar et al observed complications in 7.6% of cases in one group of patients
who were operated on within 24 hours of presentation (26 patients), and a complication rate of 68.7% in
the group operated on after 24 hours (16 patients). 13,22 Our patient underwent the procedure
approximately 12 hours after presentation. The wound was approached by a coronal suture (Fig. 2), a
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common technique which improves visibility and facilitates degloving. 2,8,19 In our patient, the rupture of
the corpus cavernosum was partial and localized on the right side, as is the case in the majority of penile
fractures. 8,21 The corpus cavernosum wound measured 2.5 cm, while the urethral wound was mostly
anterior and measured 3 cm. Studies have shown that urethral rupture is most common in bilateral
fractures. 12,13,21 Studies recommend the use of urethrography or retrograde cystography in cases of
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fracture with signs of urethral rupture. 12,13,21 Intra urethral catheter was used during the intervention.
Tunica albuginea was repaired as recommended 12 with Vicryl 2.0. Our patient had a good outcome and
discharged to the hospital two days after the surgery. He reported have a painless erection and a satisfied
sexual live after the two months of recovery.
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Conclusion

Diagnosis of penile fracture with urethral injury must be considered in every patient presenting with
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hematuria and/or urethrorrhagia in the context of penile fracture. In places where imaging is not always
available, emergency surgical management is recommended and this within the first 24 hours. The “doggy
style” position is a risk factor, as well as the use of sexual stimulants that increase the intra-cavernous
pressure beyond 1500 mmHg. Sexual activities should be resumed not before 6 to 8 weeks.
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
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Statement on participant consent:

The patient consent was obtained to participate and publish the relevant information about the case, and
the information about the identity was kept confidential.

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Acknowledge

Special thanks to Dr. Nelle-Ange Mele, Dr. Jordan Pyda, and Dr. Krithi Ravi, for their invaluable help in
translating the manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-

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for-profit sectors.

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Declaration of Competing Interest

No conflict of interest.

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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
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Reference

1. Kasaraneni P, Mylarappa P, Gowda RD, Puvvada S, Kasaraneni D. Penile fracture with urethral
injury: Our experience in a tertiary care hospital. Arch Ital di Urol e Androl. 2018;90(4):283-287.
doi:10.4081/aiua.2018.4.283

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2. Yunusa B, Wullie K, Willie SE, et al. Penile Fracture: Delayed Presentation, Primary Urethral
Repair and Satisfactory Outcome. Case Rep Urol. 2019;2019:1456914.
doi:10.1155/2019/1456914
3. Filho ACD, Ribeiro H. Editorial Comment: Lessons learned after 20 years’ experience with penile
fracture. Int Braz J Urol. 2020;46(3):417-418. doi:10.1590/S1677-5538.IBJU.2019.0367.1

v
4. Kominsky H, Beebe S, Shah N, Jenkins LC. Surgical reconstruction for penile fracture: a systematic
review. Int J Impot Res. 2020;32(1):75-80. doi:10.1038/s41443-019-0212-1

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5. Yilmazel FK, Sam E, Altay MS, et al. Surgical results in penile fracture: Our single center
experience. Am J Emerg Med. Published online August 2020. doi:10.1016/j.ajem.2020.08.073
6. Mirzazadeh M, Fallahkarkan M, Hosseini J. Penile fracture epidemiology, diagnosis and
management in Iran: a narrative review. Transl Androl Urol. 2017;6(2):158-166.
doi:10.21037/tau.2016.12.03
er
7. Barros R, Ribeiro JGA, da Silva HAM, de Sá FR, Júnior AMF, Favorito LA. Urethral injury in penile
fracture: A narrative review. Int Braz J Urol. 2020;46(2):152-157. doi:10.1590/S1677-
pe
5538.IBJU.2020.99.02
8. Derouiche A, Belhaj K, Hentati H, Hafsia G, Slama MRB, Chebil M. Management of penile
fractures complicated by urethral rupture. Int J Impot Res. 2008;20(1):111-114.
doi:10.1038/sj.ijir.3901599
9. Chahal A, Gupta S, Das C. Penile fracture. BMJ Case Rep. 2019;12. doi:10.1136/bcr-2016-215385
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10. Kati B, Akin Y, Demir M, Boran OF, Gumus K, Ciftci H. Penile fracture and investigation of early
surgical repair effects on erectile dysfunction. Urol J. 2019;86(4):207-210.
doi:10.1177/0391560319844657
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11. Kamdar C, Mooppan UMM, Kim H, Gulmi FA. Penile fracture: preoperative evaluation and
surgical technique for optimal patient outcome. BJU Int. 2008;102(11):1640-1644.
doi:10.1111/j.1464-410X.2008.07902.x
12. Ahmadnia H, Rostami MY, Kamalati A, Imani MM. Penile fracture and its treatment: Is retrograde
rin

