Penile fracture

A 28-year-old male arrives to the emergency room with swelling and acute pain in the penis after sexual intercourse an hour ago, in which he had a direct traumatism in the erect penis and subsequent immediate detumescence. An indurated area is palpated around the root of the penis, compatible with hematoma.

Ultrasound in the penis is performed:

Figure 1: Long axis. We can clearly appreciate the affected portion of the right corpus cavernosum which appears hyperechoic, as well as the defect in the overlying tunica albuginea, measuring 5.4 mm (blue crosses A-A).

Figure 2: Axial plane. We can appreciate in the axial plane that the right corpus cavernosum appears hyperechoic due to the traumatism whereas the left one is hypoechoic. We can also observe an extratunical hematoma surrounding the affected corpus cavernosum in the root of the penis, delimited its dimensions with blue crosses (A and B, A being its larger diameter and B the transverse diameter).

Figure 3: Intraoperatory image. The defect is confirmed to be in the root of the right corpus cavernosum (yellow arrow), surrounded by an already coagulated hematoma.

Penile rupture/fracture is an unusual event that requires immediate diagnosis and surgical intervention.

It only occurs while the pennis is erect. During erection, the tunica albuginea thins from 2 mm to 0.5 mm, being more susceptible to tearing due to an external force [1].

Common causes of injury include bending of the penis during self-manipulation, rolling over in bed, direct injury, or sexual intercourse, being the latter the most common cause.

An audible crack, sudden onset of pain, detumescence and swelling, as well as diffuse ecchymosis give the penis a typical appearance of an eggplant [2].

Patients with associated urethral injury may present with hematuria or dysuria too.

The integrity of the tunica albuginea is the most important factor in determining the need for surgery and therefore it is crucial to describe in our report the extent and location of the albugineal tear [1].

Emergency ultrasound is the initial imaging study. The findings that help us determine the presence of a penile fracture include the visualization of the tunica albuginea defect covering the corpora cavernosa, as well as an extratunical hematoma surrounding the defect [2, 3].

However, its use has been criticized because of added expense and false-negative results due to occlusion of the tunical rupture by the hematoma as well as excessive swelling [3].

If these occur, MRI is an optimal modality, as it has demonstrated a better evaluation of the integrity of the tunica albugínea and better identification of corpus cavernosal rupture [1, 4].

Although penile fracture can be treated conservatively, surgical repair of the defect and evacuation of the hematoma in the first 6-12 hours have demonstrated to prevent late complications such as penis angulation, scarring or fibrous plaque formation [5, 6]. Patients who undergo surgery resume normal erectile function afterwards.

Our patient went on to have immediate surgery and the defect was repaired, being discharged from the hospital two days later.