Penile fracture associated with complete urethra and bilateral corpora cavernosa transection

Abstract

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis. It occurs due to the forcible bending of the turgid erect penis against resistance leading to tunica albuginea tear. The rupture of tunica albuginea surrounding the corpora cavernosa leads to hematoma formation and classical ‘aubergine’ deformity. Timely intervention is essential to improve sexual function. Urethral injury may occur concomitantly in case of severe trauma. Blood at the meatus, inability to void and haematuria are distinctive features. We describe a case of 36-year-old man who presented to the emergency department with penile fracture during sexual intercourse associated with blood at the meatus and voiding difficulty. On surgical exploration, complete bilateral corpora cavernosa tear and penile urethral transection was noted. The patient was successfully managed with timely repair. This case highlights the need for suspicion of an associated urethral injury in patients of penile fracture with blood at the meatus.

Background

Fracture of the penis is an uncommon urological emergency. It occurs due to forcible bending of the turgid erect penis against resistance, leading to tunica albuginea tear. A typical history and clinical examination are usually diagnostic. Urethral injury is rarely described with penile fracture. Blood at the meatus, inability to void and haematuria are distinctive features. Early surgical intervention is the key to a successful outcome. We report a rare scenario of a 36-year-old man with penile fracture, bilateral corpora cavernosa and urethral transection, whose injury was managed with timely repair. We also present a brief literature review.

Case history

A 36-year-old man presented to the emergency department of our hospital with sudden-onset pain, a deformed, swollen penis and inability to void for three hours. The event occurred during sexual intercourse with his partner, when he suddenly heard a snap followed by rapid detumescence, pain and deformity of the penis, blood at the meatus and inability to pass urine. The patient had no comorbidities and no past surgical history. His sexual function was normal before the incident. On local examination, swelling and ecchymosis was present in the penis, scrotum and lower abdomen (Figure 1). The penis was deformed and tender on palpation. Blood was noted at the urethral meatus. Bilateral testes were normal. The lower abdomen was distended, probably due to a full urinary bladder.

Figure 1 .

Deformed swollen penis with hematoma up to suprapubic region

Routine blood investigations, including haemography, serum electrolytes, renal function and coagulation profile, were within normal limits. Since the history and examination findings were highly suggestive of penile fracture with suspected urethral injury, it was decided to take the patient for an emergency surgical exploration. A gentle attempt to pass a Foley catheter was not made in view of the possibility of converting a partial urethral injury to a complete one. A retrograde urethrogram would not have changed the course of management and hence was not performed. After counselling the patient about the condition and need for emergency surgery, written informed consent was taken and patient was explored under spinal anaesthesia.

A subcoronal circumcision incision was made and the penis was degloved to the penoscrotal junction. The haematoma was evacuated and thoroughly washed with physiological saline. The site of injury was noted on the ventral aspect of proximal penile shaft with complete transection of the penile urethra and of the bilateral corpora cavernosa with tunica albuginea tear (Figure 2A). A 16 Fr Foley catheter was placed in the distal urethra and traversed through proximal end to check the patency of the urethra (Figure 2B). The corpora cavernosa was repaired using vicryl 2–0 horizontal mattress sutures. The two ends of the urethra could be approximated easily with no tension and a spatulated mucosa to mucosa in a single interrupted layer using vicryl 4–0 sutures over a 16 Fr Foley catheter was done (Figure 3). The skin edges were reapproximated using catgut 4–0 absorbable sutures.

Figure 2 .

(A) Intraoperative image showing bilateral corpora cavernosa transection (white arrow) and transection of penile urethra (black arrow) with Foley’s catheter inserted in distal urethra. (B) Intraoperative image showing two ends of urethra (black arrow) and corpora cavernosa transection (white arrow) and Foleys catheter passing through the proximal urethra

Figure 3 .

Intraoperative image showing completed suturing of corpora cavernosa (white arrow) and two ends of urethra being sutured (black arrows)

The postoperative course was uneventful and the patient was discharged three days after hospital admission. At the three-week follow-up, he reported normal early morning penile erections. The wound was healthy and the urethral catheter was removed. The patient voided well without difficulty and was advised to attend follow-up after three months. There was no penile curvature and retrograde urethrogram performed showed grossly normal study. The International Index of Erectile Function-5 score on follow-up was 22 and the patient was advised to resume his sexual activity. At the one-year follow-up, the patient was doing well with normal voiding and sexual function.

