Fracture of the Penis: Demonstration by MRI with Surgical Correlation

Abstract

MRI of a 21-year-old man with a penile fracture demonstrated disruption of the tunica albuginea and adjacent hematoma. Both MRI and subsequent retrograde uretrogram showed that the urethra was not injured. The imaging findings were confirmed at surgery, and the penis was successfully repaired.

Case Report

A 21-year-old man presented to the medical center with pain and asymmetric penile swelling after “cracking” his penis. He admitted to a compulsive behavior in which he “cracked” his penis twice per day while in a mildly erect state, “like cracking your knuckles.” Just prior to presentation, the patient experienced an unfamiliar snapping sensation while “cracking” his penis, followed by the acute onset of pain and asymmetric swelling. On physical examination, the patient had a grossly deformed penis with swelling and deviation to the left. The patient also reported having the urge to urinate but was not able to void.

MR imaging of the penis was performed using a torso phased-array coil. With the patient in the supine position, the penis was elevated with surgical towels. Sagittal T1-weighted, coronal spin echo T1-weighted, axial T2-weighted fat saturated, and coronal T2-weighted fat saturated images were obtained. On coronal T2-weighted fat sat images, the patient had a unilateral 0.8 × 1.8 cm area of disruption of the right posterolateral tunica albuginea involving the mid to distal one-third of the penile shaft, adjacent to the corpus cavernosum (Figure 1A, Figure 1B). An adjacent 4.6 × 2 cm area of increased signal intensity was felt to represent a hematoma. On axial T2-weighted images, Darto's fascia was expanded on the right side (Fig. 2). Given his initial inability to void, the patient also underwent a retrograde urethrogram to evaluate the integrity of the urethra (Fig. 3). Although MR imaging had demonstrated no such injury, caution was exercised to insure the best outcome for the patient. The retrograde urethrogram also demonstrated no evidence of urethral injury; and after several attempts, the patient was able to void. His urine was noted to be yellow without any gross evidence of hematuria.

Figure 1A.

21-year-old man with fractured penis. Coronal T2-weighted fat suppressed image demonstrating unilateral 0.8 × 1.8 cm area of disruption of the right posterolateral tunia albuginea with adjacent 4.6 × 2 cm area of increased signal intensity representing associated hematoma.

Figure 1B.

21-year-old man with fractured penis. Axial T2-weighted image demonstrating expansion of Darto's fascia on the right side.

Figure 2.

21-year-old man with fractured penis. Single radiographic image with contrast in the urethra depicting a normal retrograde urethrogram without stricture, filling defect, or extravasation.

At surgery, a circumferential incision was performed, with penile degloving and exposure of the corpora cavernosum and corpus spongiosum. There was disruption of the right posterolateral tunica albuginea involving the mid to distal one-third of the penile shaft, adjacent to the corpus cavernosum. Upon further surgical exploration, surrounding hematoma was found to be isolated to the penis. The hematoma was evacuated, and the right 1.8 cm tunica laceration was repaired with interruputed 2-0 Vicryl sutures. The laceration was noted to have an angle at the center of the laceration, which appeared consistent with the reported mechanism of injury.

Discussion

A penile fracture is defined as rupture of the corpus cavernosum and its surrounding fibroelastic sheath, the tunica albuginea. In order for rupture to occur, there must be sudden increase in intracorporeal pressure by an external force resulting in tearing the tunica albuginea of the erect penis as in this case [4]. MR imaging is the diagnostic modality of choice because it precisely demonstrates the presence, location, and extent of the tunical tear, which manifests as discontinuity of the tunica albuginea [4, 5, 6]. MR imaging also depicts associated injuries to adjacent structures (ie, corpus spongiosum, urethra) [7, 8]. The most commonly reported penile injury is disruption of the right posterolateral tunica albuginea involving the mid to distal one-third of the penile shaft, adjacent to the corpus cavernosum [4, 9, 10, 11, 12, 13]. The literature reports a 13-30% incidence of urethral involvement in cases of penile fracture [6, 14, 15, 16].

Although penile fractures have been treated conservatively, studies have reported apparent, improved clinical outcomes with early surgical intervention.[1, 12, 17] If surgical repair is not undertaken, fibrous scar plaques similar to Peyronie's Disease, may develop causing angulation, bending, and erectile dysfunction.