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Table of Contents
ORIGINAL ARTICLE
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 298-302

A tertiary center experience of fracture penis: Early surgical management with a clinical diagnosis


Department of Urology, Sardar Patel Medical College, Bikaner, Rajasthan, India

Date of Web Publication22-Nov-2018

Correspondence Address:
Lalit Kumar
Flat No. 102, Tower A1, Unitech The Residencies, Sector 33, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_91_18

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  Abstract 

Introduction: Fracture penis is uncommon and often a result of sexual trauma. Diagnosis remains clinical and early surgical management is advocated. Herein, we share our experience of 20 such cases. Materials and Methods: Twenty fracture penis patients presented between August 2014 and April 2017 were included. Patients' data were retrieved retrospectively using case sheets and followed by outpatient department visits and telephonically. Eighteen patients had penile exploration while two patients were managed conservatively. Erectile and voiding functions were assessed by asking single question to the patient, which was limited to only two options in the form of normal and abnormal. All patients were followed up for a minimum of up to 6 months. Results: The patients were aged between 20 and 60 years (mean 37.7 years). Mean timing of presentation was 28.8 h (range 2 h to 7 days). Mean follow-up was 22.5 months (6–42 months). There were no long-term postoperative complications. Eighteen patients had coital trauma, one unmarried patient had a history of manipulation of erect penis, while one patient had a fall-on erect penis. Three patients had associated urethral injury. All patients had almost the same potency as preoperatively, but for one who had erectile dysfunction for a short period recovered spontaneously on tablet sildenafil. No patient had long-term voiding dysfunction, penile curvature, or sexual dysfunction. Conclusion: History and clinical examination clinch the diagnosis. Considering it as a urological emergency, radiological imaging is not required routinely. Early surgical repair preserves the potency and voiding functions.

Keywords: Fracture, penile, urethra


How to cite this article:
Kumar L, Tiwari R, Arya M C, Sandhu A, Vasudeo V, Baid M. A tertiary center experience of fracture penis: Early surgical management with a clinical diagnosis. Urol Sci 2018;29:298-302

How to cite this URL:
Kumar L, Tiwari R, Arya M C, Sandhu A, Vasudeo V, Baid M. A tertiary center experience of fracture penis: Early surgical management with a clinical diagnosis. Urol Sci [serial online] 2018 [cited 2018 Dec 13];29:298-302. Available from: http://www.e-urol-sci.com/text.asp?2018/29/6/298/245316




  Introduction Top


Penile fracture is a relatively uncommon clinical condition that frequently causes fear and embarrassment for a patient, hypothetically resulting in delayed search for medical assistance, which can lead to an impairment of sexual and voiding functions.[1] Its incidence and etiologies vary according to the geographic region, sexual behavior, marital status, and culture. The rupture of tunica albuginea of the corpora cavernosa defines penile fracture that occurs with the organ in an erectile state. Diagnosis is usually made by history and clinical examination, and the classic triad of an audible “cracking” sound, followed by immediate detumescence and pain, is usually present. Due to the typical symptoms of fracture of the penis, surgical exploration can be performed without delay, avoiding the need of further diagnostic procedures.[2],[3] Nonetheless, if the cause is atypical or obscure, further diagnostic methods can be used to make the diagnosis. Early surgical exploration and repair remain the most effective treatment strategy.


  Materials and Methods Top


The present study is a retrospective study of 20 cases of fracture penis between August 2014 and April 2017 and was approved by the ethical committee of our Institute (IRB ECR/27/SP/Inst/ RJ/2013/RR-16). Patients' data were retrieved using case sheets and followed with outpatient department visits and telephonically. A detailed history and relevant investigations for emergency surgery were done. Erectile and voiding functions were assessed by asking single question to the patient, which was limited to only two options in the form of normal and abnormal. Normal for erectile function was defined to a patient as whether he can perform intercourse or masturbation. Patients voiding without abdominal straining and thin urinary stream were considered normal. No detailed objective questionnaire was recorded. Penoscrotal compression dressing was done in all patients. On the 2nd postoperative day after catheter removal, the patients were discharged on tablet conjugated estrogen 0.625 mg 1 tablet twice a day for 3 weeks (estrogen started from day 1). In all patients, 6 months of follow-up was completed and asked for erectile and voiding functional status. They were locally examined for penile curvature, nodules, or other wound-related complications.


