Penile fracture

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Penile Fracture
Emergency surgery
Prognosis~10–50% of people develop erectile dysfunction or Peyronie's disease[2]
Frequency~1 per 175,000 men per year[3]

Penile fracture is rupture of one or both of the

erect penis, usually during vaginal intercourse, or aggressive masturbation.[4] It sometimes also involves partial or complete rupture of the urethra or injury to the dorsal nerves, veins and arteries.[5]

Signs and symptoms

A popping or cracking sound, significant pain, swelling, immediate loss of erection leading to flaccidity, and skin hematoma of various sizes are commonly associated with the sexual event.[4][6]

Causes

Bending penis in doggy style position
Cross-section of the human penis

Penile fracture is a relatively uncommon clinical condition.[7] Vaginal intercourse and aggressive masturbation are the most common causes.[4] A 2014 study of accident and emergency records at three hospitals in Campinas, Brazil, showed that woman on top positions caused the greatest risk with the missionary position being the safest. The research conjectured that when the receptive partner is on top, they usually control the movement and are not able to interrupt movement when the penis suffers a misaligned penetration. Conversely, when the penetrative partner is controlling the movement, they have better chances of stopping in response to pain from misalignment, minimizing harm.[7]

The practice of taqaandan (also taghaandan) also puts men at risk of penile fracture. Taqaandan, which comes from a

detumescence.[9]

Diagnosis

Imaging studies

Ultrasound examination is able to depict the tunica albuginea tear in the majority of cases (as a hypoechoic discontinuity in the normally echogenic tunica). In a study on 25 patients, Zare Mehrjardi et al. concluded that ultrasound is unable to find the tear just when it is located at the penile base. In their study magnetic resonance imaging (MRI) accurately diagnosed all of the tears (as a discontinuity in the normally low signal tunica on both T1- and T2-weighted sequences). They concluded that ultrasound should be considered as the initial imaging method, and MRI can be helpful in cases that ultrasound does not depict any tear but clinical suspicions for fracture are still high. In the same study, authors investigated accuracy of ultrasound and MRI for determining the tear location (mapping of fracture) in order to perform a tailored surgical repair. MRI was more accurate than ultrasound for this purpose, but ultrasound mapping was well correlated with surgical results in cases where the tear was clearly visualized on ultrasound exam.[10] The advantage of ultrasound in the diagnosis of penile fracture is unrivaled when its noninvasive, cost-effective, and nonionising nature are considered.[11]

Penile trauma can result from a blunt or penetrating injury, the latter being rarely investigated by imaging methods, almost always requiring immediate surgical exploration. In the erect penis, trauma results from stretching and narrowing of the tunica albuginea, which can undergo segmental rupture of one or both of the corpora cavernosa, constituting a penile fracture.[2]

In the ultrasound examination, a lesion of the tunica albuginea presents as an interruption in (loss of continuity of) the echoic line representing it (Figure 4). Small, moderate, or broad hematomas demonstrate the extent of that discontinuity. Intracavernous hematomas, sometimes without the presence of a tunica albuginea fracture, can be observed when there is a lesion of the smooth muscle of the trabeculae surrounding the sinusoid spaces or the subtunical venular plexus.[2]

  • Figure 4 A: Ultrasound of the penis, right lateral view. Longitudinal section showing rupture of the tunica albuginea with an adjacent 1.92 cm hematoma (between calipers), due to trauma.[2]
    Figure 4 A: Ultrasound of the penis, right lateral view. Longitudinal section showing rupture of the tunica albuginea with an adjacent 1.92 cm hematoma (between calipers), due to trauma.[2]
  • B: Axial T2-weighted turbo spin-echo magnetic resonance imaging scan showing left-sided discontinuity of the tunica albuginea (arrow), secondary to fracture.[2]
    B: Axial T2-weighted turbo spin-echo magnetic resonance imaging scan showing left-sided discontinuity of the tunica albuginea (arrow), secondary to fracture.[2]

In 10–15% of penile traumas, there can be an accompanying urethral lesion. When blood is observed in the urethral meatus, contrast-enhanced evaluation of the urethra is necessary. In cases in which the ultrasound findings are inconclusive, the use of magnetic resonance imaging can facilitate the diagnosis and is recommended by various authors.[2]

Treatment

Penile fracture is a medical emergency, and emergency surgical repair is the usual treatment. Delay in seeking treatment increases the complication rate. Non-surgical approaches result in 10–50% complication rates including erectile dysfunction, permanent penile curvature, damage to the urethra and pain during sexual intercourse, while operatively treated patients experience an 11% complication rate.[4][12]

In some cases, retrograde urethrogram may be performed to rule out concurrent urethral injury.[12]

Legal issues

In the

legally wanton
nor reckless.

References

  1. ^ "Penis fracture: Is it possible?". Mayo Clinic.
  2. ^
    PMID 30202130.
    CC-BY
    license
  3. S2CID 8901660
    .
  4. ^
    ISBN 978-0-7817-4586-4
    . Retrieved 15 October 2012.
  5. S2CID 27097515
    .
  6. S2CID 26994715
    .
  7. ^
    PMID 24822062
    .
  8. ^ Nuzzo, Regina (9 February 2009). "Preventing penile fractures and Peyronie's disease - latimes.com". Los Angeles Times. Archived from the original on 14 February 2009.
  9. PMID 10893586
    .
  10. S2CID 4094189
    .
  11. ISSN 2054-6750
    .
  12. ^
    ISBN 978-0-7817-6275-5
    . Retrieved 18 April 2010.

Further reading
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