Surgical intervention is key to prevent sexual dysfunction.
Penile fracture is a rare urological emergency requiring prompt surgical intervention to preserve sexual function. Complications secondary to penile trauma include urethral injury, permanent erectile dysfunction and a deformed penis.
We present a case of a 38-year-old male who presented to the emergency department suffering a complex penile fracture with a urethral rupture sustained during sexual intercourse.
A bedside retrograde urethrogram (RUG) was performed, which showed a urethral injury evidenced by contrast extravasation. The patient was taken for emergent surgical repair and was found to have a corpora cavernosa tear with distal urethral rupture. This case outlines the necessity to perform a RUG when suspecting urethral injury in the setting of penile trauma.
Traumatic rupture of the tunica albuginea of the corpus cavernosum, referred to as a penile “fracture,” is an uncommon urological emergency.
The incidence of penile fractures is as low as 1 in 175,000. Culprits of penile trauma resulting in disruption of the corpus cavernosum include sexual intercourse, masturbation and forced flexion of the erect penis. A meta-analysis revealed that coitus resulted in 48% whereas masturbation and forced flexion accounted for 39% of penile fractures. In the United States, most reported cases are a result of sexual intercourse when the erect penis traumatically encounters the pubic symphysis or perineum after slipping out of the vagina, resulting in forced flexion or extension of the penis. We report a case of a penile fracture with distal urethral rupture secondary to coitus.
A 38-year-old male with no past medical history presented via ambulance to the emergency department for a penile injury that was sustained during anal insertive sexual intercourse. The patient stated he heard an audible “pop” mid-coitus with his male partner and had immediate pain to his penis. The patient experienced immediate detumescence with a large amount of blood emanating from his urethral meatus with associated penile ecchymosis. The patient had not attempted to void before presenting to the emergency department.
Examination of the patient’s penis revealed an eggplant hematoma with dried blood at the urethral meatus. There was significant tenderness throughout the ventral aspect of the penis. Due to the evidence of blood at the urethral meatus in the setting of penile trauma, a retrograde urethrogram was performed in the emergency department, which revealed extravasation of contrast at the distal urethra, consistent with a urethral rupture (Figure-1).
Urology was emergently consulted, and the patient was immediately taken to the operating room for exploration and repair of the corpora and urethra. Surgical exploration revealed a large hematoma in the right ventral distal corpora.
Evacuation of the hematoma exposed a 1 cm tear in the corpus cavernosum that extended 2 cm through the spongiosum, transecting the ventral urethra. The defect in the corpus cavernosum and urethra were successfully repaired and a foley catheter was placed in the operating room. The post-operative period was uneventful and the patient was discharged with the foley catheter in place.
Penile fracture is an uncommon urological emergency requiring prompt surgical fixation. Sexual trauma is the main etiological cause of penile fracture, as highlighted in the case presented above. Physiologically the penis is at increased risk of fracture during tumescence as the tunica albuginea’s thickness decreases from 2 mm to 0.25 mm.
Buck’s fascia overlying the ventral aspect of the penis is thinner in comparison to the dorsal aspect of the penis, elucidating an area of weakness where the majority of injuries occur. Associated urethral injuries have a lower incidence of documentation, ranging from 1% to 38% of patients.
For many providers, the diagnosis of a penile fracture can be clinical in nature with a triad of penile hematoma, detumescence and a snapping sound during the inciting event of injury. In the setting of penile trauma, a retrograde urethrogram is a bedside diagnostic tool that can provide ample information regarding the integrity of the urethra.
The presentation of a urethral injury can include gross hematuria or voiding inability. Although urethral injuries are relatively uncommon in the setting of penile fractures, urethral injuries cannot be disregarded in the setting of penile trauma.
Emergency department providers must be able to perform a retrograde urethrogram (RUG) in the setting of penile trauma. To perform a bedside RUG, the emergency department provider will require a 60 mL tube feeding syringe or a standard syringe with a Christmas tree adapter of 10 percent water-soluble contrast. The syringe is securely placed in the tip of the urethral meatus allowing for contrast to be injected into the urethra.
A bedside radiograph is immediately obtained after injecting the contrast into the urethra to assess for extravasation. It is important to note to leave the tip of the syringe in the urethral meatus while the radiograph is being taken to prevent the contrast from back flowing out of the meatus. As seen with our patient, a study illustrating contrast extravasation indicates urethral injury.
Although penile fractures can be managed conservatively, a literature review supports surgical fixation as the preferred treatment method. If there is associated urethral injury, surgical fixation is required. The most-reported postoperative complication is sexual dysfunction.
Erectile dysfunction can be common as there are vascular anomalies of the arterial and venous systems. Reports show that approximately 50% of patients will have anomalies on penile duplex ultrasound one year from surgical correction of a penile fracture.
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