  Results Top


The patients were aged between 20 and 60 years (mean 37.7 years). Majority of the patients were between 30–40 years of age. Mean timing of presentation was 28.8 h (range 2 h to 7 days). Most of the patients presented within 24 h. Eighteen out of 20 patients had coital trauma as the etiology and one had a history of manipulation of erect penis while another patient had a fall-on erect penis [Table 1].
Table 1: Patients stratification by age groups, etiology, timing of presentation to hospital

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Two patients were managed conservatively and rest 18 were explored through circumcoronal degloving incision. Bleeding per urethra was seen in three patients of which two were managed conservatively (catheterization with perineal compression) because they had no penile swelling and history of sudden detumescence following trauma and one patient with penile swelling underwent immediate suprapubic catheter (SPC) insertion followed by early exploration and repair [Table 2]. Seventeen patients had a typical history of trauma during erect penis with cracking or popping sound followed by pain and swelling of penis and sudden detumescence.
Table 2: Type of management and complications

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Eighteen patients underwent exploration without any ultrasonogram (USG), magnetic resonance imaging (MRI), or urethrogram. Hence, decision of emergency surgery was solely on clinical diagnosis. All patients were explored through circumcoronal degloving incision. Ventral defect was found in 12 patients while dorsal defect in six patients. Tunical defect was transverse in all the cases and was repaired in single layer, interrupted sutures using silk 1-0 with knot inside [Figure 1]. Left corpus (11 patients) was involved more commonly, and in eight patients, right corpus was involved. Two patients had involvement of both left corpus cavernosum and urethral involvement. One patient had bilateral corpus injury associated with urethral injury.
Figure 1: Arrow demonstrating corporal defect

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Most of the tears involved proximal part of the penis except in one patient where it involved the midpenile part with a history of masturbation. One patient had associated urethral transection along with tunical tear which was repaired with vicryl 4-0 interrupted sutures over a 14 Fr Foleys catheter [Figure 2]. In addition, SPC was inserted in this patient.
Figure 2: Star mark depicting tunica albuginea defect and arrow pointing circumscribed urethral defect

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Among patients who were managed conservatively, one patient presented a month later and had local abscess. SPC insertion and abscess drainage were done immediately followed by corporal and urethral repair after 6 weeks. All of the patients had their catheter removed on the postoperative day 2, except the patient who underwent urethral repair in whom the catheter was removed on the 10th day and SPC clamped. SPC was removed 5 days later. No intraoperative complications were noted. All patients were discharged on postoperative day 2. Mean follow-up was 22.5 months (6–42 months). The early postoperative course was uneventful in all patients. Of 20 patients, 19 immediately achieved erections with adequate rigidity sufficient for intercourse. One patient had erectile dysfunction which recovered on medical therapy with sildenafil. A patient with urethral repair developed a small urethrocutaneous fistula which healed spontaneously.


  Discussion Top


The first documented report of penile fracture is credited to the Arab Physician Abu al-Qasim Al-Zahrawi in Cordoba, >1000 years ago.[4] In the modern medical literature, the first case of penile fracture was described by Malis and Zur in 1924.[5] The usual cause of penile fracture is abrupt bending of the erect penis, which may occur during sexual intercourse, masturbation, rolling over in the bed, or during the practice known as “taqaandan,” in which the erect penis is pushed down to achieve detumescence, resulting in a click.[6] The mechanism of injury depends on sociocultural characteristics, masturbation habits, and specific sexual activities that an individual engages in.

In flaccid state, penis allows a significant degree of deformation without any injury to the vital structures; however, in erect state, it is vulnerable to blunt injury. The tunica albuginea is a structure of great tensile strength that is able to withstand rupture at pressures up to 1500 mmHg. As the penis changes from a flaccid state to an erect state, the thick tunica albuginea becomes very thin from 2 mm to 0.25–0.5 mm; the tunica albuginea thins, stiffens, and loses elasticity and becomes easily fractured.[7]

Most of the times, only the patients' history and physical examination are all needed to make the correct diagnosis. A physician can easily recognize fracture of the penis as it has pathognomic clinical symptoms. An audible, sudden cracking or snapping sound heard by the patient himself is the most commont presenting complaint followed by sudden rapid detumescence, pain, swelling, ecchymosis, and deformation of the penis.[8] Urethral injury is to be suspected if there is a history or presence of blood at the external urethral meatus, gross hematuria, or inability to pass urine. Some patients may present with unexplained repeated episodes of bleeding per urethra during sleep.

