Delayed approach of a penile fracture with encapsulated hematoma

Abstract

Penile fracture (PF) is defined as the rupture of the tunica albuginea (TA) of the corpora cavernosa (CC) caused by trauma to the erect penis. We present a case and clinical evolution of the delayed approach of PF. Physical examination showed a ventral rounded mass in the middle surface of the penile shaft, associated with mild discoloration and edema. Surgery was performed with a vertical penoscrotal incision. We found an encapsulated hematoma on the right ventral mid penile shaft connected at its base to an approximate 1 cm transverse defect on the TA and we performed debridement and excision of the hematoma. Tunical defect was repaired with PDS 3/0 simple suture. The patient had a great postoperative evolution without local complications. The early diagnosis and surgical treatment reaches better functional results, with maintenance of erectile function in patients with penile fracture.

INTRODUCTION

Penile fracture (PF) is defined as the rupture of the tunica albuginea (TA) of the corpora cavernosa (CC) caused by trauma to the erect penis. The diagnosis is mainly clinical. Patients often report the trauma accompanied by an audible sound, followed by pain and penile detumescence. Findings may include local edema, ecchymosis, and deformity (eggplant deformity).[1]

The standard approach includes immediate exploration for favorable results.[2] The objective of this article is to present a case and clinical evolution of the delayed approach of PF.

CASE REPORT

A 42-year-old patient was involved in sexual activity in the “woman on top” position when his penis slipped out and hit the perineum of his partner with immediate pain, slow detumescence ranging 3–5 min and progressive swelling of his penis. After 1 h, the patient seeked for emergency care and was informed about the need of an urgent surgical procedure. However, despite being informed of all the risks, he refused treatment and was discharged.

The patient presented for the first time in our hospital 4 weeks later with the painless swollen penis. There were no urinary symptoms, erectile dysfunction (ED), or penile curvature prior to the trauma. Physical examination showed a ventral rounded mass in the middle surface of the penile shaft, associated with mild discoloration and edema [Figure 1].

Figure 1.

(a) Physical examination showing a round mass in the middle ventral surface of the penile shaft with discoloration and scrotal edema. (b) Encapsulated hematoma. (c) Encapsulated hematoma connected to the tunical defect. (d) Final aspect of the repair

The diagnosis was made only by clinical findings. We recommended immediate surgical treatment, but again, the patient refused prompt treatment. He opted to be operated after 2 weeks for personal reasons (total delay time of 6 weeks).

Surgery was performed with a vertical penoscrotal incision. We found an encapsulated hematoma under the Buck Fascia on the right ventral mid penile shaft connected at its base to an approximate 1 cm transverse defect on the TA. Then, we performed debridement and excision of the encapsulated hematoma. Tunical defect was repaired with PDS 3/0 simple suture. The Buck’s and Dartos fascia and the penile skin were closed in layers in a simple interrupted fashion. The total time procedure was about 1 h [Figure 1].

The patient had a great postoperative evolution without local complications. After 2 months, there were no urinary symptoms, penile plaques, or curvature. Erectile function was maintained, with a maximum score on the International Index of Erectile Function-5.

DISCUSSION

PF is accompanied by pathological and psychosocial aspects that can have a major impact on the lives of these patients. Coitus seems to be the most common cause. It occurs usually during sexual relations when the penis slips out of the vagina and strikes against the pubic bone or perineum.[3] Barros et al. showed that coitus was responsible for 255 (88%) of all cases of PF (n = 285). Regarding sexual position, “Doggy style” was most common, with 110 cases (43.1%). “Woman on top” was the second most common, with 103 cases (40.3%).[4]

Vaginal penetration appears to be more related to PF than anal penetration. In a study published in 2014, Reis et al., 28 cases of PF were related to coitus (n = 42). Twenty-six (92.9%) patients reported vaginal penetration and only 2 (7%) confirmed anal penetration. The same results are found in the literature.[3,5,6]

The injury mostly occurs near the base or mid-shaft region. The TA lacks longitudinal layer at 5 and 7 o’clock positions and thus is extremely thin and has been mentioned to be the most common site for PF; the average length of the lesion varies between 1 and 2 cm.[7] These data are corroborated by our report.

Clinical history and physical examination usually are sufficient for diagnosis. When there is suspicion of urethral involvement, a retrograde urethrogram and cystoscopy may be useful.[1] Ultrasound is the cheapest investigative procedure in PF. However, subcutaneous blood embedding and edema may complicate diagnosis.[8] Magnetic resonance imaging (MRI) is the most accurate exam. It identifies the site and extension of the lesion. However, it has a high cost and may delay management. In addition, MRI is not always available, especially in developing countries like Brazil. Thus, clinical diagnosis is the gold standard evaluation, and the procedure should not be delayed by the absence of imaging procedures.[8]

Regarding the incision technique, a distal degloving incision is most common. It allows full inspection of the corporal body and detection of the contralateral corporal body or urethral injuries. It also confers the most natural cosmetic result, although there may be a risk for neurovascular injury and skin necrosis.[1,9] Vertical penoscrotal incision is described and provides direct exposure to the defect by only incising the overlying penile skin. It has proved to be an excellent technique in the approach of the CC injury.[10] There are no publications comparing long-term patient outcomes between the two techniques.[1,9] In our report, we performed the penoscrotal incision with good exposure, but we believe we would have the same results in the distal degloving incision.

Regarding the clinical evolution, advanced age and the extent of rupture in the TA may be related to the development of ED. The timing of surgery is also related to better results. Özorak et al. described a series of cases that underwent PF repair within 5 h-injury and compared those with patients who refused surgery opting for conservative measures. After 6 months, there were no complications reported for those submitted to surgery, and those managed conservatively had a 60% rate of complications, as ED or penile curvature.[9] Nevertheless, there is no evidence about standardization regarding the maximum delay for the surgical procedure.

Some studies show functional benefits even in cases of delayed presentation, after 48 h of trauma,[7] and our patient had good results after 6 weeks of the fracture, but data are still limited. Notwithstanding, the literature review supports that an early diagnosis and surgical treatment reaches better functional results, with maintenance of erectile function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.