Case report

38 yrs old male presented with severe excruciating pain over the penis and immediate loss of erection, following a cracking noise in the penis while having intercourse with his wife previous night. Patient denied use of sildenafil (Viagra) or artificial tumescence device before intercourse. On examination penis was grossly enlarged and tender with ecchymoses over suprapubic region and scrotum (See Figure 1). Patient could pass the urine effortlessly. He gave history of religious circumcision at the age of two years.

Figure 1

Figure 1: On presentation

Depending on significant history and gross external examination, diagnosis of fracture penis was made and need of cavernography is obviated. Under spinal anesthesia and gauze tourniquet applied at the root of penis, a circular incision was kept over the shaft of penis, 5 mm proximal to corona glandis. The incision deepened and Bucks fascia was cut in circular manner as that of skin. (See Figure 2) About 20 ml of organized hematoma was evacuated and penis was degloved till its root. A tear of 4mm in the tunica albuginea was found at the base of right corpora cavernosa. (See Figure 3) The edges of the defect in the tunica were freshened. A watertight closure was achieved by interrupted sutures in inverted manner so that knots will not be palpable. (See Figure 4) We preferred absorbable suture vicryl 3-0 for this purpose.

Figure 2

Figure 2: Incision over Skin and Buck's fascia

Figure 3

Figure 3: Defect in the corpora cavernosa

Figure 4

Figure 4: After 4 days of surgery

Hemostasis was achieved and checked again. Opposite corpus cavernosum was found essentially normal. Bucks fascia was repaired and skin was approximated with Nylon 3-0 suture. Patient was given broad spectrum antibiotics, anti-inflammatory drug along with diazepam which helped in alleviating the spontaneous erections. Elevation to the penis was given with the help of tongue depressor for two postoperative days. Patient showed significant improvement with decreased swelling and ecchymoses, within 4 days. Sutures were removed on 7th day and patient was discharged. Examination after 1 month showed painless erection of penis without any apparent deviation.

Discussion

Penile fracture is defined as a rupture of the tunica albuginea of the corpus cavernosa when the penis is in a fully erect state. The age of patients with penile fracture discussed in the literature ranges from 26 to 41 years [₁]. Fractures to the penis, although uncommon, do occur when an abnormal force is applied to the erect penis. The 'fracture' is actually a tear in the tunica albuginea, the thick fibrous coat surrounding the corpora cavernosum tissue that produces an erection.

Penis consists of two corpora cavernosae and a carpora spongiosum. Tunica albuginea snugly covers the corpora cavernosa. All three corpora are surrounded individually by Buck fascia. Penis is supplied by internal pudendal artery. During sexual erotism, because of parasympathetic stimulation the venous outflow of the corpora cavernosa is occluded leading to accumulation of blood into the sinusoids of carpora cavernosa. This hardens penile shaft causing its erection. Tunica albuginea is an elastic covering of the corpora cavernosa. As the penis changes from a flaccid state to an erect state, the tunica albuginea thins from 2 mm to 0.25-0.5 mm, stiffens, and loses elasticity. The expansion and stiffness of the tunica albuginea impede venous return and are responsible for maintaining tumescence during male erection. Sudden bending of the penis due to any reason in this erected condition may cause rupture of thinned out tunica albuginea.

Most common cause of the fracture penis is during hasty sexual intercourse [₂]. As the penis thrusts in and out during the intercourse it becomes dislodged from the vagina and when attempting to reinsert, it may slip out striking the female pelvic bone, and creating a sudden bending of the penis leading to fracture of penis. Most common position responsible for this situation is the female partner on top during intercourse. Penile fractures can also occur during masturbation. Although, most injuries that result from masturbation come from forcibly hiding an erection without care and fracturing it. In the western world the incidence of fracture penis was significantly increased with discovery of sildenafil. Other potential causes include industrial accidents, masturbation, gunshot wounds, or any other mechanical trauma that causes forcible breaking of an erect penis. Rarely may it occur while turning over in bed, forced bending, or hastily removing or applying clothing when the penis is erect.

