FRACTURE OF THE PENIS IN THE NIGER DELTA REGION OF NIGERIA

Abstract

Background

Penile fracture is a surgical emergency which often frightens the patient and partner. Varying incident rates, precipitating mechanisms and outcomes of treatment have been reported from different parts of the world.

Aim:

To determine clinical presentation, aetiological factors and outcome of treatment of penile fracture in Port Harcourt, Niger Delta region of Nigeria.

Methods:

This was a retrospective study of all patients who presented with penile fracture to our institution from 2007 and 2015. Data on age of patient, events leading to the injury, mode and time of presentation, mode and outcome and complications of treatment were collected and analysed with SPSS 20.0 software

Results

Twenty one patients with a median age of 34.0 years (21-45) were treated within the study period. Nine patients (42.9%) were married. Overenthusiastic/ vigorous sex-related events were responsible for penile fracture in 17 patients (81.0%). Seven injuries were self inflicted while in 14 patients (66.7%), partners were involved. All the patients presented with pain, swelling, sudden detumescence and deviation of the penis. The right side was affected in 61.9% of the cases. The penile mid-shaft was the site of injury in 57.1% of cases. Six patients (28.6%) had associated urethral injuries. Eighteen patients (85.7%) had immediate surgery, 2 patients (9.5%) refused surgery and were treated conservatively. One patient who presented late was also managed conservatively. All but one patient had satisfactory penile erections with no significant complications.

Conclusion

Overenthusiastic and vigorous sexual activities were the most common causes of penile fracture in this study. A third of the patients had associated urethral injuries. Early surgical repair led to satisfactory outcome.

Introduction

Penile fracture (PF) is defined as the rupture of the tunica albuginea of the corpus cavernosum with a resultant corporal defect caused by trauma to the erect penis1. One or both corpora may be involved and concomitant injury to the penile urethra may occur 2. Urethral trauma is more common when both corpora cavernosa are injured. Traumatic rupture of penis is relatively uncommon and is considered a urological emergency3. The diagnosis of penile fracture is clinical, from history and physical examination. In early classical presentation, the patient reports a snap or cracking sound accompanied by immediate pain and rapid detumescence, followed immediately by development of swelling and ecchymosis and deviation to opposite site4^-6. Careful palpation usually reveals a firm haematoma overlying the corporal defect on which penile skin can be rolled (or “rolling sign”)7,8. Recent studies favour early surgical repair9,10. The events leading the penile fracture have been documented. These events include: vigorous sexual intercourse, penile masturbations, fall on erect penis and rolling over the bed 3,9. Spontaneous rupture of the penis has been reported10. Different mechanisms preceding these injuries have been postulated11^-15. This study was to determine the aetiological factors, clinical presentation and outcome of treatment of penile fracture in Port Harcourt, Rivers State, in the Niger Delta region of Nigeria over a period of 8 years.

Patients & Methods

All the patients that presented to the University of Port Harcourt Teaching Hospital (UPTH) and a private clinic, Potters Touch Medical Consultants, both in Port Harcourt, Nigeria from April 2007 to February 2015 were studied retrospectively from the case note records. The case notes were accessed from the record departments of the hospitals. Information recorded using a pre-designed proforma included: patient’s age, marital status, event leading to the injury, mode and time of presentation, clinical features including sites of injuries as well as presence of haematuria and or blood at the tip of the penis, type of treatment, outcome of treatment, and possible complications after treatment. Fracture of the penis was diagnosed clinically following an injury to an erect penis resulting in a cracking sound, pain, sudden detumescence and swelling of the penis. The presence of haematuria and/or blood at the tip of the penis heightened the suspicion for associated urethral injuries. No invasive or radiological investigation was used for diagnosis of penile fracture or associated urethral injuries. The diagnosis was made in each case from history and clinical examinations and was confirmed during surgical exploration.

