Suspected penile fracture: to operate or not to operate?

tau.amegroups.com © Translational Andrology and Urology. All rights reserved. Distinguishing penile ecchymosis from a true penile fracture, or a rupture through the tunical albuginea, can be a challenging clinical conundrum. A penile fracture typically occurs in the setting of blunt penile trauma to the erect penis, most often during sexual intercourse or masturbation. The characteristic symptoms of penile fracture are a “snapping” or “popping” sound, penile pain, and immediate detumescence followed by ecchymosis and swelling of the penile shaft (1). Physical examination findings may vary significantly in patients with a history suggestive of penile fracture, and the severity of the penile ecchymosis frequently does not correlate with the presence or absence of tunical rupture. History and physical examination may be inaccurate in 15% of patients with a suspected penile fracture (2). This clinical picture can be even more confusing if the patient received collagenase clostridium histolyticum (CCH) in the days or weeks prior to presentation. In recent years, the increasing use of CCH for Peyronie’s disease has resulted in an upsurge in the number of patients presenting to urgent care with a history suggestive of penile fracture and significant penile edema and ecchymosis. Penile fracture is considered an urgent urologic condition that requires timely repair to prevent long-term complications of corporal fibrosis, penile curvature, chronic pain, and erectile dysfunction (3). Concomitant urethral injury occurs in 10–25% of cases and can result in bleeding from the urethra or voiding difficulty (4). If the fracture decompresses through the urethra, the findings on physical examination are typically relatively benign. Rapid operative repair of the corporal injury and urethral injury, if present, is associated with a lower risk of permanent erectile dysfunction and wound-healing complications (5). On the other hand, penile ecchymosis or hematoma secondary to rupture of the superficial vessels of the penis is not a surgical emergency and may be managed conservatively without any longterm detriment to the patient. Differentiating these clinical scenarios is critical to making the correct management decision, and physical examination alone may not be sufficient. Informed consent was obtained from all patients prior to publication of these case reports and accompanying images. Figure 1 depicts the presentation, with impressive physical exam, of a 52-year-old-male with a history of Peyronie’s disease and CCH injection 2 weeks prior to presentation. This patient has both a history convincing for penile fracture and an impressive physical exam with severe ecchymosis and edema of the penis. However, in the setting of CCH injection, he was also at high risk for superficial penile hematoma without corporal rupture. Penile ultrasound (US) performed at the bedside revealed a subcutaneous hematoma with an intact tunica albuginea (TA) and no intracavernous hematoma. Conservative treatment was recommended with loose compression dressings for 7 days and abstinence from intercourse until ecchymosis resolved. His ecchymosis was completely resolved and normal erections returned after 3 weeks. To augment the diagnostic evaluation of severe penile ecchymosis and to avoid unnecessary penile surgery and the subsequent associated morbidity, various imaging modalities, such as magnetic resonance imaging (MRI), retrograde urethrography (RUG), cavernosography, and US have been utilized. MRI has high sensitivity for soft tissue and is effective in detecting disruption of the TA (6). However, cost, time, and availability are all obstacles to its use in the routine evaluation of penile trauma (7). RUG should be performed if there is any suspicion of urethral injury, and if positive, the patient should be taken for penile exploration and surgical repair. RUG is sensitive, low cost, familiar, and readily available. Nonetheless, it does not Editorial