Penile Fracture and Trauma - Causes, Symptoms, and Treatment

What Is a Penile Fracture?

Penile fracture is a rupture in tunica albuginea (a rubber-like outer lining of cylinder-like structures in the penis) responsible for the erection of the penis. The penis is boneless but can still fracture. Anatomically, the penis consists of two columns or passages called corpora cavernosa and corpus cavernosum that get filled with blood during an erection. The corpora cavernosa and corpus cavernosum are covered by tunica albuginea. The tunica albuginea provides protection, but when a force is applied, it undergoes rupture, causing a fractured or broken penis. Penile fracture is common in middle-aged men between thirty and fifty years of age. Individuals affected are usually heterosexual males. Penile fractures are also seen in the MSM (men who have sex with men) population.

What Are the Causes of Penile Fracture?

The causes are:

• Penile fractures most of the time happen during sexual intercourse. The penis slips out of the partner and thrusts between the anus and the pelvic bone or the perineum, creating pressure on the filled corpus cavernosa. Sexual positions such as female superior or rear entry have a higher incidence of penile fracture.
• Forceful or energetic masturbation.
• During an erection, the individual may hurt their penis by hitting a wall or door or rolling over the erect penis.
• Taqadaan is a practice performed by middle eastern or Central Asian men where they bend an erect penis to change the size and shape of the penis or make an erection go away.

What Are the Symptoms of a Penile Fracture?

The symptoms involve:

• Cracking or popping sound while the fracture occurs.
• Intense pain that may or may not subside.
• Immediate softening of the penis during erection.
• Swelling and bruising due to accumulation of blood under the skin.
• Bleeding at the tip of the penis.
• Hematuria (blood in urine).

Can a Penile Fracture go Unnoticed?

Most commonly, the affected person will hear a pop or cracking sound from an erect penis at the time of the injury, followed by a rapid loss of erection, acute pain varying from minimal to severe, swelling, and penile deformity known as “eggplant deformity,” resulting from penile swelling, purplish discoloration, and penile deviation toward the opposite side of the fracture. Hence, if one has a penile fracture, it will be noticed for the above reasons. In the absence of the above signs and symptoms, one might have other types of soft tissue injury.

How Is Penile Fracture Diagnosed?

The doctor will take a thorough history of the case to rule out conditions like dorsal penile vein injuries and nerve injuries.

To check for tunica rupture, the healthcare provider may order the following imaging tests:

• Ultrasound detects irregular sites at cavernosa rupture.
• Magnetic resonance imaging (MRI) helps in diagnosis and perioperative management. Its sensitivity and specificity rate are 100 % and 77.8 %, respectively.
• Retrograde urethrogram or cystoscopy (imaging test performed to check for urethral injury).
• Computed tomography (CT) provides the location and size of the injury.

During the examination for penile fracture, the doctor will conduct tests to rule out urethral injury. Symptoms of urethral injury involve hematuria (blood in urine), blood in the urethral meatus, and difficulty voiding.

Differential Diagnosis for Penile Fracture:

The differential diagnosis involves:

• Dorsal vein rupture.
• Urethral tear.
• Penile contusion.
• Pelvic trauma.
• Coagulation disorders.

Is it Possible to Cure Penile Fracture Without Surgery?

Initially, non-operative treatment was regarded as the standard management of penile fracture, it includes ice packs at the site of swelling, foley catheterization (placing a flexible tube into the bladder to drain urine), and anti-inflammatory medicines. Still, non-operative management is associated with high long-term complication rates. Therefore, clinicians recommend immediate surgical intervention and repair instead of conservative therapy.

What Happens if a Penile Fracture is Left Untreated?

If the penile fracture is left untreated, it will cause anatomical and sexual deformities, which are far more common and debilitating. For example, an affected person may suffer from the following:

• Painful erection.
• Loss of length of the erect penis.
• Scar tissue may lead to a curve in the penis.
• In the case of urethral injury, dysuria (inability to urinate), urinary retention, and hematuria (blood in urine).

Can Penile Fractures Be Cured Without Surgery?