All consenting patients had surgical exploration on the day of presentation. Sub-arachnoid spinal anaesthesia was used for all the surgical operations. Circumferential sub-coronal incisions were made in all cases with complete degloving of the penis, haematomata evacuated and lacerations identified. Absorbable sutures (Vicryl 3/0) were used to repair the lacerations after refreshing the margins. All patients were catheterized with size 16Fr Foley catheter intra-operatively. Patients with urethral injury had the urethra repaired at the time of exploration with 4/0 vicryl sutures. All operated cases were given antibiotics, analgesics and were admitted for a few days. Catheters were removed soon after surgery in patients without urethral injury. In patients with urethral injuries, indwelling urethral catheters were removed after 21 days if pericatheter contrast studies (pericatheter urethrography, PUG) showed no extravasations of the dye. The pericatheter study was performed by placing a small-gauge 6fr Foley catheter alongside the indwelling catheter. The balloon of the small-gauge was inflated with 2 ml at the fossa navicularis. The contrast was injected through paediatric catheter for the urethrography.

Those who declined surgical treatment were managed conservatively using cold compress, antibiotics, and non-steroidal anti-inflammatory agents. All the patients received oestrogens for 2 weeks to suppress erections. Each patient was advised to abstain from sexual intercourse for 6- 8 weeks after discharge.

The patients were followed up at outpatient clinics for a minimum of 6 months. At outpatient visits the patients were evaluated for the presence of any deviations of the penis, presence of indurations, and level of satisfaction with penile erection. The data were analysed using SPSS version 20.0 and the results were presented in tables and figures.

Results

Twenty one patients were treated within the study period. Their ages ranged between 21 and 45 years with a median age of 34.0 years, the mean age was 32.28 years +/- 1.4 years (S.D.6.60). The age distribution is shown in Table 1.

Table 1. Age of patients.

Age Range (Years)	Frequency	Percentage
21 – 30	8	38.10
31 – 40	10	47.61
41 – 50	3	14.29
Total	21	100.00

Nine of the patients (42.9%) were married while 12(57.1%) were not married. Seven of the injuries (33.3%) were self inflicted from masturbation. In 14 cases (66.7%), penile fracture occurred when the patients were with their partners. Of these, the event happened during sex with women: their wives were the partner in 7 cases while 5 of them were girl friends as shown in figure 1.

Figure 1 . Causes of penile fracture .

All the patients presented with a history of cracking sound, pain, sudden detumescence, swelling and deviation of the penis to one side as shown in figure 2. Eight patients (38.1%) had haematuria and 6 of them (28.5%) had associated urethral injuries as shown in figure 3.

Figure 2 . Penile fracture with bleeding from the urethral meatus .

Figure 3 . Associated urethral injury .

Sexual intercourse-related events preceded the injuries in 17 (81.0%) patients while 2 patients each had injuries from a fall on an erect penis and forceful bending of the penis respectively (figure 4.).

Figure 4 . Sexual partners involved at the time of penile fracture .

Table 2 shows the events during sexual intercourse resulting in penile fracture. Of these, 41.1% were as a result of vigorous thrusting, 35.3% from ‘misfire’ while 25.5% resulted from massaging. Different sex positions associated with the injuries were also shown with ‘’woman on top’’ and ’’rear’’ positions predominant.

Table 2. Preceding sexual activity.

Event during sexual activity (Frequency)	Position during sexual activity (Frequency)
Misfire (n = 6) (35.3%)
	Rear (n = 5) (29.4%)
	Missionary (n = 1) (2.9%)
Vigorous thrusting (n = 7) (41.1%)
	Woman on top (n = 5) (29.4%)
	Rear (n = 1) (5.9%)
	Missionary (n = 1) (5.9%)
Massaging (n = 4 ) (23.5%)
	Self (n = 3) (17.6%)
	Foreplay (n = 1) (5.9%)

The most common site of injury was the midshaft 12 (57.1%) patients while 4 (19.0%) patients had fractures at the proximal third of the penis. Four (19.0%) patients had fractures at the root of the penis while one (4.7%) patient had the injury at the distal third of the penis (figure 5). The right side was affected in 61.9 % of cases while the left side was affected in 38.1%. No bilateral cases were encountered.

