26/04/2024, 23:36 Penis Fracture - StatPearls - NCBI Bookshelf

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Penis Fracture
Kyle C. Diaz; Heather Cronovich.

Author Information and Affiliations

Last Update: July 29, 2022.

Continuing Education Activity

Penis fracture is an uncommon but severe injury. Often the direct result of penile trauma during
intercourse penis fractures has a deleterious effect on a patient's sexual health if left untreated.
This activity illustrates the evaluation and treatment of penis fractures and highlights the role of
the interprofessional team in managing patients with this condition.

Objectives:

Identify the etiology of penis fracture.

Review the typical presentation and physical exam findings in a patient with a penis
fracture.

Identify management considerations for patients with a penile fracture.

Describe some interprofessional team strategies for improving care coordination and
communication to improve outcomes for patients affected by penile fractures.

Access free multiple choice questions on this topic.

Introduction
Penile fracture is uncommon, but it is essential to note this specific urogenital injury. The
majority of penile fractures occur with direct trauma during sexual intercourse. Direct trauma to
an erect penis results in increased pressure in the cavernosa. This increased pressure, in turn,
results in the rupture of the tunica albuginea. Delay in the treatment of penile fracture can lead to
long-lasting sexual and anatomical dysfunction. Penile fracture is considered a urological
emergency. Given the sequelae of this injury, this article will review the identification, prompt
treatment, and long-term management of penile fractures.

Etiology
Penile fracture is most commonly a direct result of trauma during sexual intercourse. In one
study, 57.2% of patients with confirmed penile fracture reported direct trauma to the erect penis
during intercourse.[1] The erect penis typically slips from the vagina and is thrust into either the
perineum or pelvic bone. This thrust results in increased pressure of the filled corpus cavernosa.
This pressure results in a tear of the tunica albuginea. The most commonly associated sexual
positions are "female superior" or "rear entry," however, one study noted that meta-analysis
showed no sexual position had an increased risk.[2][3] Masturbation injuries and falls landing on
an erect penis are other notable causes of penile fracture.[4]

Epidemiology
This injury is isolated to persons with phenotypically male genitalia for obvious reasons. Penile
fractures most commonly occur in middle-aged men; multiple studies note that the average age
of patients is between 30 and 50 years of age.[1][5][6] Patients are typically heterosexual males,
which lends to the classic teaching of penile trauma during intercourse, as described above.

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However, this injury can also occur in men who have sex with men (MSM); in one study, 1.8%
of penile fractures were in the MSM population.[7] As such, for all men who report urogenital
trauma, penile fracture should remain in the differential regardless of sexual orientation.[1] One
study noted a disproportionately higher number of penile fractures occurring during the summer
months and on weekends.[8]

History and Physical

Typical historical findings commonly associated with penile fracture include the following:

Trauma to the genitals

Often occurs during intercourse

Often associated with an erect penis at the time of trauma

Patients may report hearing a "pop" or "snap."

Pain in the genitals

Bruising of the penis and surrounding area

Angulation of the penis

Immediate detumescence

Physical exam should be comprehensive and may include the following findings:

Ecchymotic shaft (an "eggplant" deformity)

Angulated penis

Flaccid penis or asymmetric erection

Tenderness of the penis

Evaluation
Correct identification of penile fracture is typically a clinical diagnosis.[9] However, suspicion of
penile fracture based on history should warrant a thorough evaluation to rule out compounded
injuries, including dorsal penile vein and nerve injuries, while simultaneously correctly
diagnosing the penile fracture. In addition to clinical suspicion for tunica rupture, multiple
imaging modalities can be useful to identify penile fractures. Ultrasound (US) is readily available
in most areas; however, there is some debate over its clinical utility as the actual test is operator
dependent, and successful identification of injury requires specific expertise. The US may show
irregular defects at the site of cavernosa rupture.[10] However, if there is a significant hematoma,
it may increase difficulty in the diagnosis of tunica rupture by the US. CT certainly is widely
available and has been demonstrated to be helpful in identification in location and size of injury
to aid surgical repair.[11] MRI, while not the most readily available test, has been shown to assist
in the diagnosis and perioperative management of penile fractures. One study demonstrated
100% sensitivity along with 77.8% specificity for the identification of penile fracture by MRI.
[12]

Workup surrounding penile fractures should include preoperative laboratory evaluation, and
other studies to rule out concomitant urethral injury may be warranted. Blood at the urethral
meatus, hematuria, and difficulty voiding should prompt assessment for urethral injury.[8] The
American Urological Association guidelines recommend provocative testing with the intent to
rule out urethral injury if there is a suspicion that this may be the case. This testing could either
be intraoperative cystoscopy or retrograde urethrogram.[13]

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Treatment / Management
Treatment of penile fractures should be prompt operative repair. After demonstrating that the
patient is an acceptable surgical candidate, the operator should plan for the identification of the
repair of the tunica rupture. Circumcising or linear incision is acceptable for the opening of the
skin. After opening the skin, the hematoma should be evacuated. Hematoma evacuation should
allow for direct visualization of tunica defects. An absorbable suture is then used to repair the
tunica defect. The type of suture and suture material is entirely user dependant. Buck's fascia
should also undergo repair, and finally, skin closure achieved with non-absorbable suture.