The sure sign is sudden pain with immediate detumescence of the penis. Patient may also notice cracking sound in the penis. Clinically patients presents with grossly enlarged penis with bruising and ecchymoses over surrounding skin. The penis may be abnormally curved taking S shape. The penis is often deviated away from the site of the tear secondary to mass effect of the hematoma. Penile ecchymosis is confined to the penile shaft if the Buck fascia is intact. Swelling and ecchymosis spreads to perineum, scrotum, and lower abdominal wall within the Colles fascia if the buck's fascia gives way. This produces typical “butterfly-pattern” ecchymosis . Rolling sign can be demonstrated which is nothing but the movement of penile skin over the organized hematoma at the site of rupture of tunica albuginea.

The incidence of concomitant urethral injury in reported cases is 10-38% [₃]. Incidence of urethral injury is low in coital injuries. Associated urethral injuries may present as gross hematuria, blood at the tip of meatus or as retention of urine which may be secondary to urethral injury or periurethral hematoma.

In case of equivocal diagnosis (a large bruise, but no obvious distortion or destruction) diagnosis can be sought by corporal cavernosography [₄,₅]. A fine needle into the corporal body of the penis and contrast material is injected followed by X- ray. Leakage of the dye is diagnostic of fractured penis. Some patients with the classical symptoms and signs of penile fracture may not have a tear on cavernosography and that “the gap” in the tunica considered being pathognomonic of fracture may not be easily felt. Hence, some authors advocate routine cavernosography, while others discourage its use unless the diagnosis is in doubt. Significant incidence of false-negativity, soft tissue reaction to the contrast material and increased corporal fibrosis are the drawbacks of cavernosography. Most authors report using penile cavernosography if physical examination findings are equivocal but the history indicates a possible injury. In associated urethral injury, a retrograde urethrogram is mandatory to look for urethral disruption as well as extravasation of the dye into the surrounding tissues which may present as late complication.

Conservative therapy in the form of cold compresses, pressure dressings, and penile splinting was advocated by some surgeons in the past. But it was evident that the conservative treatment has high rate of complications i.e. 29-53% [₆]. Immediate complications include blood clot accumulation or a hematoma, or an infection of the hematoma. Most common and troublesome complication is painful erection and painful coitus. Other common complications are penile abscess, nodule formation at the site of rupture, permanent penile curvature, erectile dysfunction, corporourethral fistula, arteriovenous fistula, and fibrotic plaque formation. Missed urethral injury is rare but grave complication. Fibrosis of the lining of the corporal body can create a bend and poor healing. Therefore the early surgical management is considered as gold standard (₁, ₂).

Subcoronal circumferential incision is preferred for distal tears and large hematomas, while direct incisions at the site of tunica tear is appropriate for basal tears. Direct incisions allow minimal dissection of neurovascular bundles. Circumferential incisions provides good exposure for the localization of the tear and repair any gaps in the albuginea which might be wider or more irregular than suggested by physical examination before surgery. However, decreased penile sensation has been reported with this type of incision. Grossly injured penis with large hematoma of extravasation of urine due to urethral injury demands the inguinal-scrotal incision which provides excellent exposure of the base, root, and dorsal surfaces of the penis. We preferred subcoronal circumferential incisions with degloving of the penis In view of the fact that the diagnosis was based on clinical findings. Also our patient had a previous circumcision scar and we felt that it was more cosmetic to perform the incision at the site of the scar. Although non-absorbable suture is recommended in the repair of tunica tears (₇) many surgeons have reported the use of absorbable sutures. In our case, vicryl was used without significant squeal.

Partial and complete urethral transections that are clean require a primary anastomosis over a catheter and urinary diversion via a suprapubic tube. Close the urethral defect with 4-0 chromic sutures in an interrupted fashion, and leave an indwelling urethral catheter for 2-3 weeks. Suppression of spontaneous erections is done with diazepam or stilboestrol (₈). Early diagnosis and surgical management is the key for better results and less complications.