EM@3AM: Penile Fracture

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Answer: Penile fracture; retrograde urethrogram

Pathophysiology:

• Penile fracture is a relatively uncommon urologic emergency that is due to the rupture of the tunica albuginea of one or both corpora cavernosa due to direct trauma of an erect penis²
  • The tunica albuginea is connective tissue that encases the corpus cavernosum
  • In a flaccid state it is up to 2.4 mm thick but thins to 0.25-0.5 mm with an erection³
  • Force applied to an erect penis can cause this tissue to tear

• Most commonly occurs during sexual intercourse, but it can also be caused by aggressive bending to achieve rapid detumescence and stab or bullet wounds²
• Blood from the corpora cavernosa leaks into the surrounding tissues causing a hematoma deep to Buck’s fascia
• If Buck’s fascia is also ruptured, a hematoma can spread into the scrotum, perineum, and inguinal region, resulting in a “butterfly” sign³

Physical Exam:

• Patients classically present with sharp pain after hearing a cracking sound, followed by immediate flaccidity, swelling, and discoloration
  • “Eggplant deformity” or “aubergine sign” have been commonly used to describe the appearance of a fractured penis⁶
• The deformed penis will often be bent in the direction of the uninjured corpora cavernosa
• Urethral injuries can be present in up to 20% of patients⁶
  • Suspect with blood at the meatus, hematuria on urinalysis, and inability to void

Diagnosis:

• Clinical diagnosis based on exam and history; consult Urology specialist once suspected
• Ultrasound (US) has a potential role in the diagnosis of suspected cases and for preoperative imaging
  • It can identify the exact location of the tear, which could potentially lead to a modified repair as opposed to complete degloving and blind exploration⁸
  • In one study, US detected a tear in 88% of patients, but was unable to detect any tears at the base of the penis⁸
  • In the same study, US mapping was compatible with surgical results in 72% of patients⁸
  • US can also be used to rule out other causes
    • Rupture or thrombosis of the dorsal vein can present similarly but immediate flaccidity and deformation are absent³
      • Use doppler to evaluate intact corporal arteries
      • Tunica albuginea will be intact
    • Intra-cavernosal hematomas will also demonstrate an intact tunica albuginea³
  • However, there are limited studies to validate using ultrasound⁹
  • US is operator-dependent, and the lack of tissue contrast and penis edema can be challenging⁹

• MRI can also be used; however, this is not readily available and should not delay care⁶
• If concern for urethral involvement is present, obtain a retrograde urethrogram

Management/Disposition:

• Consult Urology, as this warrants prompt surgical exploration and repair¹²
• Complications that can arise in the absence of appropriate treatment include persistent clot, erectile dysfunction, deformity, abscess, and fibrosis¹³
• Conservative management has a success rate of 59% compared with 92% for surgical treatment³
  • If this is the chosen management with urology consultation, it consists of pressure dressings, cold compresses, and NSAIDs¹³

Pearls:

• Clinical diagnosis in a patient with pain, ecchymosis, and swelling after hearing a cracking sound during intercourse or manipulation followed by immediate detumescence
• If inability to void, blood at the meatus, or hematuria, then obtain a retrograde urethrogram to evaluate for urethral injury
• US can identify rupture of tunica albuginea and evaluate for other causes
• Consult Urology, as surgical repair is standard treatment

Further Reading:

#FOAMed

FOAMcast

LITFL

ALiEM

NUEMblog

References:

1. Eggplant Deformity. ResearchGate.net. https://www.researchgate.net/figure/Eggplant-deformity-the-classic-appearance-of-a-penile-fracture-with-hematoma-of-the_fig2_323615816.
2. Tintinalli JE. Emergency Medicine: A Comprehensive Study Guide. 9th ed. New York, NY: McGraw-Hill Medical; 2016.
3. Gupta N, Goyal P, Sharma K, et al. Penile fracture: Role of Ultrasound. Transl Androl Urol. 2017;6(3):580-584. doi:10.21037/tau.2017.03.38
4. Hacking C. Penile Fracture Grading. Radiopaedia Blog RSS. https://radiopaedia.org/articles/penile-fracture-grading.
5. Alfonso D. Penis Fracture: Diagnosis and Treatment. Kings County/SUNY Downstate Emergency Medicine Blog. http://blog.clinicalmonster.com/2017/06/27/bored-broke-hot-dog-penis-fracture/. Published July 4, 2017.
6. McEleny, K., Ramsden, P. & Pickard, R. Penile Fracture. Nat Rev Urol3, 170–174 (2006). https://doi-org.foyer.swmed.edu/10.1038/ncpuro0433.
7. Penis Fracture: Penile Fracture Treatment and Repair. The Center for Reconstructive Urology. https://www.centerforreconstructiveurology.org/peyronies-disease/penile-fracture/. Published November 4, 2019.
8. Zare Mehrjardi M, Darabi M, Bagheri SM, Kamali K, Bijan B. The role of ultrasound (US) and magnetic resonance imaging (MRI) in penile fracture mapping for modified surgical repair. Int Urol Nephrol. 2017 Jun;49(6):937-945. doi: 10.1007/s11255-017-1550-x. Epub 2017 Mar 3. PMID: 28258528.
9. Dell’Atti L. The role of ultrasonography in the diagnosis and management of penile trauma. J Ultrasound. 2016;19(3):161-166. Published 2016 Jan 22. doi:10.1007/s40477-016-0195-4
10. Aldawood A, Rippey J. Ultrasound Case 107. Life in the Fast Lane • LITFL. https://litfl.com/ultrasound-case-107/. Published November 3, 2020.
11. Penile Fracture with Urethral Injury. ResearchGate.net. https://www.researchgate.net/figure/Penile-fracture-with-urethral-injury-a-Clinical-photograph-shows-the-eggplant-deformity_fig2_337930320.
12. Morey AF, Brandes S, Dugi DD 3rd et al: Urotrauma: AUA guideline. J Urol 2014, 192: 327. Published 2014; Amended 2017, 2020.
13. Ouellette L, Hamati M, Hawkins D, Bush C, Emery M, Jones J. Penile Fracture: Surgical vs. Conservative Treatment. The American Journal of Emergency Medicine. 2019;37(2):366-367. doi:10.1016/j.ajem.2018.06.051