Penile fracture means rupture during erection of the tunica albuginea enveloping the corpus cavernosum.
The most common causes of such an injury are twisting of the penis during intercourse and other traumas.
Partner-on-top coital position bears the highest risk.
The most important symptoms are sudden loss of erection, pain, and large haematoma forming under the penile skin (aubergine-like appearance).
Due to the embarrassing nature of the injury, patients may often seek treatment with delay.
The rupture should be repaired surgically as soon as possible.
Minor penile traumas, possibly with local pain or bruising but no penile malposition and maintained ability to have an erection are more common. The treatment of these injuries is conservative.
Mechanism of injury
The tunica albuginea forms strong, elastic sheaths of connective tissue enveloping each of the two cylinders of erectile tissue (corpora cavernosa).
Twisting of the erect penis may cause rupture of the tunica albuginea.
The rupture is typically unilateral and transverse and situated at the base of the penis.
Rupture of the tunica albuginea may in some cases be associated with injury to the urethra and the surrounding corpus spongiosum.
The most common cause of such an injury is twisting of the penis during intercourse, i.e. "missing the introitus".
Rarer causes include forceful masturbation, turning over in bed, and intentional twisting of the penis to achieve detumescence.
It should be noted, however, that in some Middle Eastern countries the last mentioned practice ("taghaandan") causes over a half of all penile fractures.
Symptoms and findings
Rupture of the tunica albuginea often gives an audible snapping sound.
This is followed by immediate detumescence, severe pain and significant swelling and bruising of the penis.
Penile deviation away from the site of the rupture can often be seen.
Even though the rupture as such is often impossible to locate by palpation, the haematoma forming on top may be palpable.
Further examinations
A typical history and clinical findings are sufficient for making the diagnosis.
Penile ultrasound or MRI examination may be considered in order to locate the rupture more accurately before surgery.
Examinations using contrast media or MRI may be considered in select cases.
Further examinations must not delay surgical treatment if there is sufficiently strong suspicion of penile fracture.
Treatment
Sufficiently early surgical repair (within less than 48 hours after injury) of the rupture will provide the best results.
In the surgical operation, the rupture is located and closed with absorbable sutures.
The skin incision is made like in circumcision on the base of the glans penis or directly on the rupture as a longitudinal incision.
In the surgical operation, the water-tightness of the urethra (no leaks) must be ensured.
Following surgical repair, patients may return to normal sexual activity after 4 weeks.
References
Kominsky H, Beebe S, Shah N, et al. Surgical reconstruction for penile fracture: a systematic review. Int J Impot Res 2020;32(1):75-80. [PubMed]
Ateyah A, Mostafa T, Nasser TA, et al. Penile fracture: surgical repair and late effects on erectile function. J Sex Med 2008;5(6):1496-502. [PubMed]