Treatment of penile fracture without surgery can be done with ice packs, foley catheterization, anti-inflammatory medicines, erection-inhibiting estrogens, penis splints, use of compression bandages, antibiotics, and fibrinolytic agents. However, it is not advised due to long-term complications.

What Is the Treatment for Penile Fracture?

The treatment of choice is prompt operative repair. Surgery is performed after evaluating the case and following all the case selection criteria. The surgery's main aim is to identify and repair tunica rupture. A linear incision or circumcision is used to open the skin. After opening the skin, the hematoma is removed. Removal of the hematoma gives direct visualization of the tunica defects. The tunica defect is repaired with an absorbable suture.

The surgeon decides the suture type and suture material. The buck's fascia is repaired with a non-absorbable suture. A delay in the repair of a penile fracture may result in significant changes in functional outcomes. According to a study, an eight-hour delay increased postoperative erectile dysfunction. Post-operative counseling should be provided to individuals to cope with it mentally.

Postoperative Care for Penile Fracture:

The doctor will give postoperative instructions on the maintenance and care of the Foley catheter that might be placed for four weeks to avoid any urethral injury.

The doctor will also give wound care instructions for penile incisions, such as below:

• Keep the area clean and contaminant-free.
• Avoid shaving around the wounds or incisions.
• Avoid sexual activity.

How Long Is the Recovery Period?

Surgical procedures involve hospital admissions and may require admission even after the procedure, depending on the healthcare provider's advice. Follow-up visit instructions may be given, which should be promptly followed to avoid complications.

How to Prevent Penile Fracture?

1. One can prevent penile fracture by avoiding bending their erect penis on purpose. As people get older, their erections may get softer, which increases the risk of bending a soft erection unexpectedly during sexual intercourse. In case one notices a softer erection, they can consult their doctor.

Their doctor may prescribe them medications that help get them harder erections; this medications may include:

• Sildenafil.
• Vardenafil.
• Tadalafil.
• Avanafil.

2. Additionally, one also needs to take precautions during sexual intercourse, such as the following:

• Guide their penis if they change positions or if their penis slips out.
• Use lubricants to help reduce friction.
• Be cautious in positions where they can not make eye contact with their partner, such as if their partner is on top or if they are behind their partner.

Risk Factors for Penile Fracture:

Even if penile fractures can occur from injury with any position in sexual intercourse, some circumstances may increase the risk.

• In heterosexual men.
• The woman-on-top position raises the risk. When the penis is blocked for a moment at the entrance of the vagina, in this situation, the full weight of the woman can forcefully bend the erected penis. In another scenario, the woman in the top position may rock too far forward or backward, leading to a bend of the shaft of the erected penis.
• The back entry position can also increase the risk of penile injuries.
• Kneading and snapping of the penis to achieve rapid detumescence (subsiding the erection). It happens most commonly in Mediterranean countries,
• Placing an erect penis into tight pants.

The Prognosis for Penile Fracture:

The prognosis for the on-time identified and repaired penile fracture is fair. However, there is a particular risk for long-term sexual effects caused by this incident. As discussed above, delayed repair may lead to sexual dysfunctions.

When Should One See a Healthcare Provider?

A person should go to the nearest emergency room in case their erect penis is injured and are experiencing penile fracture symptoms. In case a person has injured their erect penis and did not get immediate care, still they should see a healthcare provider, especially in case of the following:

• Difficulty getting erections.
• Problems peeing.
• Blood in their pee.
• Discoloration, swelling, or pain in their penis.
• Any other symptoms that are bothering them.

After penile fracture surgery, one should contact a healthcare provider if they feel excessive pain, bleeding, or any other sign of infection, such as the following:

• Chills.
• Fever.
• Headache.

Conclusion:

A penile fracture is a rare but severe injury that can affect sexual activity if left untreated. Even in the absence of bones, the penis can undergo a fracture. This is caused by the force applied to an erect penis during sexual intercourse. Common in middle-aged men between thirty and fifty years of age. If left untreated, it can affect sexual activity and cause complications. Surgery is the treatment of choice, followed by counseling and postoperative follow-up.