Definition, basic anatomy, aetiopathogenesis, clinical features and treatment of penile fractures.

1. Penile Fracture
Dr Eretare C Odjugo

2. Outline
• Introduction
• Relevant anatomy
• Pathophysiology
• Aetiology
• Epidemiology
• Clinical presentation

3. Outline
• Investigations
• Treatment options
• Post operative complications
• Prognosis
• Follow up
• Conclusion
• References

4. Introduction
• There are few emergencies that cause as much embarrassment to a man as
penile fracture.
• Its name is actually a misnomer as technically in the human penis, there is no
bone to be fractured.
• It is defined as the blunt traumatic rupture of the corpus cavernosum of an
erect penis, particularly the tunica albuginea surrounding it.
• This may be of one or both of the corpora cavernosa.

5. Relevant anatomy
• The layers of the penis include the
• Skin
• Dartos fascia
• Bucks fascia
• Tunica albuginea (covers the
cavernous bodies only)

6. Relevant anatomy
• The penis has 3 parts
• Root
• Body (Shaft)
• Glans
• Arterial supply is mostly via branches
of the internal pudendal artery
• Venous drainage is via the dorsal vein
and deep dorsal vein

7. Relevant anatomy
• Lymphatics drain to the superficial
inguinal, deep inguinal and external
iliac lymph nodes.
• Sensory innervation is by the dorsal
nerves of the penis and by
branches of the pudendal nerve.
• Parasympathetic supply is via the
pelvic splanchnic nerves

8. Epidemiology
• Most common in the 4th decade of life
• Mostly unilateral and mostly right sided (54%)
• Urethral injury seen in roughly 20 – 30%

9. Aetiology
• Sexual intercourse (66.7%)
• Woman on top positions
• Forced flexion
• Masturbation
• Rolling over

10. Pathophysiology
• Injury to the flaccid penis is rare due to the flexibility and mobility of the
organ.
• Erection is achieved via engorgement of the corporal bodies especially the
sinusoids of the cavernous bodies.
• The erect penis is less mobile and the tunica albuginea reduces on thickness
from 2mm to 0.25mm.
• The differential between inflow and outflow is responsible for the
maintenance of tumescence.

11. Pathophysiology
• Sudden longitudinal trauma to the erect penis or a quick forceful lateral bending to
the erect penis can result in a tear or rent in the tunica albuginea.
• With tear of the cavernosa, there is an extra corporal loss of blood into the loose
fascia of the penis with sudden detumescence.
• There is a subsequent haematoma formation, abnormal shape of the penis and
pain.
• If the corpus spongiosum is involved with urethral injury, there may be bleeding per
urethra and depending on the severity of urethral injury, urinary retention.

12. Clinical presentation.
• Most cases present as emergencies and the complaints are mostly those of
• Pain
• Swelling
• Loss of erection
• Popping sound
• ± bleeding per urethra and inability to pass urine.

13. Clinical presentation
• It is important to ascertain the sexual position (most commonly the female
partner is on top straddling the phallus)
• Most are coincidental with sexual intercourse.
• The use of performance enhancing medication should also be obtained.

14. Examination
• Discomfort
• Anxious
• Egg plant deformity
• Lateral bend of the phallus if only one
side is involved
• Butterfly pattern ecchymoses
• Bleeding per urethra
• Tenderness

15. Diagnosis
• This is essentially clinical but there are some instances where investigations
may be required for confirmation.
• Differentials
• Rupture of the dorsal penile vessels
• Rupture of the suspensory ligament of the penis

16. Investigations (Imaging)
• Imaging modalities are not essential to make a diagnosis as they usually just
increase cost and do not necessarily change the treatment plan.
• Supportive investigations
• Penile ultrasound
• Magnetic Resonance imaging
• Penile Cavernosography
• Retrograde urethrography

17. Investigations (imaging)
Retrogade urethrogram Penile cavernosography

18. Investigations (imaging)
MRI

19. Investigations (Laboratory)
• Full blood count
• Serum electrolytes
• Clotting profile
• Urinalysis
• Routine screening for STIs
• Cross matching of blood.

