Penile fracture: A case report

Abstract

Introduction and importance

Penile fracture, resulting from trauma to an erect penis, is a rare urogenital injury with potentially serious complications including erectile dysfunction. This case report emphasizes the significance of prompt recognition, accurate diagnosis, and timely surgical management to optimize patient outcomes.

Case presentation

The case involves a 34-year-old male presenting with acute pain, swelling, and a visibly deformed penis following sexual intercourse. Clinical examination confirmed the diagnosis of penile fracture, leading to surgical repair of the tunica albuginea. The patient had an uneventful post-operative recovery and received appropriate post-operative instructions.

Clinical discussion

A penile fracture is a rare but serious injury occurs due to a tear in the tunica albuginea that can occur during vigorous sexual activity causing sudden pain, swelling, and produce a popping sound. Classical presentation often leads to establish a clinical diagnosis. However, immediate surgical exploration and repair is needed for better outcomes and to prevent long term complications such as erectile dysfunction or curvature of the penis that are associated with relying solely on conservative management. Delayed presentation also affects the optimal outcomes of surgery.

Conclusion

This report highlights the importance of early surgical intervention, the impact of delayed presentation, and the need for increased awareness regarding penile fractures. This case adds to the existing surgical literature by providing insights into the clinical presentation and management of penile fractures. The comprehensive overview of the case contributes to a better understanding of penile fractures and their management, helping healthcare professionals, improves patient care and outcomes.

Highlights

• •Prompt recognition and accurate diagnosis of penile fracture are crucial for optimal patient outcomes, emphasizing the importance of early surgical intervention.
• •This case report underscores the significance of timely surgical management and highlights the impact of delayed presentation on patient prognosis.
• •Insights from this case contribute to a better understanding of penile fractures, increasing awareness among healthcare professionals and improving patient care and outcomes.

1. Introduction

Penile fracture, though a rare urogenital injury, warrants attention due to its potential for serious complications. It most commonly occurs as a result of direct impact during sexual contact, causing a sudden increase in pressure within the cavernosal and subsequent rupture of the tunica albuginea [1]. Other mechanisms of injury include forceful bending of an erect penis, vigorous masturbation, accidental trauma, and even the use of collagenase Clostridium histolyticum in the treatment of Peyronie's disease [[2], [3], [4], [5]]. The clinical features of penile fracture are distinctive, typically involving a history of blunt trauma to an erect penis accompanied by an audible “snap” or “pop,” immediate pain, and rapid loss of erection. Physical examination findings often reveal visible swelling, bruising (ecchymosis), and a characteristic penile deformity described as an “eggplant deformity” [1]. While the diagnosis of penile fracture is primarily clinical, imaging studies such as ultrasound or magnetic resonance imaging may be employed in complex cases to assess the extent of the injury and rule out associated complications [6].

Management of penile fracture primarily involves surgical repair, which is considered the gold standard treatment. The main objective of surgery is to promptly evacuate any hematoma and meticulously repair the ruptured tunica albuginea, aims to ensure proper healing and restoration of penile anatomy and function and reduces the likelihood of subsequent complications associated with relying solely on conservative management [7,8]. It is important to note that the timing of presentation significantly impacts the long-term outcome of surgical intervention. Early surgical repair, typically within hours to a few days of injury, has been associated with superior functional outcomes and reduced morbidity [9]. Unfortunately, societal taboos and cultural factors often lead to hesitancy in seeking medical attention, resulting in delayed presentation and potential complications [10]. Consequently, the reported incidence of penile fractures may be underestimated in certain regions, such as Pakistan, due to underreporting. Hence, we present the compelling case of a 34-year-old man who presented with a penile fracture during sexual intercourse, underscoring the importance of prompt recognition, accurate diagnosis, and time management to optimize patient outcomes. We reported the case according to the Surgical Case Reports (SCARE) guidelines [11].