This surgical repair should be prompt. Studies have demonstrated a significant change in
functional outcomes with the delayed repair of penile fractures. One study showed that a delay of
approximately 8 hours resulted in substantial increases in erectile dysfunction postoperatively.
[14] Postoperatively patients should receive routine post-surgical care instructions, including
incisional care and information regarding indications to return to the emergency department.
Patients should be instructed to refrain from intercourse during the postoperative period as well.

Differential Diagnosis

Penile contusion

Dorsal vein rupture

Urethral tear

Pelvic trauma

Coagulation disorders

Prognosis
The prognosis for a promptly identified and repaired penile fracture is fair. There is certainly a
risk for long-lasting sexual effects due to this injury.[3] As discussed above, immediate surgical
repair of penile fracture serves to minimize this comorbidity. However, given the importance of
sexuality in a person's overall health identification and expedited management of the injury is
imperative to maintain this fair prognosis.

Complications
The most obvious and concerning complication of penile fracture is sexual dysfunction. All
patients who are subject to penile fracture will experience some degree of sexual dysfunction.
Some may be limited to the immediate postoperative period; however, many patients will
experience long-lasting dysfunction. Many patients will have anxiety over sexual performance
after a penile fracture. Patients may also exhibit changes in sexual practices due to fears of
recurrent injury. Counseling is also essential to guide a patient through the postoperative period
to minimize sexual dysfunction following a penile fracture.[6] Surgical complications may also
include plaques/nodules, curvature, erectile dysfunction, pain, infection, mild chordee,
reoperation, aneurysm, wound edema, and urinary disorders.[3]

Additionally, there is a significant risk for concomitant urethral injury. Special attention is
necessary to ensure foley placement intraoperatively during cystoscopy does not cause further
harm due to a missed urethral injury.

Conservative management of penile fracture has significantly more complications than surgical
intervention, most concerning erectile dysfunction.[3] Additionally, the patient may have
resultant scar tissue development resulting in curvature of the penis, painful erections, and a
consequent loss of length of the erect penis. These reasons all serve as supporting factors for

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operative repair of the penile fracture. They should be discussed thoroughly with the patient
when explaining the risks and benefits of surgical repair.

Postoperative and Rehabilitation Care

Patients should receive clear and concise postoperative care instructions. Understanding, on the
patient's part, of the condition is imperative for a smooth recovery. The patient should understand
that the maintenance and care of the foley catheter are of paramount importance. The clinical
team should advise the patient that the foley will be in place for at least four weeks to prevent or
protect any urethral injury. Additionally, the patient will need instruction for wound care
regarding the penile incision. Wounds should be kept clean and free of contaminants. The patient
should not attempt shaving around the wounds. Preference for removal of sutures will be
provider dependant.

Deterrence and Patient Education

Patient education should include discussion regarding the common causes of penile trauma.
Healthy sexual practices should be a topic covered with the patient, including avoidance of
vigorous sexual positions, which can be associated with penile trauma. As stated above, patients
should be educated on incisional care and provided clear instructions regarding follow-up.

Enhancing Healthcare Team Outcomes

Surgical repair of any injury is no small feat. In penile fractures, this remains true; not only is the
urologist necessary, but the patient must also have a broad interprofessional team for a successful
outcome. The emergency department, with its team of physicians, advanced practice providers,
nurses, and ancillary staff, is often essential for the identification and diagnosis of penile
fractures. Regarding the actual repair of the injury, the entirety of the operating room staff has a
part to play in a patient's outcome. Postoperatively the patient will require surgical wound care
instructions by urology nurses, close follow-up in the urologic offices with interaction, and care
by office staff. Finally, the management of complications may include counseling by licensed
therapists or psychologists for the facilitation of return to baseline sexual function. In no way is
the successful management of a penile fracture possible without a cohesive and comprehensive
interprofessional healthcare team who are all coordinated and collectively invested in the patient
and their outcome. [Level 5]

Review Questions

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Comment on this article.

References
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28659630]
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5. Ortac M, Özgor F, Caglar U, Esmeray A, Savun M, Sarılar Ö. Older age and a large tunical
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9. Kasaraneni P, Mylarappa P, Gowda RD, Puvvada S, Kasaraneni D. Penile fracture with
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Disclosure: Kyle Diaz declares no relevant financial relationships with ineligible companies.

Disclosure: Heather Cronovich declares no relevant financial relationships with ineligible companies.

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