20. Management
• Aims
• Expedite pain relief
• Prevent erectile dysfunction
• Allow normal voiding
• Minimize potential complications

21. Management
• At the emergency room,
• Adequate analgesia
• Evaluate state of the urethra by asking the patient to void. Urinary diversion to be
performed if there is urinary retention
• Counselling
• Consent for surgery
• Anaesthetic evaluation

22. Treatment
• Surgical
• Conservative.
• Rarely performed.
• Higher rates of complications
• May be attempted if the history is suggestive but the examination findings are not in
line with penile fracture.
• Investigations do not show any tear in the tunica albuginea ot the tear is < 0.5cm with
minimal haematoma formation.

23. Surgical principles
• Adequate exposure
• Haematoma evacuation
• Identification and repair of the tear in the tunica albuginea
• Repair of urethral injury if any.

24. Surgical approaches
• Circumferential incision and degloving
• Most common approach
• Gives good exposure
• Excellent results
• Inguinoscrotal
• Usually for injuries at or close t the base of the phallus
• Incision over defect.

25. Intra-op
• Anaesthesia
• General or Spinal
• Supine position
• Cleaning and draping.
• Application of tourniquet
• Circumferential incision through to Bucks fascia and then degloving
• Evacuation of the haematoma

26. Surgery
• Thorough inspection both corpora cavernosa and the corpus spongiosum for tears
• Injection of contrast to identify the tear in the tunica albuginea.
• Freshen the edges of the tear and repair with small absorbable sutures.
• Test the repair by inducing tumescence with the aid of normal saline injected into
the cavernous body.
• If there is a urethral injury, a catheter is passed under direct vision and a primary
repair of the tear or an anastomosis in the event of a transection is performed.

27. Surgery

28. Surgery
• Repair the fascial layers and then the skin with absorbable sutures ensuring
the proper orientation and length of penis is maintained.
• In the event of a urethral repair, catheter is left for a period of 7 – 14 days.

29. Post operative care
• Analgesics
• Antibiotics
• Erection suppression
• Stilboestrol
• Chlorpromazine
• Diazepam
• Abstinence from sexual activity for 6 – 8 weeks.

30. Complications
• Erectile dysfunction
• Penile deformity
• Urethral strictures
• Painful erection
• Painful intercourse
• Skin necrosis
• Fistulas (A-V, urethro-cavernous)
• Priapism
• Peyronie’s disease

31. Management of chronic penile haematomas
• Patients may have a much delayed presentation following penile fracture
• In these patients, the haematoma may have become organised with resultant
fibrosis and curvature of the penis.
• The treatment is a modified Nesbit procedure.

32. Follow-up
• Discharge is usually within 5 days of the procedure and follow-up is on an
outpatient basis
• Most patients make a full recovery with restoration of normal sexual
function and micturition.
• The catheter in patients that had a urethral repair is removed after about 2
weeks.

33. Conclusion
• Penile fracture as an emergency is under reported due to the embarrassment
the patients feel
• It is a clinical diagnosis that’s easy to identify but may have some false
negatives.
• Surgical intervention is preferable as it has much better outcomes.

34. References
• Imtiaz Wani. Management of Penile Fractures. Oman Med J. 2008 Jul; 23(3): 162 –
165.
• Gregory S Jack et al. Current treatment options for penile fractures. Rev Urol. 2004
Summer; 6(3): 114 – 120.
• Galanakis I, Adamos K, Spyropoulos E, Mavrikos S. Delayed successful repair of a
penile fracture: A case report. Curr Urol. 2018; 12: 111 -112
• Richard A Santucci. Penile fracture and trauma. 2019 Jan. accessed via the Medscape
app
• Images obtained via a google search.

35. References
• Omisanjo OA, Bioku MJ, Ikuerowo SO, Sule GA, Esho JO. African Journal
of Urology. 2015. 21(1), 52 - 56

36. THANK YOU