urethrograghy necessary for management of penile fracture? Chinese J Traumatol - English Ed.
2014;17(6):338-340. doi:10.3760/cma.j.issn.1008-1275.2014.06.008
13. Ory J, Bailly G. Management of penile fracture. Can Urol Assoc J. 2019;113(6):S72-S74.
doi:10.5489/cuaj.5932
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14. Barros R, Hampl D, Guilherme Cavalcanti A, Favorito LA, Koifman L, Alves L. Lessons learned after
20 years’ experience with penile fracture. Int Braz J Urol. 2020;46:409-425. doi:10.1590/S1677-
5538.IBJU.2019.0367
15. Yan C, Liang BX, Huang H Bin, et al. CT-guided minimally-invasive penile fracture repair. Int Braz J
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Urol. 2019;45(1):183-186. doi:10.1590/S1677-5538.IBJU.2018.0525

This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
 ed
16. Reis LO, Cartapatti M, Marmiroli R, Oliveira Júnior EJ De, Saade RD, Fregonesi A. Mechanisms
predisposing penile fracture and long-term outcomes on erectile and voiding functions. Adv Urol.
Published online 2014. doi:10.1155/2014/768158
17. Ahmadnia H, Younesi Rostami M, Kamalati A, Imani MM. Penile fracture and its treatment: is

iew
retrograde urethrograghy necessary for management of penile fracture? Chinese J Traumatol =
Zhonghua chuang shang za zhi. 2014;17(6):338-340. doi:10.3760/cma.j.issn.1008-
1275.2014.06.008
18. Metzler IS, Reed-Maldonado AB, Lue TF. Suspected penile fracture: to operate or not to operate?
Transl Androl Urol. 2017;6(5):981-986. doi:10.21037/tau.2017.07.25

v
19. Amer T, Wilson R, Chlosta P, et al. Penile fracture: A meta-analysis. Urol Int. 2016;96(3):315-329.
doi:10.1159/000444884

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20. Yilmazel FK, Sam E, Altay MS, et al. Surgical results in penile fracture: Our single center
experience. Am J Emerg Med. 2020;(xxxx):8-10. doi:10.1016/j.ajem.2020.08.073
21. Bozzini G, Albersen M, Otero JR, et al. Delaying Surgical Treatment of Penile Fracture Results in
Poor Functional Outcomes: Results from a Large Retrospective Multicenter European Study. Eur
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Urol Focus. 2018;4(1):106-110. doi:10.1016/j.euf.2016.02.012
22. Naouar S, Boussaffa H, Braiek S, Kamel R El. Management of penile fracture : Can it wait ? African
J Urol. 2018;(2017):4-7. doi:10.1016/j.afju.2017.07.006
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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174
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Figure 1: Fractured penis with leftward deformation and edema without ecchymosis of the penile shaft

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Figure 2: Circular incision and penile stripping
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Figure 3: Lesions of the corpus cavernosum and anterior urethra

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This preprint research paper has not been peer reviewed. Electronic copy available at: https://ssrn.com/abstract=3901174