2. Case presentation

We present a case of a 34-year-old male who presented to the urology outpatient department with a chief complaint of pain and swelling in the penis for one day. The patient provided a detailed history, stating that the pain was acute in onset and occurred during sexual intercourse, accompanied by the loss of tumescence (firmness of the penis) and a snapping sound. The physical examination revealed notable findings, including significant swelling, ecchymosis (bruising), and a visibly deformed penis as shown in Fig. 1. The patient's vital signs were stable, and there were no signs of urethral bleeding or difficulties with voiding, indicating an uncompromised urethra. Based on the typical history and physical examination findings, a clinical diagnosis of penile fracture was made, and the patient was promptly admitted to the urology ward.

Fig. 1.

A pre-operative picture showing a swollen and deformed penis.

Upon admission, the patient underwent urinary catheterization with a Foley catheter of 16 French (F) to facilitate urine drainage and continuous monitoring of urine output and was managed conservatively with analgesics and antibiotics. The patient also underwent further preoperative investigations, including a complete blood count, renal function test, urine routine microscopic examination, and serology, all of which yielded normal results. Additionally, patient past medical and surgical history was insignificant for any of the long-term treatment. Also, the patient did not have any associated co-morbidities that could potentially impact the management or outcome of the penile fracture.

In the operation theatre, a careful exploration of the penile area was performed. It revealed a defect measuring 2.6 mm in the inferolateral tunica albuginea with the presence of a hematoma. The defect was repaired using prolene sutures, ensuring proper alignment and closure as shown in Fig. 2 a, b, and c. The Foley catheter was removed on the second postoperative day, and the patient experienced an uneventful recovery with no immediate post-operative complications. After a thorough assessment, the patient was discharged from the hospital on the third postoperative day. The patient was prescribed a course of oral antibiotics, analgesics for pain management, and sedatives. Additionally, the patient received detailed post-operative instructions, including strict adherence to medication regimens and the avoidance of sexual contact for approximately three months, to ensure proper healing and reduce the risk of re-injury or complications.

Fig. 2.

(a) Penile surgical exploration showing defect in the inferolateral tunica albugenia. (b) Defect repaired with prolene sutures (c) Immediate post-operative penis.

3. Discussion

Penile fractures most commonly occur in middle-aged men; multiple studies note that the average age of patients is between 30 and 50 years of age [12]. The incidence of penile fracture varies considerably among different geographical areas. The largest series is reported from the Middle East and North Africa, which seems higher than in the United States and Europe [13]. For example, a study conducted in the United States reported an annual incidence rate of approximately 1.4 cases per 100,000 population [14]. In contrast, studies from other countries such as Brazil and Iran have reported higher incidence rates of 4.1 and 10.8 cases per 100,000 populations, respectively [15,16].

Penile fracture, a rare urological emergency, results from rupturing the tunica albuginea—the penis's fibrous covering. Trauma during vigorous sexual intercourse or due to blunt force impact can cause this rupture [1]. The tunica albuginea, which can withstand pressures up to 1500 mmHg, markedly thins during erection, which when combined with abnormal bending leads to excessive intracavernosal pressure making it susceptible to transverse lacerations of the proximal shaft [17]. Traumatic penile rupture might link to histologic changes in the tunica albuginea, increasing fracture vulnerability. Fibrosclerosis and cellular infiltrates found in ruptured tunica albuginea cases suggest prior trauma, potentially lowering rupture thresholds compared to healthy tissue [18]. However, penile fractures vary in location, severity, and presentations. The common type involves the tunica albuginea, causing sudden pain, swelling, and deformity, often accompanied by a snapping sound during sexual activity or trauma [19]. Urethral extension of tunica albuginea rupture leads to blood at the meatus, painful urination, or urinary retention, requiring prompt evaluation to prevent complications like strictures [20]. Fractures can also be categorized by corpora cavernosa involvement: unilateral affects one side, bilateral affects both. Bilateral fractures can result in significant deformity, require careful surgical repair for functional and cosmetic restoration. Understanding fracture types and presentations is vital for accurate diagnosis and effective management [21].

