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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 31  |  Issue : 2  |  Page : 73-76

Assessment of long-term outcomes with immediate versus delayed surgical repair of penile fractures


Department of Urology, SCB Medical College and Hospital, Cuttack, Odisha, India

Date of Submission01-Sep-2019
Date of Decision21-Jan-2020
Date of Acceptance31-Jan-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Md Faizul Haque
Department of Urology, SCB Medical College and Hospital, Cuttack, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/UROS.UROS_58_19

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  Abstract 


Purpose: Penile fracture may affect erectile dysfunction (ED) and overall sexual satisfaction. This study aimed to compare the long-term effects of immediate versus delayed surgical repair of penile fractures on postoperative ED, fibrous tunica plaques, and chordee formation. Materials and Methods: This is a prospective observational study conducted between January 2016 and June 2018, which included patients with penile fracture. Details of injury, symptoms, treatment, and long-term outcomes (up to 12 months) were collected. Data were presented using summary statistics. Results: A total of 21 patients (early surgical repair [Group A], n = 13; delayed surgical repair [Group B], n = 8) were enrolled in this study. The common cause of penile fracture was masturbation (n 1 = 5 [early presentation]; n 2 = 5 [delayed presentation]) and sexual intercourse (n 3 = 7 [early presentation]; n 4 = 4 [delayed presentation]) in Groups A and B, respectively. Penile ecchymosis/swelling and pain were present in all the patients of Group A (n = 13), while typical pop-up sound was heard by eight patients (61.54%) of Group A and six patients (75.00%) of Group B. The most common reason for delay in presentation was fear/embarrassment (75.00%). Penile paresthesia (n = 2) and penile curvature (n = 3) were observed in Group A, while penile paresthesia (n = 3) was also reported in Group B. None of the patients from both groups reported ED. All the three patients with urethral injury repaired had mild degree of ventral chordee with a satisfactory erection and a good penetration. Conclusion: The results showed that delayed repair did not affect the long-term outcome with no major impact on erectile function and overall sexual satisfaction.

Keywords: Erectile dysfunction, reconstruction, trauma


How to cite this article:
Haque MF, Paul AS, Swain S, Goyal G. Assessment of long-term outcomes with immediate versus delayed surgical repair of penile fractures. Urol Sci 2020;31:73-6

How to cite this URL:
Haque MF, Paul AS, Swain S, Goyal G. Assessment of long-term outcomes with immediate versus delayed surgical repair of penile fractures. Urol Sci [serial online] 2020 [cited 2020 May 24];31:73-6. Available from: http://www.e-urol-sci.com/text.asp?2020/31/2/73/283249




  Introduction Top


Penile fracture is a rare urological emergency resulting from the rupture of the tunica albuginea of corpus cavernosum.[1] It usually occurs in erected penis. The etiology of penile fractures varies greatly, which includes sexual intercourse, masturbation, direct blunt trauma, sudden forced flexion, and rolling over in bed.[2],[3],[4] Most of the patients with penile fracture experience immediate severe pain, penile detumescence, rapid swelling, hematoma, urethral bleeding, and widespread ecchymosis.[2],[3],[4]

Previous series of reports recommend management of these patients with immediate surgical repair due to associated minimal risk of postoperative complications, as compared to conservative management.[3],[5],[6],[7] The main challenge in the management of penile fracture is the delay in seeking medical care due to fear of embarrassment, poverty, or ignorance. Early presentation and immediate surgical repair of penile fracture are considered better because of the excellent long-term outcomes in terms of low risk of erectile dysfunction (ED) and good overall sexual satisfaction.[3] However, a few previous studies have reported that maintenance of erectile potency and long-term overall sexual satisfaction are similar in patients with penile fractures irrespective of the time of surgical repair.[4],[8],[9]

It is currently still debatable if delays in repair offer similar long-term patient outcomes. Therefore, the present study aimed to compare the long-term effects of immediate versus delayed surgical repair of penile fractures on postoperative ED, fibrous tunica plaques, and chordee formation.


