Penile Fracture - Urgent Surgical Repair

Key Points

• A classic pop, immediate detumescence and rapid swelling is penile fracture until proven otherwise.
• Penile fracture is rupture of the tunica albuginea and requires prompt urologic surgical repair.
• Do not delay classic cases for unnecessary imaging.
• Blood at the meatus, gross hematuria or inability to void suggests associated urethral injury.
• Retrograde urethrogram or cystoscopy evaluates the urethra when indicated.
• Early surgical repair has better erectile and curvature outcomes than conservative treatment.
• Avoid blind catheterization when urethral disruption is suspected.
• Follow patients after repair for erectile dysfunction, curvature and urinary symptoms.

Algorithm

1. Obtain the injury mechanism and ask about pop, immediate detumescence, swelling and urinary symptoms.
2. Examine deformity, hematoma distribution, skin, meatus and ability to void.
3. If classic, consult urology and proceed toward prompt exploration without diagnostic delay.
4. If urethral injury is suspected, evaluate with retrograde urethrogram or cystoscopy.
5. Use ultrasound or MRI only when diagnosis is equivocal and imaging will change management without harmful delay.
6. Perform operative hematoma evacuation and tunical repair; repair urethral injury if present.
7. Provide postoperative wound, pain and sexual-activity instructions.
8. Reassess erectile function, curvature and voiding during follow-up.

Clinical Synopsis & Reasoning

Penile fracture most often occurs during intercourse or forceful manipulation of an erect penis. The classic history is a cracking or popping sound followed by immediate loss of erection, rapid swelling, pain, and deformity. Examination may show the “eggplant” deformity from hematoma and deviation away from the injury. If Buck fascia remains intact, hematoma can be more localized. The diagnosis is usually clinical and imaging should not delay surgery when the history and examination are classic.

Important mimics include rupture of the dorsal penile vein or artery, superficial hematoma without tunical rupture, and other soft-tissue injury. Ultrasound or MRI can clarify equivocal cases when available without significant delay. Urethral injury occurs in a minority and should be suspected with blood at the urethral meatus, gross hematuria, dysuria, urinary retention, or bilateral corporal injury. Retrograde urethrography or flexible cystoscopy can evaluate the urethra, often at the time of surgery. Avoid blind urethral instrumentation when disruption is suspected.

Treatment Strategy & Disposition

The AUA urotrauma guideline recommends prompt surgical exploration and repair for acute clinical penile fracture. Through degloving or targeted incision, the hematoma is evacuated, the tunical tear identified, and the defect closed. Associated urethral injury is repaired according to its extent. Early surgery reduces erectile dysfunction, painful erections, penile curvature, plaque and missed urethral injury compared with conservative compression and observation.

Provide analgesia, ice/elevation while awaiting surgery, NPO status, and perioperative antibiotics according to the operative protocol. If the diagnosis is uncertain and imaging confirms no tunical tear, conservative care may be appropriate for isolated vascular injury or soft-tissue contusion. After repair, patients generally abstain from sexual activity for several weeks as directed by urology and are followed for erectile function, curvature, pain, voiding symptoms and wound complications. Persistent erectile dysfunction can be evaluated with validated questionnaires and penile Doppler when indicated.

Epidemiology / Risk Factors

• Penile fracture is uncommon and usually affects sexually active adults.
• Mechanisms vary geographically, including intercourse, manual bending, rolling onto an erect penis, and intentional detumescence maneuvers.
• Urethral injury is more frequent with high-energy or bilateral corporal rupture.
• Underreporting can occur because of embarrassment or delayed care.

Investigations

Urethral Injury Clues

Pharmacology

Prognosis / Complications

• Prompt surgical repair usually preserves erectile function and penile anatomy.
• Delayed or nonoperative care increases risk of erectile dysfunction, curvature, painful erections and fibrotic plaque.
• Associated urethral injury can cause stricture if missed.
• Psychological distress and anxiety about resuming intercourse are common but often improve with counseling and successful healing.

Patient Education / Counseling

• Seek emergency care after a pop with immediate detumescence and swelling rather than waiting to see whether bruising resolves.
• Explain that surgery repairs the tough corporal covering and generally has excellent functional outcomes.
• Follow the surgeon’s restriction on intercourse/masturbation until healing is complete.
• Report fever, worsening swelling, wound drainage, urinary retention or blood in the urine after repair.
• Discuss erectile or curvature concerns openly at follow-up because effective evaluation and treatments are available.

Notes

The most important diagnostic rule is that a classic penile-fracture history is enough to call urology. Imaging is valuable for uncertainty, not a mandatory gate before surgery. The tunica becomes thin during erection, so a sudden bending force can create a transverse tear with rapid hematoma and immediate detumescence.

The AUA guideline favors prompt repair because conservative treatment has consistently worse functional outcomes. Follow-up should include more than wound healing: erectile rigidity, pain, curvature, plaque and urinary stream should be discussed explicitly because patients may not volunteer sexual symptoms.

References

1. AUA Urotrauma Guideline — Link