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.

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. 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]

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 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]