Figure 5 . Site of penile fracture .

One patient presented after 8 days with haematoma and deviation of the penis to the contra- lateral side. The remaining 21(95.2%) patients presented within 24 hours. Eighteen patients (85.7%) had immediate surgical exploration and repair of the lacerated tunica albuginea. Two patients refused surgical treatment and were managed conservatively with antibiotics and anti-inflammatory agents. These patients complained of deviation of the penis and ‘’bumps’’ at the sites of injury afterwards. The patient who presented on the 8 day after injuries was also managed conservatively. Six (28.5 %) patients had associated urethral injuries. These associated injuries were also repaired primarily.

After 6 months of treatment, the patient who presented late and was treated conservatively developed mild deviation of his penis and weak penile erection. Four of the patients (19.0%) who had surgical treatment complained of bumps at the incision site few weeks after repair, but these had resolved by the time of review six months later. All the patients except one were satisfied with their penile erections after treatment. This was the patient that presented very late and was managed conservatively.

Discussion

The placid thickness of the penile tunica albuginea is about 2mm16,17. During an erection the tunica albuginea thins out and may be as thin as 0.2.5-0.5mm18. As the tunica albuginea thins and stiffens, it loses elasticity and becomes easily fracturable19. Blunt trauma to an erect penis may result in rapid build up of pressure to an already engorged corpus cavernosum. This may overwhelm the tensile strength of the tunica albuginea leading to the rupture20. Pressures as high as 1500mm Hg have been reported21.

Penile fracture can be described as simple when the skin remains intact and can be described as compound when the urethra is involved 22. In this study, the diagnosis of penile fracture was made based on history and physical examination. Penile ultrasonography – which is non-invasive, is sufficient to confirm the diagnosis in a majority of cases. Nevertheless, magnetic resonance imaging can be carried out in equivocal cases. Furthermore, urethrography, ultrasonography, colour Doppler duplex scan, and angiography can be performed 8.

The true incidence of penile fracture is not known because it is under-reported or hidden probably because of social embarrassment and sociocultural characteristics 19. Twenty one patients were seen within 8 years in this study. Thus penile fracture can be said to be uncommon in this environment as reported elsewhere3. However the low incidence may be apparent since the embarrassing nature of the injuries or circumstances surrounding them may make people not to report the cases to care givers19,20.

The incidence of PF is greater in Middle Eastern and North African countries (almost 55% of the total number reported) than in the United States or Europe (almost 30% of those reported)23,24. The relatively high incidence in that part of the world can be attributed to the habitual practice of Taqaandan25. Taqaandan or ‘’Taghaandan,” or “breaking the Qholenj” which comes from a Kurdish word meaning “to click,” involves bending the top part of the erect penis while holding the lower part of the shaft in place, until a click is heard and felt. Taqaandan is said to be painless and has been compared to cracking one’s knuckles. Taqaandan may be performed to achieve detumescence25.

Most (88%) of the patients in this study were aged between 20 and 40 years with a median age of 32.0 years. This was similar to reports from Srinagar, Korea, and Iran1,2,8. Thus penile fracture is a condition seen mainly in young adult males. The reason for this affectation of young adults may be related to the aetiological factors. Young men are more likely to be involved in vigourous and overenthusiastic sexual practices than older men who would have more incidence of erectile dysfunction. This may explain the preponderance in this age group. Habitual acts of Taqaandan and masturbation are also more common in young men as reported in middle East8. Reduced blood flow in the elderly and attendant tendency towards erectile dysfunction may be ‘’protective’’ against PF in men with advanced age.

All but one patient (95.2%) presented to our hospital within 24 hours. A similar picture has been presented elsewhere10. However, some authors have reported late presentation mostly due to social embarrassment7,26,27. In this study, most of the patients were frightened and that made them to seek for medical help early.

