Current Management of Penile Fracture: An Up-to-Date Systematic Review

Complications after surgical correction of penile fractures-Is there a clinical impact?

BACKGROUND

Surgical exploration and closure of the tunica albuginea is the recommended treatment for penile fractures. The recovery of sexual function is the main result that surgeons and patients pursue.

OBJECTIVE

We sought to evaluate the sexual health effects of a surgically corrected penile fracture. Secondarily, we sought to identify risk factors that may influence long-term sexual function and their effects on genital body image satisfaction.

METHODS

A retrospective analysis of patients who underwent surgical correction of penile fractures between 2007 and 2022 in a tertiary center was performed. Lesion characteristics, weeks until the resumption of sexual activity, and post-operative sexual function were recorded. The presence of glans hypoesthesia, penile deformation, penile nodule palpation, and self-satisfaction with body image were assessed.

RESULTS

Sixty-nine patients with a mean age of 42.30 ± 12.98 years and a median follow-up of 70 (20-134) months were identified. Sexual intercourse was recorded as a percentage. Penile deformation was the most common complication, appearing in 14.5% of patients, erectile dysfunction in 5.8%, penile nodules in 4.3%, and glans hypoesthesia in 2.9%. The median post-operative International Index of Erectile Function-5 was 24 (21.5-24). Self-satisfaction with body image had a median of 9 and was negatively associated with bilateral lesions and penile deformation.

DISCUSSION AND CONCLUSION

Distal fractures could be linked to erectile dysfunction and glans hypoesthesia. Surgical correction of penile fractures shows positive functional and self-reported outcomes, and the potential andrological complications rarely necessitate specific treatment.

Surgical management and post-operative functional outcomes of patients with a penile fracture-a single centre experience over 10 years

BACKGROUND

Penile fractures are uncommon urological emergencies which occur when there has been a breach in the tunica albuginea of the corpora cavernosum that may be unilateral and bilateral and can extend to involve the urethra.

AIM

To assess the management and outcomes of penile fractures in a single institution in Ireland.

METHODS

A retrospective review of the emergency theatre logbooks was performed between 2011 and 2021 to identify patients who had undergone an exploration for a suspected penile fracture.

OUTCOMES

Seventeen patients were initially identified on review of theatre logbooks as having an exploration for a suspected penile fracture. Two patients were excluded from the study due to a lack of clinical notes being available. A further 4 patients on chart review were found to not have a penile fracture at exploration.

RESULTS

Eleven patients had a confirmed penile fracture intra-operatively, four of whom had an associated urethral injury. Nine (9/11) patients had preserved normal erections post-operatively documented on follow-up; two, however, reported erectile dysfunction requiring phosphodiesterase inhibitors.

CLINICAL IMPLICATIONS

Our study supports urgent surgical exploration for penile fractures to ensure good functional outcomes.

STRENGTHS AND LIMITATIONS

This is a retrospective review of theatre logbooks to identify patients with a suspected penile fracture.

CONCLUSION

The results of our cohort show a good outcome of erectile function following surgical repair of a penile fracture (9/11; 82%). Four patients (4/11; 36%) had a urethral injury diagnosed intra-operatively, one of whom required a formal urethroplasty.

A review of the literature and proposed algorithm for penile fracture management

INTRODUCTION

In the management of penile fractures, immediate surgical repair has resulted in better outcomes when compared with a conservative approach; however, there is currently no consensus on the treatment of patients presenting beyond the immediate period (>24 hours) following injury.

OBJECTIVES

To examine the latest literature on management strategies in penile fracture and propose an optimal algorithm for the treatment of patients with delayed presentation.

METHODS

A comprehensive search was conducted following the PRISMA-P 2020 guidelines. A search was performed in several databases with the following strategy: ("Penile fracture" OR "fracture of penis" OR "rupture of corpora cavernosa" OR "rupture of tunica albuginea") AND (management OR treatment OR surgery OR "surgical reconstruction" OR "surgical repair"). This resulted in 108 relevant articles. Two independent reviewers screened these articles according to the inclusion criteria. Full-text review of 56 articles was performed, and ultimately 20 studies were selected. Measures included the use of diagnostic imaging, timing of surgical repair (immediate, <24 hours after injury; delayed, >24 hours), surgical approach, and long-term complications (ie, erectile dysfunction and penile curvature).

RESULTS

The review highlighted the benefits of immediate surgical repair in penile fractures, demonstrating improved patient outcomes. Furthermore, it found that surgical repair should be considered even in cases with delayed presentation (>24 hours after injury). To better evaluate the long-term impact of delayed surgical intervention on patient outcomes, we recommend standardized postoperative follow-up, with routine assessments of erectile function and penile curvature.

CONCLUSION

Contemporary literature suggests that immediate and delayed surgical repair of penile fractures leads to adequate postoperative outcomes, and patients presenting >24 hours after injury should still be considered for surgery.

