Penile Fracture

A 34-year-old man came to the emergency department after a mishap during sexual intercourse resulted in a cracking sound in his penis with immediate pain and loss of erection. He had no significant medical history. The patient was in moderate physical pain but severe emotional distress. Vital signs were normal. Examination of the penis showed 2 areas of ecchymosis and swelling. Mild swelling affected the shaft, which was abnormally twisted. There was no meatal blood; testicles appeared normal and were nontender. Dr D. Brady Pregerson of Los Angeles made a clinical diagnosis of acute penile fracture. A urologist was consulted. The patient was able to urinate without evidence of macroscopic blood. Emergent surgical repair was performed. Penile fracture usually occurs during sexual intercourse or from a fall onto an erect penis. A tear in the tunica albuginea corporum cavernosorum results in pain, swelling, angulation, ecchymosis, and detumescence. About 25% of patients have a concomitant urethral injury, which may present with blood at the meatus, hematuria, dysuria, urinary retention, or increased swelling after attempted urination. Initial care of the fracture consists of application of ice; insertion of a Foley catheter, when there is no urethral injury; and possibly, splinting with 2 tongue blades. Urethral injuries may require suprapubic cystotomy and retrograde urethrographic evaluation. The differential diagnosis of penile fracture includes contusion, paraphimosis, cellulitis, and vascular injury. Immediate surgical intervention is usually needed in patients with an obvious fracture; in equivocal cases, cavernosonography and MRI may be elucidating. Early operative care can minimize complications of penile fracture, such as impotence, deformity, and urethral stenosis.