Traumatic events leading to penile fracture may be sex related, forceful bending of the penis during kneading, masturbation, or ritual bending from Taqaandan. Trauma may occur during coitus with the penis slipping out of the vagina and hitting the pubis or the rigid perineum9,28. Masturbations, self-manipulations and kneading of the penis to achieve detumescence or hide an erection have also been reported to result in penile fractures2,9. In this study, sex-related events were responsible for most of the PFs. In the United States, the majority of cases are the result of traumatic coitus, usually from thrusting an erect penis against the symphysis pubis or perineum 9. In a report from Japan, only 19% of cases are attributed to sexual intercourse, with the majority of cases reported as the result of masturbation and rolling over in bed onto an erect penis25. A majority of the cases in Mediterranean countries are the result of patients kneading and snapping their penis during erection to achieve detumescence1,7. In Iran, only 8% of the cases were attributed to sexual intercourse; the remaining cases were due to self-manipulation and potentially fabricated events, such as a donkey bite to the erect penis, a man falling from a mountain onto his erect penis, and a brick falling onto an erect penis9. Other rare reports in the world literature include cases resulting from banging an erect penis against a toilet, masturbating into a cocktail shaker, and placing an erect penis into tight pants1,2,4,7; Dienye et al have reported a case resulting from husband abuse15. Here the husband tried to coerce his wife to have sex; she held the penis and forcibly bent it resulting in penile fracture.

Fourteen patients had PF resulting from injuries involving a partner while 7 persons (33.3%) had injuries with no partner involved. The partners involved in this study were their wives, girl friends or commercial sex workers. In India, 27.8% were unmarried while 72.2% were married men. This is contrary to the picture reported elsewhere in which most of the cases were unmarried patients and injuries were self inflicted2,25. The difference we observed may be due to varied aetiological mechanisms.

Previous Nigerian studies have reported association with both voluntary coitus and rape12^-14. Coital accident resulting from vigorous/overenthusiastic sexual activity was the most common sex-related event responsible for penile fracture in this study. This is comparable with reports from Ibadan, Nigeria and New Delhi1,13. Most of these events involved consensual sex as have also been reported by Mansarani29. However, penile fracture secondary to rape has been reported 13. No priapism associated penile fracture was seen in this study. Badmus et al reported priapism associated penile fracture22. No penile fracture associated with PD5 inhibitors was encountered as was reported elsewhere 19.

The lateral surfaces of the corpora were involved in most of the cases except in those with associated urethral injuries where the ventral aspects were injured. The right side was more commonly injured than the left side as separately reported by Amit, Mbonu, and Omisanjo7,14,26. In all these reports sexual intercourse was the preceding activity before the PF. However, a report from Srinagar postulates that the left side was more common in their centre because most of the cases of PF resulted from habitual masturbation using the left hand. This made the left side more prone to injury from masturbation19. It may be speculated that the preceding event may determine the side more commonly affected. While left hand was reported as predominant when masturbation was the major preceding event, the right side was more common when sexual intercourse was the predominant preceding event.

All the injuries reported in this study affected only one side, this is keeping with reports from other centres29, 30. However, some authors have reported injuries affecting both sides5,10,19,24. The most common sites of injuries were the midshaft and proximal 1/3 of the penis as was also reported in Mansoura, Egypt31.

The incidence of urethral injuries varies from 0 to 3% in Asia and Middle East to 20 to 38% in United States of America and Europe9,32,33. In this study, six (28.5%) patients had associated urethral injuries. The relatively high incidence of associated urethral injuries was similar to reports in Europe and United States of America where sexual intercourse is the major cause of PF as opposed to the Asia and Middle East where self penile manipulations was the major cause of PF. It may be postulated that difference in incidence rates of associated urethral injuries may be related to the aetiological factors. The bending force generated by sexual intercourse is perhaps greater than that resulting from self penile manipulation.

The associated urethral injuries were located at the same level as the laceration of the corpus cavernosum. This was similar to the picture in Lagos and Egypt26,31. Unlike in Mansoura where some patients had complete urethral ruptures, all cases in this study were partial ruptures. Haematuria, blood at the tip of the penis and voiding symptoms were used to suspect associated urethral injuries. In other reports presence of bilateral corpus cavernosa injuries also heighten the suspicion for urethral injuries9. All our diagnoses were based on clinical features and findings during surgical exploration. Although retrograde urethrography and ultrasonography have been used for confirmation of associated bladder injuries, none of these investigations were carried out in this study. Surgical exploration can easily reveal any associated urethral injuries.