  Materials and Methods Top


A prospective observational study was conducted at the Department of Urology, S.C.B. Medical College and Hospital, Cuttack, Odisha, India, between January 2016 and June 2018. The study protocol was approved by the institutional ethics committee (approval no. 40) and conducted in accordance with the principles of the Declaration of Helsinki. Written informed consent was obtained from all patients before enrollment.

Patients with penile fracture were included in this study. Patients were classified into two groups: Group A, patients undergoing early repair (≤24 h), and Group B, patients undergoing delayed repair (>24 h) of fractured penis. Time duration of 24 h was taken arbitrarily.

A detailed history, symptoms, type of sexual relationship (homosexual/heterosexual), mechanism of trauma, sexual position at the time of trauma (when applied), history of substance abuse, clinical findings at physical examination, imaging results (when requested by the urologist), and presence of urethral injury were assessed.

All patients were subjected to immediate surgery using a circumcoronal penile degloving incision (in some patients with circumcision) up to the tunical laceration site. Corpora spongiosa was inspected. The hematoma was evacuated, and the defect was washed with hydrogen peroxide. [Figure 1] depicting Intraoperative image of fracture penis with urethral injury on left lateral side seen during exploration. In addition, defect in the tunica was repaired with polydioxanone (PDS) 3-0 suture in a continuous manner. Patients with a history of urethral bleeding (three patients) underwent retrograde urethrogram (RGU) before exploration. All of them had normal urethral continuity with mild urethrovenous intravasation of dye. After that, gentle 14 Fr Foley catheterization was done. In patients with a defect in corpora spongiosa with Foley's catheter along with tunical tear, the margins of urethra were freshened along with tunical repair and defects in urethra and spongiosa were closed in two layers with PDS 4-0 suture. The skin was sutured with approximate 3-0 chromic catgut suture. The patients were advised to take diazepam 10 mg once daily at bedtime and ethinyl estradiol 0.01 μg to prevent penile erection, postoperatively. Patients with Grade 1 urethral injuries who underwent operation after 24 h were maintained on periurethral catheter (PUC) for the next 7 days. All patients were routinely followed up at 1, 3, 6, and 12 months after surgery. During the follow-up visits, patients' complaints regarding wound-site complication, voiding dysfunction, satisfactory erection, and penile bending were noted, and all patients were examined clinically and the International Index of Erectile Function-5 scores were determined at 6 and 12 months of follow-up.
Figure 1: Intraoperative image of fracture penis with urethral injury on left lateral side seen during exploration

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  Results Top


Of the total 21 patients as shown in [Table 1], (Group A, n = 13; Group B, n = 8), 15 patients had done ultrasonography (USG) of penis and perineum before referral to us, although it felt unnecessary during surgical intervention. Typical pop-up sound and sudden detumescence of the erected penis were experienced in 14 patients. The majority of patients were adults. The common cause of penile fracture was masturbation (n 1 = 5 [early presentation]; n 2 = 5 [delayed presentation]) and sexual intercourse (n 3 = 7 [early presentation]; n 4 = 4 [delayed presentation]) in Groups A and B, respectively. One patient (7.69%) from Group A had penile fracture due to falling on a hard surface during masturbation. Penile ecchymosis/swelling and pain were present in all the patients of Group A (n = 13). Typical pop-up sound was heard by eight patients (61.54%) of Group A and six patients (75.00%) of Group B. Three patients (14.3%) had a history of bleeding per urethra. 14 Fr Foley's catheter was placed following RGU.
Table 1: Clinical profile of the patients

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Majority of the patients had single transverse tunical tear near the root of the penis at the dorsolateral aspect of the corpora cavernosa (right > left), with an average size of 1.5 cm (range 1–2.5 cm). Two patients of Group A and three patients of Group B had tunical tear on the left side, whereas eight and five patients from Groups A and B, respectively, had tunical tear on the right side. In Group A, proximal tear was found in 11 patients (84.62%) and midshaft tear was found in two patients (5.38%), whereas all patients from Group B (n = 8) had proximal tear. Three patients from Group A had bilateral tunical tear extending to the corpora spongiosum resulting in urethral injury. In follow-up periods, none of the patients complained about any voiding problems.