Penile fracture is considered a urological emergency. Clinical diagnosis based on the history and examination is sufficient. Although imaging such as USG, MRI, cavernosography, or urethrography may be required for better evaluation in equivocal cases, usually, it is unnecessary.[9] The use of USG as a routine diagnostic method is also controversial. In one study, Beysel et al. noticed USG inaccuracy of 15% of patients in a series of 13 cases.[10] At our center, we went for immediate surgery without any imaging in all patients like previously described by Amit et al. and Reis et al.[11],[12] Pseudo-fracture of the penis and rupture of dorsal vein of the penis can mimic fracture penis and must be kept in mind as a differential diagnosis. They are difficult to be differentiated on the basis of clinical findings or preoperative imaging. Their diagnosis is generally confirmed after penile exploration.[13],[14]

Treatment of the penile fracture has been a controversial issue. Previously nonsurgical management was recommended which included bed rest, pressure dressings, catheterization, and ice packs for 24–48 h in addition to antibiotics, fibrinolytics, estrogens, and diazepam for suppressing erection.[15],[16] Ten to thirty percent of patients receiving such conservative management developed impaired erections, permanent deformity, or suboptimal coitus.[2]

Nowadays, immediate surgical treatment of all cases of penile fracture is preferred as it offers a chance for complete recovery, even in the presence of urethral injury, and is the best method for providing a good functional prognosis.[8] Sometimes, fracture site is not easily identified during exploration; at that instance, tunica should be carefully palpated for any defect and buck fascia needs to be incised at the site of defect to uncover it which we encountered in one of our patients.

If urethral injury is encountered, it should be repaired in a spatulated, watertight fashion with subsequent long-term urethral catheter drainage [Figure 2]. Patients should be counseled to abstain from sexual activity for at least 6–8 weeks.[17]

In our study, all 17 patients without suspicion of urethral injury had immediate penile exploration. All had uneventful follow-up except in one patient who required sildenafil for erectile dysfunction. Three patients were considered to have urethral injury based on the positive history of bleeding per urethra. One patient of urethral injury associated with penile swelling had immediate exploration. Intraoperatively, complete urethral injury was found. He developed urethrocutaneous fistula after catheter removal. It may be due to early catheter removal at 10 days without any urethrography. Previous studies suggested catheter-free trial at 2 weeks after pericatheter catheter study to rule out extravasation. Some authors have suggested up to 3 weeks of catheterization.[11],[18] Two patients who had bleeding per meatus without penile hematoma were managed conservatively considering it to be a low-grade urethral injury. One out of two patients had penile abscess postoperatively requiring incision and drainage. Two out of 18 patients (11.11%) who were managed surgically developed postoperative complication compared to 50% (one out of two patients) of patients managed conservatively. Similarly, in previous literature, after surgery, chances of subsequent erectile dysfunction and deformity too far less than 5%–10% compared to over 50% of morbidity after conservative management.[19],[20]

In the present study, two patients had short-term postoperative complications after surgical exploration. These patients have delayed presentation to hospital (ᡐ h). Patients who presented early within 24 h did not have any postoperative morbidity. This scores the importance of early surgery as shown previously.[12],[21] Presentation to the hospital is more delayed especially in developing countries like India due to lack of awareness and social stigma regarding this condition. We support early surgical management of penile fracture considering it to be a clinical diagnosis without wasting time and money on investigations.

The current work is not free of limitations. It is a retrospective noncomparative study with limited number of patients. Data regarding erectile and voiding functions were obtained by asking single question to the patient, which was limited to only two options in the form of normal and abnormal. Hence, the outcome measured was subjective and not assessed using standard validated questionnaires.