The diagnosis of penile fractures primarily relies on a combination of clinical history, physical examination, and imaging studies. However, accurately identifying penile fractures is typically a clinical diagnosis [22]. Although the clinical presentation can strongly indicate the condition, additional diagnostic methods are often utilized to confirm the diagnosis and assess the extent of the injury. Ultrasonography is frequently employed as an initial imaging technique due to its accessibility and its ability to detect defects in the tunica albuginea as well as any associated hematoma or damage to adjacent structures [6]. However, more detailed information may be obtained through techniques such as magnetic resonance imaging (MRI) and CT scans, particularly in complex cases [23,24]. On occasions, retrograde urethrography or cavernosography might be performed when there are concerns about potential accompanying urethral or vascular injuries [25]. These diagnostic tools contribute to establishing an accurate diagnosis, guiding appropriate decisions regarding management, and identifying any additional injuries that may necessitate surgical intervention.

Regarding the management of penile fractures, an ongoing debate centers on choosing between conservative methods and surgical exploration. Conservative management employs analgesics, antibiotics, and sexual abstinence, often for uncertain diagnoses or contraindicated surgery cases. Some studies suggest success in specific instances, especially with small tunica albuginea defects and no complications [8,26]. Nevertheless, surgical exploration remains the preferred approach for most penile fractures. Surgery provides direct visualization and precise repair of the defect, immediate anatomical and functional restoration, reducing long-term risks. It also addresses concurrent issues like urethral injuries or hematoma evacuation [7,27]. Immediate surgical intervention, including hematoma evacuation and tunica albuginea repair, was initially recommended by Fernstrom [28]. Studies favoring surgery show shorter hospital stays, heightened patient satisfaction, and improved outcomes, including lower erectile dysfunction rates [29]. However, we could not assess the patient long term surgical outcomes as patient did not follow the follow-up plan.

The timing of presentation in cases of penile fracture has been shown to have an impact on the outcomes of repair. Early recognition and prompt surgical intervention are crucial for achieving optimal outcomes [30]. Delayed presentation, on the other hand, may result in several challenges. A delay in seeking medical attention can lead to delayed diagnosis and subsequent delayed surgical repair, which may increase the risk of complications and poorer functional outcomes. Prolonged delays can also result in fibrosis and scarring of the tunica albuginea, making the repair more challenging and increasing the likelihood of long-term sequelae such as erectile dysfunction and penile curvature, stricture urethra or urethra cutaneous fistula in cases of urethral tear [10]. Studies have shown that patients, who present early, within hours to a few days of injury, have better outcomes in terms of complete resolution of symptoms, preservation of erectile function, and cosmetic appearance [9]. Therefore, patient education regarding the importance of seeking immediate medical attention and healthcare provider awareness of the potential impact of delayed presentation is essential for optimizing outcomes in cases of penile fracture repair.

4. Conclusion

Penile fractures, demand timely attention and specialized management. Surgical intervention stands as the preferred choice, ensuring precise repair and reduced long-term complications. Early presentation proves pivotal, with rapid surgical intervention showing superior outcomes in terms of symptom resolution, erectile function preservation, and aesthetic restoration. Effective patient education and heightened awareness among healthcare providers regarding the importance of timely intervention are vital for achieving optimal results in penile fracture cases.

Consent

Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Guarantor

Mohamad Ali Farho.

Registration of research studies

Not applicable

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

The publication of this case report has been authorized by the quality service of our Institution because case reports are exempted from ethical approval in our institute (University College of Medicine and Dentistry, University of Lahore, Lahore, Pakistan).

CRediT authorship contribution statement

All authors were both involved in the conception and coordination of this report and drafted the manuscript. Additionally, all authors have read and approved the final version.

Declaration of competing interest

No conflicts of interest.