Eight patients showed delay in presentation with a mean delay of 78.6 h (range: 36–120 h). The reasons of delay in presentation were fear/embarrassment (75.00%), ignorance (12.50%), and delay in referral (12.50%) [Table 2].
Table 2: Reasons for delayed presentation

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Long-term complications in both groups are listed in [Table 3]. At 12-month follow-up, penile paresthesia (n = 2) and penile curvature (n = 3) were the complications observed in early-operated patients (Group A). Penile paresthesia was also observed in three patients who delayed in presentation (Group B). A total of five patients (Group A, n = 2; Group B, n = 3) had complaints of decreased penile skin sensation. Only two patients had mild-degree penile pain during erection which gradually resolved during follow-up, and all had successful satisfactory erection and penetration with no palpable tunical scar. All the three patients with urethral injury repaired had mild degree of ventral chordee with a satisfactory erection and a good penetration. IIFE-5 questionnaire scores in all patients at 6-month and 12-month follow-up revealed a score of ≥22, similar to prefracture state.
Table 3: Long-term comparison between two groups at 1 year of follow-up

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Thirteen patients were discharged on postoperative day 2 with removal of PUC. Five patients from Group B suspected with Grade 1 urethral injuries were maintained on PUC for the next 7 days. In three patients with repaired urethral injuries, PUC maintained for 21 days, and following PUC removal, all patients voided well.


  Discussion Top


In the majority of cases, diagnosis of penile fracture is easily made based on clinical examination and history of injury. In most of the cases, patients describe a cracking sound. Although penile fracture can be managed by both surgical and conservative approaches, surgical option is preferred. In several studies, it has been demonstrated that conservative treatment has worse outcomes than surgery. [7,10-12] Injury leads to hematoma and the blood may remain between the skin and tunica albuginea, resulting in eggplant deformity. The worse long-term outcome could be due to increased amount of fibrosis during the spontaneous tissue repair process.

Among the causes of penile fracture in the present study, the majority of patients who underwent early repair had fracture during sexual intercourse; however, the majority of patients who underwent delayed repair had fracture due to masturbation. Because of embarrassment, they presented late. The literature shows mixed causes of penile fractures. In a previous study, 80.9% of patients had penile fracture due to sexual intercourse;[7] however, another study reports that manual bending of the erected penis was the reason of penile fractures in 54.1% of patients.[13] Another study from Nigeria reported forced bending of erected penis (47.62%) and sexual intercourse (53.38%) as the reasons of penile fracture.[14]

In the present study, all the patients who presented early had penile ecchymosis/swelling and penile pain; however, none of the patients who had these symptoms reported late. Pop-up sound was heard by 61.54% and 75% of patients, respectively. These results are consistent with the fact that most of the patients do hear some sound during fracture. The most common reason for delay in presentation was fear or embarrassment. It has been reported that there is a significant delay in seeking treatment for penile fracture, mostly due to fear or embarrassment. There are several reports that confirm delay in seeking treatment for penile fracture.[15] Delay in seeking treatment has been associated with higher rates of complications including penile curvature and pain during intercourse.[16],[17],[18]

Although surgical approach is considered beneficial in patients with penile fracture, time of surgery is a major factor. Immediate surgical reconstruction is associated with faster recovery, decreasing overall morbidity, lesser adverse events or complications, and reducing the risk of penile curvature.[19],[20] A recent systematic review of 12 studies (with a total of 502 patients) evaluated complication rates between immediate and delayed repair of penile fractures.[15] The authors concluded that the rates of ED and tunical scar formation were almost similar in both the groups; however, patients who underwent immediate repair had a lower rate of penile curvature. Another meta-analysis of 58 studies showed that early surgical intervention was associated with significantly fewer complications.[20] Another study reports similar results that ED or serious deformities do not occur in patients without urethral involvement who received surgical treatment within the first 24 h.[21] In the present study, none of the patients reported tunical plaque/nodule or ED. However, in contrast, three patients from the present study who underwent early repair had penile curvature.

