Penis fracture

Penile fracture, amputation and penetrating trauma of the penis, and traumatic soft tissue injuries are considered urological emergencies and usually require surgical intervention.

The goals of treatment for these injuries are universal: maintaining penile length, erectile function, and maintaining the ability to urinate while standing.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ]

Causes penile fracture

Penile fracture is a classic but not universal occurrence. About 60% of penile fractures occur when the penis is hit during an erection. The tunica albuginea is about 2 mm thick but elastic, so it is most often damaged during sexual intercourse during penile rigidity due to a sharp bend. When hit during detumescence, a subcutaneous hematoma is most often observed without damage to the tunica albuginea. Penile fracture (subcutaneous rupture of the corpora cavernosa) most often occurs during rough sexual intercourse, when the penis, slipping out of the vagina, is damaged as a result of a rapid and intense bending of the erect penis when resting on the woman's pubic bones (symphysis) or perineum, which, according to various authors, accounts for 2.2 to 10.3% of all penile injuries. In 10-25%, penile fracture is accompanied by damage to the urethra and spongy substance.

[ 6 ], [ 7 ], [ 8 ], [ 9 ]

Symptoms penile fracture

During a penile fracture, the patient experiences pain, the erection stops, after which internal bleeding begins, a hematoma appears, the penis deviates to the opposite side, the pain increases intensively, shock is possible. In this case, the size of the penile hematoma, which occurs when the Buck fascia is torn, depends on the extent of the damage to the protein membrane and cavernous bodies.

It can be large, often the accumulated blood spreads to the scrotum, pubis, perineum, inner thighs, anterior abdominal wall. The skin becomes bluish, darkens over time. If the urethra is damaged during the fracture, urinary retention may occur. If the hematoma is not pronounced, then the defect of the cavernous bodies can be palpated. Often the edema can reach large sizes, making it difficult to palpate the organ. In this case, ultrasound with Doppler mapping and X-ray examinations (cavernosography, urethrography) are used.

Diagnostics penile fracture

A penile fracture is diagnosed in case of damage to the tunica albuginea of the cavernous bodies. In 10-22% of cases, damage to the cavernous bodies is combined with damage to the urethra. With concomitant trauma to the urethra (observed in 25% of cases), urethrorrhagia is possible. Often, due to a feeling of shame, men seek medical attention late (according to one study, in 89% of cases), on average 6 hours after the injury.

The diagnosis of a penile fracture is established based on the anamnesis and examination. Ultrasound of the penis, and if it is necessary to clarify the damage to the tunica albuginea, cavernosography and MRI are indicated, which allow us to identify a rupture of the tunica albuginea and decide on the need for surgical intervention. Cavernosography in most cases makes it possible to identify injuries to the penis that require surgical treatment, but is less informative in identifying damage to the deep veins.

The use of MRI allows not only to more accurately identify defects of the cavernous bodies, but also to clarify the presence and location of concomitant injuries (urethra, testicles) and the location of the hematoma. In case of urethrorrhagia or macro- or microhematuria detected during urine examination, retrograde urethrography is indicated to exclude trauma to the urethra. If extravasation of the contrast agent with the involvement of the cavernous bodies is observed during retrograde urethrography, then the need for cavernosography disappears.

[ 10 ], [ 11 ], [ 12 ], [ 13 ]

Treatment penile fracture

Treatment of a penile fracture depends on the extent of the hematoma and the size of the damage to the tunica albuginea. In the case of minimal damage, treatment can be limited to the same measures as for a contusion of the penis. In the case of extensive damage to the tunica albuginea and cavernous bodies, usually accompanied by massive hemorrhage, emergency surgery is necessary, which necessarily includes opening the hematoma, removing blood clots, stopping the bleeding, suturing the defect of the tunica albuginea and cavernous bodies (with both absorbable and non-absorbable threads) and draining the wound in the area of the hematoma. As a rule, such treatment gives good results.

In the early postoperative period, infectious complications occur in 8.7% of cases, in the late period - impotence in 1.3%, and curvature of the penis in 14% of cases.

In case of damage to the urethra, surgical treatment includes restoration of the damaged urethra with an end-to-end anastomosis, after gentle refreshing of its ends and adequate drainage of the bladder, most often with a suprapubic epicystostomy.

In the postoperative period, antibacterial therapy with broad-spectrum antibiotics, cold, adequate pain relief therapy and prevention of impotence are necessary.

Penile fracture is not treated conservatively, as in 35% of patients it is fraught with a high risk of complications (penile abscess due to undiagnosed partial damage to the urethra, adhesive fibrosis, penile curvature, painful erection and development of arteriovenous fistula), which may lead to the need for surgical treatment at a later date.