Penile fractures: the price of a merry Christmas

OBJECTIVES

To explore whether Christmas might be a risk factor for penile fractures due to the Christmas spirit related to the intimacy and euphoria of these holly jolly days.

PATIENTS AND METHODS

We evaluated the incidence of penile fractures during Christmas and New Year's Eve through the GeRmAn Nationwide inpatient Data (GRAND) from the Research Data Center of the Federal Bureau of Statistics (Wiesbaden, Germany). Furthermore, we assessed the impact of COVID-19 on penile fractures and their seasonality.

RESULTS

A total of 3,421 patients with a median, interquartile range (IQR) age of 42 (32-51) years had a penile fracture requiring a hospital stay from 2005 to 2021. In all, 40 (1.2%) penile fractures occurred in 51 days of Christmas (from 24/12 to 26/12 in each year). The daily incidence of penile fractures during Christmas was 0.78 with an incidence rate ratio (IRR) of 1.43 (95% confidence interval [CI] 1.05-1.95, P = 0.02). If every day was like Christmas, 43% more penile fractures would have occurred in Germany from 2005 on. Interestingly, only 28 (0.82%) penile fractures occurred during the New Year's Eve period (31/12 to 02/01 from 2005 to 2021). This resulted in an IRR of 0.98 (95% CI 0.69-1.5, P = 0.98) in the New Year's Eve period. Most patients with penile fractures were admitted to hospital at the weekend (n = 1,322; IRR 1.58, 95% CI 1.48-1.69; P < 0.001). Summer was also associated with more penile fractures (n = 929; IRR 1.11, 95% CI 1.03-1.19; P = 0.008). Both the COVID-19 pandemic (n = 385; IRR 1.06, 95% CI 0.95-1.18, P = 0.29) and its lockdown period (n = 93; IRR 1, 95% CI 0.82-1.23; P = 0.96) did not affect the incidence of penile fractures.

CONCLUSION

The incidence of penile fractures displays a seasonality. Last Christmas penile fractures occurred more often. This year to save us from tears, we will NOT do something special (the new Christmas hit of the year).

Penile fracture: a case series of 18 patients

Introduction

Penile fractures are a rare urological emergency. It is defined as 'rupture of the tunica albuginea of one or both corpora cavernosa. The corpus spongiosum and the urethra may also be involved in this process.' The tunica albuginea is stiff and significantly thinner during erection than in the flaccid state, which is when injury generally happens.

Method

This case series was completed between January 2018 and January 2023 at the Department of General Surgery. Eighteen patients suspected of having penile fractures participated in were included this study. All patients were thoroughly evaluated upon hospital admission to identify the diagnosis, length of time since the accident, the site of the fracture, the extent of the penile hematoma, occurrence of blood at the external meatus, presence of urine retention, and intraoperative outcomes.

Results

The patients were between the ages of 24 and 70, with a mean age of 37. The duration before the presentation ranged from 7 h to 1 month (the median was 22 h). Sexual intercourse was the cause in 12 (66%) cases, rolling in the bed in three cases (16%), and blunt trauma in three cases (kicking and the edge of the bed) (16%). Pain and swelling were present in all of the patients. In 15 patients (or 83%), there was evidence of penile deviation. At presentation, 15 (72%) patients reported experiencing rapid detumescence, discomfort, and penile swelling after hearing a cracking (popping) sound. None of these individuals experienced urine retention or urethral hemorrhage, and all were emptied on their own following the episode. Physical examination showed penile ecchymosis, swelling, and substantial discomfort when the penile shaft was examined. All but three patients had an evident penile deformity. Surgery was performed under spinal anesthesia in 14 (77.7%) patients. Four patients with a delayed presentation (more than 1 week) were managed conservatively.

Conclusion

As a true urologic emergency, penile fractures should be treated immediately to reduce pain and swelling and ensure better functional and esthetic outcomes. Despite taking more time, a subcoronal circumcising degloving incision is the ideal method because it is exploratory and esthetically pleasing.

Summary Paper of the Updated 2023 European Association of Urology Guidelines on Urological Trauma

CONTEXT

The European Association of Urology (EAU) Guidelines Panel for Urological Trauma has produced guidelines in order to assist medical professionals in the management of urological trauma in adults for the past 20 yr. It must be emphasised that clinical guidelines present the best evidence available to the experts, but following guideline recommendations will not necessarily result in the best outcome. Guidelines can never replace clinical expertise when making treatment decisions for individual patients regarding other parameters such as experience and available facilities. Guidelines are not mandates and do not purport to be a legal standard of care.

OBJECTIVE

To present a summary of the 2023 version of the EAU guidelines on the management of urological trauma.

EVIDENCE ACQUISITION

A systematic literature search was conducted from 1966 to 2022, and articles with the highest certainty evidence were selected. It is important to note that due to its nature, genitourinary trauma literature still relies heavily on expert opinion and retrospective series.

