penile trauma / fractured penis

Introduction

most blunt penile injuries can be managed conservatively, however, the main concerns are
- a fractured penis - rupture of the sheath around the erectile cylinder of the penis
- urethral injury which would be suggested by haematuria

this is the term used for when there is traumatic rupture of the outer sheath surrounding the erectile cylinders of the erect penis usually caused by blunt injury, particularly a force causing the erect penis to buckle
the tunica of the erect penis thins to approximately 0.25 mm on expansion, and the firmly engorged corpora under the strain of buckling can generate pressures in excess of 1500 mm Hg and exceed the limit of the thinned tunica¹⁾
history and physical examination may be inaccurate in 15% of patients with a suspected penile fracture
clinical picture can be even more confusing if the patient received collagenase clostridium histolyticum (CCH) for Peyronie’s disease in the days or weeks prior to presentation, as these patients are also at high risk for superficial penile hematoma without corporal rupture ²⁾

buckling of the erect penis:
- during intercourse when the penis slips out of the vagina and strikes the perineum
- very forcible masturbation
- falling, rolling over in bed, or hitting a object such as a wall direct on with the erect penis
- majority of the cases in Mediterranean countries are the result of patients kneading and snapping their penis during erection to achieve detumescence³⁾

audible popping sound when the sheath ruptures followed by acute pain, rapid loss of erection, bruising, swelling, and penile deformity
deformity is often called eggplant deformity, which refers to the combination of localized penile swelling, discoloration, and deviation toward the opposite side of the fracture ⁴⁾
there may be a palpable defect under the local haematoma
there may be a rolling sign of a firm, immobile hematoma, which is palpable as the penile skin is rolled over it
if there is also rupture of Buck's fascia, this allows the escaping blood to cause:
- suprapubic bruising
- swollen scrotum
- fullness of perineum
the penis usually has a bend away from the side of the fracture
testes should be non-tender
presence of voiding difficulties, retention or haematuria would suggest a concurrent urethral injury which is rare in Asia and Middle East but more common in USA and Europe (10-25% of cases), and is more likely in bilateral corporal rupture ⁵⁾

simple bruising
- not a surgical emergency and may be managed conservatively without long-term effects
rupture of the dorsal artery
- usually indiscernible from corporal rupture except by cavernosography
rupture of the dorsal vein
- usually indiscernible from corporal rupture except by cavernosography
- not a surgical emergency and may be managed conservatively without long-term effects
- no sexual activity for 4 weeks to allow healing
rupture of the suspensory ligament of the penis
- injury identifiable based on presentation of the floppy penis
isolated urethral injury

assess FWT urine for presence of blood which would suggest a concurrent urethral injury and is an indication for a retrograde urethrogram
penile USS can be diagnostic (Turkish eye sign) but may be of limited utility as it is difficult to interpret, especially for those without expertise in assessing these injuries
emergent referral to urology team for assessment and consideration of emergent repair
cavernosography is invasive, time consuming, and plagued by false negatives ⁶⁾
MRI may have a role
conservative Mx without emergent surgery (within 48hrs of injury) may have a higher risk (30% vs 4%) of:
- scarring at the site of rupture and resultant:
  - chordee (a traumatic scarring cause of Peyronie's disease) which may impact on sexual intercourse
  - painful erections
- impotence
- A-V fistulae
- infected haematoma and abscess formation

¹⁾ , ³⁾ , ⁴⁾ , ⁵⁾

²⁾ , ⁶⁾