Discussion

Penile fracture was first documented by the Arab physician Abul Kaseem 1000 years ago.¹ It is defined as breach of the tunica albuginea overlying the corpora cavernosa following a blunt trauma to the erect penis. Associated injuries could be partial or complete transection of the urethra or corpus spongiosum, dorsal veins and nerves. Injuries involving bilateral corpora and urethra are infrequent.² Fracture mechanics are explained by a review of the anatomy.

The tunica albuginea is a fibroelastic sheath which covers both the corpora cavernosa and the ventrally placed corpus spongiosum. It can resist pressures up to 1500 mmHg due to its tensile strength. With penile erections, as the cavernosa becomes turgid, the tunica albuginea attenuates from 2mm to 0.25–0.5mm and loses its elasticity. Abnormal bending of the penis in this erect state may lead to abrupt increase in intracavernosal pressure and rupture.³ It is most commonly observed with sexual intercourse, occurring when the rigid penis slips from the vagina and strikes the partner’s perineum or pubic bone. While most cases are reported with sexual intercourse, other aetiologies include masturbation, rolling over an erect penis during a morning tumescence, accidental falls and taqaandan. Taqaandan has been described as a cultural practice wherein the erect penis is intentionally bent to achieve relaxation.⁴

Most injuries occur on the ventral or lateral aspect where the tunica is the thinnest and transverse tears of 1–2cm length are observed. Diagnosis of penile fracture is predominantly clinical and made by the typical history and clinical examination findings. The usual history is of an injury associated with sexual intercourse with a snapping or popping sound followed by pain, deformed swollen penis and rapid detumescence. The rupture of tunica with intact Buck’s fascia results in an ‘aubergine’ sign. With disruption of Buck’s fascia, spread of haemorrhage may occur around Colles fascia to perineal, scrotal and lower abdominal wall structures and represent a ‘butterfly’ injury pattern, as seen in the index case.

Occasionally, the ‘rolling sign’ may be felt at the site of tunica fracture. It is usually difficult to locate due to the tenderness and overlying oedema. A condition imitating penile fracture may occur due to disruption of the dorsal penile artery or vein or nonspecific dartos bleeding. This may occur during sexual intercourse or trauma in 5% of clinically diagnosed patients. There is no rupture of the tunica in these patients. Certain nonspecific findings, such as lack of an audible cracking sound, slow post-injury detumescence and the ability to have an erection at a time removed from the insult suggest pseudo penile fracture. These false fractures due to dorsal vein disruption are associated with history of childhood circumcision. Circumcision causes stretching of the penile skin, which may lacerate during intercourse.⁵

Penile fracture may be associated with findings of blood at the meatus, inability to void and distended urinary bladder. One meta-analysis has reported that an associated urethral injury should be suspected in patients with gross haematuria, microscopic haematuria or who are unable to micturate.⁶ Disease conditions that render the urethra more rigid, such as spongiofibrosis or stricture disease render the urethra vulnerable for further injury.⁷ Urethral injuries could be partial or complete transection.⁸

Investigations such as ultrasound, magnetic resonance imaging, cavernosogram and retrograde urethrogram in case of suspected urethral injury have been used.^9,10 However, these investigations rarely influence the course of management.¹¹ Surgical exploration remains the standard of care. Immediate repair is the optimal treatment since it has fewer complications, reduced hospital stay and better outcomes. Subcoronal or circumferential incision with excellent visualisation of all corporal compartments and facilitating repair of any concomitant urethral injury is the most suitable surgical approach. Closing the tunical gap with interrupted 2–0 or 3–0 absorbable sutures is approved. Urethral integrity is restored by debridement and mucosa to mucosa anastomosis in tension free fashion over a catheter. Wrapping of the urethral anastomotic site with a subdartos vascularised flap can be done to prevent fistula formation in case of overlapping suture lines.¹²

After surgery, Gittes test may be performed to confirm the tunica integrity. Long-term outcomes following early surgery are reported in literature to be good with satisfactory erectile function.¹³ Long-term complaints following fracture repair are varied and range from painful erection and intercourse to erectile dysfunction and priapism.^14,15 Conservative management of penile fractures are associated with higher incidence of these complications, longer periods of hospitalisation and recovery. In the index case, we subjectively assessed patient sexual function with International Index of Erectile Function-5 questionnaire prior to trauma and subsequently in the follow-up period. The patient was able to resume his sexual activities as before, as a result of early surgical intervention.

Conclusion

Fracture of the penis may be occasionally encountered as an emergency in urological practice. While the history and clinical findings are usually diagnostic, blood at the meatus, inability to void and bilateral corpora cavernosa injury are red flags that should prompt the surgeon to locate the site of the urethral injury.