  Conclusion Top


History and clinical examination clinch the diagnosis. Early surgical repair preserves the potency. Careful palpation followed by incision of Bucks's fascia to uncover the defect in cases where the fracture site is not easily identified.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kamdar C, Mooppan UM, Kim H, Gulmi FA. Penile fracture: Preoperative evaluation and surgical technique for optimal patient outcome. BJU Int 2008;102:1640-4.  Back to cited text no. 1
    
2.
Ozen HA, Erkan I, Alkibay T, Kendi S, Remzi D. Fracture of the penis and long-term results of surgical treatment. Br J Urol 1986;58:551-2.  Back to cited text no. 2
    
3.
Fedel M, Venz S, Andreessen R, Sudhoff F, Loening SA. The value of magnetic resonance imaging in the diagnosis of suspected penile fracture with atypical clinical findings. J Urol 1996;155:1924-7.  Back to cited text no. 3
    
4.
Agarwal MM, Singh SK, Sharma DK, Ranjan P, Kumar S, Chandramohan V, et al. Fracture of the penis: A radiological or clinical diagnosis? A case series and literature review. Can J Urol 2009;16:4568-75.  Back to cited text no. 4
    
5.
Malis J, Zur K. Der fractura penis. Arch Klin Chir 1924;129:651.  Back to cited text no. 5
    
6.
Zargooshi J. Penile fracture in Kermanshah, Iran: Report of 172 cases. J Urol 2000;164:364-6.  Back to cited text no. 6
    
7.
Bitsch M, Kromann-Andersen B, Schou J, Sjøntoft E. The elasticity and the tensile strength of tunica albuginea of the corpora cavernosa. J Urol 1990;143:642-5.  Back to cited text no. 7
    
8.
Hinev A. Fracture of the penis: Treatment and complications. Acta Med Okayama 2000;54:211-6.  Back to cited text no. 8
    
9.
Sawh SL, O'Leary MP, Ferreira MD, Berry AM, Maharaj D. Fractured penis: A review. Int J Impot Res 2008;20:366-9.  Back to cited text no. 9
    
10.
Beysel M, Tekin A, Gürdal M, Yücebaş E, Sengör F. Evaluation and treatment of penile fractures: Accuracy of clinical diagnosis and the value of corpus cavernosography. Urology 2002;60:492-6.  Back to cited text no. 10
    
11.
Amit A, Arun K, Bharat B, Navin R, Sameer T, Shankar DU, et al. Penile fracture and associated urethral injury: Experience at a tertiary care hospital. Can Urol Assoc J 2013;7:E168-70.  Back to cited text no. 11
    
12.
Reis LO, Cartapatti M, Marmiroli R, de Oliveira Júnior EJ, Saade RD, Fregonesi A. Mechanisms predisposing penile fracture and long-term outcomes on erectile and voiding functions. Adv Urol 2014;2014:768158.  Back to cited text no. 12
    
13.
Karadeniz T, Topsakal M, Ariman A, Erton H, Basak D. Penile fracture: Differential diagnosis, management and outcome. Br J Urol 1996;77:279-81.  Back to cited text no. 13
    
14.
Sharma GR. Rupture of the superficial dorsal vein of the penis. Int J Urol 2005;12:1071-3.  Back to cited text no. 14
    
15.
Farah RN, Stiles R Jr., Cerny JC. Surgical treatment of deformity and coital difficulty in healed traumatic rupture of the corpora cavernosa. J Urol 1978;120:118-20.  Back to cited text no. 15
    
16.
Jallu A, Wani NA, Rashid PA. Fracture of the penis. J Urol 1980;123:285-6.  Back to cited text no. 16
    
17.
Masarani M, Dinneen M. Penile fracture: Diagnosis and management. Trends Urol Gynaecol Sex Health 2007;12:20-4.  Back to cited text no. 17
    
18.
Tsang T, Demby AM. Penile fracture with urethral injury. J Urol 1992;147:466-8.  Back to cited text no. 18
    
19.
Hatzichristodoulou G, Dorstewitz A, Gschwend JE, Herkommer K, Zantl N. Surgical management of penile fracture and long-term outcome on erectile function and voiding. J Sex Med 2013;10:1424-30.  Back to cited text no. 19
    
20.
Gamal WM, Osman MM, Hammady A, Aldahshoury MZ, Hussein MM, Saleem M. Penile fracture: Long-term results of surgical and conservative management. J Trauma 2011;71:491-3.  Back to cited text no. 20
    
21.
Tamhankar AS, Pawar PW, Sawant AS, Kasat GV, Savaliya A, Mundhe S, et al. Fractured penis: Not so rare! Urol Int 2017;99:63-8.  Back to cited text no. 21
    


    Figures

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  [Table 1], [Table 2]



 

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