The goals of treatment of penile fracture are universal: preservation of penile length, erectile function, maintenance of ability to void while standing16. Current literature advocates immediate surgical repair of penile fracture upon arrival at the hospital9. This was the practice in 86% of the patients in this report. The rest were treated conservatively. Conservative management involved the use of analgesics, antibiotics, ice packs and anti-inflammatory agents. Other agents that may be used for non-operative managements include oestrogens, penile splints, compression bandages and urethral catheterisation 9.

Subarachnoid spinal anaesthesia was used for all the surgical repairs. Local anaesthesia and general anaesthesia have also been used elsewhere9,34. Surgical repair of penile fractures requires evacuation of the haematoma, identification of the tunica injury, local debridement of the corpus cavernosum, closure of the tunica lacerations, repair of ruptured corpus cavernosum and ligation of any disrupted blood vessel9. Degloving incision was used in each case. This incision allowed exposure to the entire tunica bilaterally. It also facilitated recognition of the tear and diagnosis of associated urethral and contra-lateral injuries35. However, this incision has been argued to increase neurovascular injuries and skin necrosis36. These complications were not encountered in this study. Some surgeons advocate less invasive lateral incisions directly over the haematoma site while other surgeons prefer the selective use of each incision based on the clinical presentation, diagnostic imaging findings and severity of injury9,37. Some authors have also reported the use of perineal, suprapubic and inguino-scrotal incisions with excellent functional and cosmetic outcome 9,38.

When the tear was identified, haematomata were evacuated and vicryl 3/0 running sutures were used for the repairs. Other absorbable and even non-absorbable sutures have also been used by some authors3.

A patient was routinely catheterised for a few days when the urethral was not involved. Some authors removed the catheter immediately after surgery to reduce the risk of urinary tract infection and bladder spasm. In this study, the catheter was left in situ for about 2 days to reduce pain that accompanied voiding. The catheter was left for 21 days to allow for proper healing if the urethra was repaired. This was also the practice in many series7,9,19. However, Zargooshi used the catheters only when there was co-existing urethral rupture25.

Patients in this study were given oestrogens to suppress erection for two weeks to minimize penile erections during the healing phase. Penile erections worsen patients’ pain and discomfort. The use of erection suppressants have been reported elsewhere9. Some authors have opined that pain in the immediate post operative period was enough to suppress erections, and therefore they did not give any drugs to suppress penile erection39.

One of the patients in this study who presented late and had conservative treatment developed weak erection and mild deviation of his penis after healing of the fracture. He was given antibiotics, analgesics and anti-inflammatory agents. The rest of the patients had no significant complications after treatment. If the fracture is left untreated for a long time, the haematoma would organise, fibrosis would occur in the cavernosal tissue leading the long term complication of induration, penile deviation and erectile dysfunction20. Other complications reported in the literature included: abscess, wound infection, skin necrosis, decrease in rigidity, penile deformity, pulsatile cavernosal diverticulum ( an untreated penile fracture leads to an arterio-venous fistula with expanding haematoma) , permanent induration, urethral stricture, priapism, etc1,9,24,31.

The satisfactory outcome in this study may be attributed to the early presentation and prompt surgical intervention in these patients. Late presentation has been recognised as one of the factors responsible for poor outcomes of treatment25. Patients were advised to avoid sexual intercourse for 6-8 weeks to allow full recovery26. However, patients who resumed sexual activities 2 weeks after injury have been reported40.

Conclusions

The apparent low prevalence of penile fracture in our region may be due to under-reporting attributable to social embarrassment. Young men were the most commonly affected age group. Vigourous and overenthusiastic sex-related events were the most common causes of penile fracture in this study. Early surgical treatment led to restoration of penile function without significant complications. Vigourous and overenthusiastic sexual intercourse should be discouraged.