Q. A 34-year-old man presents with acute penile pain and swelling following sexual intercourse. He says he heard a ‘cracking’ sound during coitus and there was immediate detumescence. What is the likely diagnosis?
A. Penile fracture.
Q. Anatomically, what actually gets ‘fractured’ in this condition?
A. A penile fracture involves a full-thickness tear of the tunica albuginea of the penis. However, it may also involve the urethra in approximately 10% of cases. During erection, the thickness of the tunica albuginea typically reduces from 2 to 0.25 mm, predisposing the penis to injury, either from bending or buckling. The ventral tunica albuginea is the thinnest area and penile fractures are commonly located in this area.
Q. How do you diagnose this condition?
A. It is actually a clinical diagnosis based on the history and examination findings.
However, I am aware that additional investigations can help with confirming the diagnosis and locating the site of the fracture which helps with surgical planning:
Penile ultrasound is non-invasive and easily available. Ultrasonography can detect the site of the tunical tear and overlying haematoma.
Magnetic resonance imaging (MRI) is an accurate pre-operative investigation and can detect even small tears of the tunica albuginea. Although difficult to perform in the emergency setting, it can be used when there is diagnostic doubt.
Cavernosography is an invasive procedure rarely used and has potential side effects including reaction to contrast, priapism and risk of corporal fibrosis from extravasated contrast material.
Q. How do you exclude a urethral injury?
A. Clinical features suggesting urethral injury include blood at urethral meatus, haematuria and an inability to pass urine, following the injury. An on-table retrograde urethrogram should be performed if urethral injury cannot be excluded.
Q. What is the management of penile fracture?
A. I would consider penile fracture as a urological emergency and see the patient myself, without delay. Early surgical exploration and repair of the tunica albuginea is considered the treatment of choice. Conservative treatment is associated with high incidence of penile fibrosis, erectile dysfunction and penile curvature.
Q. Outline the principles of surgical repair.
A. The surgical approach depends on the site of the fracture and the experience of the surgeon. Surgical exploration can be performed by degloving the penis using a circum-coronal incision together with a circumcision.
Alternatively a longitudinal peno-scrotal incision avoids the need for degloving and circumcision and provides exposure to the urethra and corpus cavernosum. Once the haematoma overlying the fracture has been evacuated and the defect in the tunica albuginea identified, the defect should be repaired using interrupted absorbable sutures, either 0 PDS or 2/0 PDS. If there is a concomitant urethral injury, then 4/0 absorbable sutures are used to repair the defect over a urethral catheter. Depending on the size of the urethral disruption, a pericatheter urethrogram can be performed before removing the catheter.
References
1. Li CY, Zaman F, Minhas S. Testicular torsion and acute testicular pain. In: Urological Emergencies in Hospital Medicine (eds. Shergill IS, Arya, M, Patel HR, Gill IS), pp. 1-9. London: Quay Books; 2007.
2. https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Torsion%20of%20testis.pdf
3. Mebust WK et al. Transurethral prostatectomy: Immediate and postoperative complications. A cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol 1989; 141: 243-247.
4. Pickard R et al. The management of men with acute urinary retention. National Prostatectomy Audit Steering Group. BJU 1998; 81: 712-720.