Presentation, Management and Outcome of Penile Fractures in a Nigerian Tertiary Hospital

Agbugui JO, Obarisiagbon EO, Osaigbovo EO, Okolo JC, Okojie CI

Department of surgery, University of Benin Tteaching Hospital

Correspondence to: Dr Agbugui JO, E mail: orumuah@yahoo.com

ABSTRACT

Background

Penile fracture is a relatively rare acquired urologic condition which may occur following blunt trauma to an erect penis. The aim of the study is to review the presentation, management and outcome of penile fractures in a tertiary hospital in Nigeria over a 7 year period.

 

Patient and Methods

Medical records of 6 patients with diagnosis of penile fracture seen over a 7 year period were retrieved and information regarding the aaetiology, mode of presentation, treatment, outcome and follow up were recorded.

 

Results

The mean age of the patients was 32.3 years. Blunt trauma during sexual intercourse was the mechanism of trauma in 5 patients. In one patient it was due to abrupt bending of an erect penis against tight underwear during foreplay. The mean time interval before presentation was 22 hours. All patients presented with the classical symptoms of penile pain, swelling and detumescence. All patients had immediate penile exploration and repair of tunica albuginea via a circumferential sub- coronal incision. The mean period of follow up after repair was 9.3 weeks. Penile erection and sexual function were satisfactory in all patients following repair. Complications noted included mild pain at the site of repair during sexual intercourse in 1 patient and mild lateral deviation in another.

 

Conclusion

Penile fracture was a rare condition in this centre during the period. The immediate outcome of the repair of penile fracture is satisfactory. Long term follow up is needed to further evaluate patients with this condition.

 

Key words: Penile fracture, Tunica Albuginea, Repair, Outcome

Introduction

Penile fracture is a rare urologic condition which occurs when there is a tear in the tunica albuginea covering the corpora cavernosa as a result of blunt trauma to an erect penis (1,2). It occurs usually during vigorous sexual intercourse when the erect penis is thrust against the pubic bone or perineum of the partner. Other reported mechanisms of injury include falling on an erect penis, rolling over on an erect penis during sleep, masturbation and other forms of penile manipulation (2,3,4). The thinning out of the tunica albuginea from 2mm to 0.25 – 0.5mm during erection puts it at risk of rupture with a sudden increase in intracorporeal pressure(5). Previous studies have proposed that an intra cavernosal pressure of 1500mmHg and above during erection can result in rupture of the tunica albuginea (5,6).

The penis consists of two corpora cavenosa and a corpus spongiosum, which contains the urethra. The corpora are capped distally by the glans. A fascial sheath, the tunica albuginea encloses each corpus while a thick envelope, the Buck’s fascia surrounds the corporeal bodies. A loose covering of skin devoid of fat is applied around the above structures. Beneath the skin of the penis, the Colle’s fascia extends from the base of the glans to the urogenital diaphragm and continues as the Scarpa’s fascia of the anterior abdominal wall. Proximally, the corpora cavernosa are attached to the pelvic bones just anterior to the ischial tuberosities while in the midline the corpus spongiosum is attached to the under surface of the urogenital diaghragm through which emerges the membranous urethra. The suspensory ligament of the penis which arises from the linea alba and pubic symphysis inserts into the fascial covering of the corpus cavernosa(7). The pathological lesion of penile fracture consists of a tear in the tunica albuginea resulting in penile hematoma, swelling and skin discolouration. The hematoma is limited to the penile shaft if the Buck’s fascia over the tunica albuginea is intact. An associated tear of this fascia results in perineal and scrotal ecchymosis limited only by the Colle’s fascia(2,8). The classical presentation consists of a cracking sound followed by pain, rapid detumescence and penile swelling (3,4,8). Urethral injury may be associated with the condition in up to 30% of cases(8). Diagnosis is usually based on the history and physical examination. However, radiological investigations such as ultrasonography, caversonography and magnetic resonance imaging may be required to establish a diagnosis in the few equivocal cases. Differential diagnosis of penile fracture includes rupture of the deep dorsal vein/artery which lies between the buck’s fascia and tunica albuginea as well rupture of the suspensory ligament of the penis which results in deviation or ‘dislocation’ of the penis, with or without hematoma (10,11). Prompt surgical exploration and repair of the tunica albuginea is advocated for restoration of normal penile erection and sexual activity. Delayed surgical intervention and non operative treatment alternatives carries a higher risk of post traumatic curvatures and erectile dysfunction(2-6).

 

The study reports on the presentation, management and outcome of 6 cases of penile fracture managed by 4 urologists over a 7 year period in a tertiary hospital in Nigeria.

 

Patients and Methods

Case files of 6 patients with a diagnosis of penile fracture managed in the urology unit of the University of Benin Teaching Hospital, Nigeria over a 7 year period (between February 2005 and January 2012) were retrieved from the medical records department. Clearance was obtained from the Hospital’s Ethical committee prior to commencement of the study. The patients were referred to the urology unit via the accident and emergency department during the period. Information relating to the mechanism of injury, clinical presentation, operative findings, repair and outcome of repair during follow up was recorded.

RESULTS

The patients’ age at the time of presentation ranged between 20 and 55 years with a mean of 32.33 ±11.08 years. Five out of the 6 patients sustained penile fracture during sexual intercourse, while in one case it was due to forceful and abrupt bending of the erect penis against tight underwear during foreplay. Two out of the 6 patients were married while 4 were unmarried. Out of the 5 patients who sustained penile fracture during intercourse, 2 were from the ‘woman on top’ position, 2 from the ‘rear’ position and 1 from the ‘missionary’ position. The mean interval before presentation was 22 hours (range, 3-48 hours). All patients described the classical cracking sound followed by pain, swelling and rapid detumescence (FigThe 1)diagnosisagnosis.Theofpenileofpenilefracturefracturewaswasmade in all cases based on history and physical examination without the need for additional investigations. One patient gave a wrong initial history on presentation but later revealed the true mechanism of injury when seen by the urology unit. The proximal penile shaft was the area involved in all cases. The patients had unilateral corporeal tears with the right side affected in 2 cases, left side in 1 while in 3 cases the affected corporeal body was not recorded. All the patients had surgical repair of the tunica albuginea with a mean operative time of 65 minutes. Penile exploration involved degloving of the penis down to the site of injury and repair of tunica albuginea with continuous absorbable sutures (vicryl 3/0) via a circumferential sub coronal incision under regional anaesthesia in the six cases (Fig. 1)2).. They all had intra-operative erection induced with intracavernosal saline injection to assess the integrity of the tunica albuginea repair. Foley’s catheter that was routinely inserted intra-operatively to prevent iatrogenic injury to the urethra was removed within two days of repair in all cases. The pe