There is still controversy on the use of preoperative imaging in patients with penile fracture. Penile USG, magnetic resonance imaging, cavernosography, and retrograde urethrography are considered useful in the diagnosis of penile fracture and to assess the site and extent of damage. However, they can be time-consuming and are not cost-effective, thus delaying surgical exploration; hence, they should not replace clinical assessment.[22] Currently, there is no evidence-based literature to recommend any of them for patients with clinically diagnosed penile fracture.[22],[23],[24]

The authors acknowledge that the small sample size is a major limitation of this study. Hence, care must be taken when generalizing the study's results.


  Conclusion Top


Despite the limitations of this study, it demonstrated that delayed repair (maximum up to 5 days in our series) did not affect the long-term outcome with no major impact on erectile function and overall sexual satisfaction. Although there is no consensus on the optimal timing of surgical intervention, we believe the best approach is clinical diagnosis of penile fracture and prompt exploration and surgical repair without any delay.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cendron M, Whitmore KE, Carpiniello V, Kurzweil SJ, Hanno PM, Snyder HM, et al. Traumatic rupture of the corpus cavernosum: Evaluation and management. J Urol 1990;144:987-91.  Back to cited text no. 1
    
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Yapanoglu T, Aksoy Y, Adanur S, Kabadayi B, Ozturk G, Ozbey I. Seventeen years' experience of penile fracture: Conservative vs. surgical treatment. J Sex Med 2009;6:2058-63.  Back to cited text no. 11
    
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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. 12
    
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Al Ansari A, Talib RA, Shamsodini A, Hayati A, Canguven O, Al Naimi A. Which is guilty in self-induced penile fractures: Marital status, culture or geographic region? A case series and literature review. Int J Impot Res 2013;25:221-3.  Back to cited text no. 13
    
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Tijani KH, Ogo CN, Ojewola RW, Akanmu NO. Increase in fracture of the penis in South-West Nigeria. Arab J Urol 2012;10:440-4.  Back to cited text no. 14
    
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Wong NC, Dason S, Bansal RK, Davies TO, Braga LH. Can it wait? A systematic review of immediate vs. delayed surgical repair of penile fractures. Can Urol Assoc J 2017;11:53-60.  Back to cited text no. 15
    
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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. 16
    
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Asgari MA, Hosseini SY, Safarinejad MR, Samadzadeh B, Bardideh AR. Penile fractures: Evaluation, therapeutic approaches and long-term results. J Urol 1996;155:148-9.  Back to cited text no. 18
    
19.
El-Taher AM, Aboul-Ella HA, Sayed MA, Gaafar AA. Management of penile fracture. J Trauma 2004;56:1138-40.  Back to cited text no. 19
    
20.
Amer T, Wilson R, Chlosta P, AlBuheissi S, Qazi H, Fraser M, et al. Penile fracture: A meta-analysis. Urol Int 2016;96:315-29.  Back to cited text no. 20
    
21.
Kozacıoǧlu Z, Ceylan Y, Aydoǧdu Ö, Bolat D, Günlüsoy B, Minareci S. An update of penile fractures: Long-term significance of the number of hours elapsed till surgical repair on long-term outcomes. Turk J Urol 2017;43:25-9.  Back to cited text no. 21
    
22.
Koga S, Saito Y, Arakaki Y, Nakamura N, Matsuoka M, Saita H, et al. Sonography in fracture of the penis. Br J Urol 1993;72:228-9.  Back to cited text no. 22
    
23.
Swanson DE, Polackwich AS, Helfand BT, Masson P, Hwong J, Dugi DD 3rd, et al. Penile fracture: Outcomes of early surgical intervention. Urology 2014;84:1117-21.  Back to cited text no. 23
    
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Lynch TH, Martínez-Piñeiro L, Plas E, Serafetinides E, Türkeri L, Santucci RA, et al. EAU guidelines on urological trauma. Eur Urol 2005;47:1-5.  Back to cited text no. 24
    


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