EVIDENCE SYNTHESIS

Databases searched included Medline, EMBASE, and the Cochrane Libraries, covering a time frame between May 1, 2021 and April 29, 2022. A total of 1236 unique records were identified, retrieved, and screened for relevance.

CONCLUSIONS

The guidelines provide an evidence-based approach for the management of urological trauma.

PATIENT SUMMARY

Trauma is a serious public health problem with significant social and economic costs. Urological trauma is common; traffic accidents, falls, intrapersonal violence, and iatrogenic injuries are the main causes. Developments in technology, continuous training of medical professionals, and improved care of polytrauma patients reduce morbidity and maximise the opportunity for quick recovery.

A penile fracture hidden behind a urethral bleeding

Penile fracture with urethral injury is uncommon. Diagnosis is usually based on clinical history and physical examination. Nonetheless, atypical presentation obliges complementary examinations to be performed. We report a case of a 45-years-old man with urethral bleeding after a blunt penile trauma that was ultimately diagnosed as having a cavernous body laceration on top of an urethral rupture.

Immediately repaired penile fractures: age is the only predictor of postoperative long-term functional outcomes

Background

Penile fractures can lead to many functional complications, especially erectile dysfunction (ED). Few studies have evaluated the factors that predict late complications of an immediately repaired penile fracture.

Aim

To identify the potential predictors of long-term poor functional outcomes following immediate surgical intervention for penile fractures.

Methods

Sixty-eight consecutive patients with suspected penile fracture between 2003 and 2022 were retrospectively reviewed. Functional outcomes, postoperative complications, and follow-up duration were obtained from the records of follow-up visits. Age at presentation, location and length of the tunical tear, the presence of urethral rupture, and time to surgery were all analyzed as potential risk factors for postoperative functional outcomes.

Outcomes

Postoperative erectile function and intercourse satisfaction were measured by the IIEF-5 (the 5-item version of the International Index of Erectile Function). Penile curvature, a palpable nodule, and paresthesia/numbness were detected by physical examination. Uroflowmetry was used to assess urinary flow in patients who underwent urethral repair.

Results

Fifty-eight patients were analyzed. The mean ± SD age was 38.1 ± 10.4 years; the median follow-up was 79.0 months (range, 13-180); the median time to surgery was 9.8 hours (4-30); and the median tunical tear length was 15.5 mm (4-40). Urethral rupture was observed in 8 patients (13.8%). In univariable analyses, urethral rupture was associated with postoperative complications (P = .034). In addition, age at presentation and tunical tear size were significantly associated with postoperative complications and ED (P < .05). However, in multivariable analyses, only age at presentation significantly predicted postoperative complications and ED (P = .004 and P = .037).

Clinical Implications

Age at presentation is the most important factor determining the prognosis of immediate surgical repair of the penile fracture, which aids in predicting potential complications and discussing them with patients prior to surgical intervention and during the follow-up period.

Strengths and Limitations

The study's retrospective design is an important limitation. Furthermore, there were no data on an IIEF-5 outcome measuring preoperative erectile function.

Conclusion

These results revealed an association between (1) urethral rupture, longer tunical tears, and older age and (2) the development of late complications. The remarkable finding of this study was that age at presentation was the only significant predictor of functional complications based on multivariable analyses. This relationship also remained robust in tests evaluating the covariance of the effects of aging on ED.

Outcomes of Surgical Exploration of Acute Scrotal Pain Raising Suspicion of Testicular Torsion

Background and objective Testicular torsion (TT) is a surgical emergency, affecting approximately one in every 4000 males under the age of 25 years annually in the United States. In this study, we aimed to determine the outcomes of emergency scrotal surgical exploration of cases that raised suspicion of TT presenting to Salmaniya Medical Complex (SMC), Bahrain's largest secondary and tertiary care center. Methods This was a retrospective cohort study. The data were collected from the hospital's electronic medical record software (I-SEHA). The data included patient age, Doppler ultrasound (DUS) findings prior to any surgical procedure, type of surgical procedure, and the surgical findings of that procedure. Results Of the 198 patients who underwent scrotal exploration, 141 had presented with signs and symptoms suggestive of TT. The mean age of the patients was 22.3 ±9.3 years. Doppler imaging was performed preoperatively on 135 out of 141 (95.7%) patients. After scrotal exploration, 91.4% of the patients were found to have TT. The proportion of patients with salvageable testis was 78.7%. Conclusions The study found that surgical exploration remains the definitive method in the management of acute scrotum in TT patients. Our findings are in line with those from other similar studies and meta-analyses.

Urethral rupture concomitant with penile fracture does not adversely affect functional outcomes

INTRODUCTION

The aim of this study was to identify possible risk factors for urethral rupture and to evaluate the effect of urethral rupture repair on long-term functional outcomes and complications.

MATERIALS AND METHODS

The medical records of consecutive penile fracture patients were retrospectively reviewed. Penile fracture patients with and without urethral rupture were compared according to demographics, clinical and intraoperative findings. Comparisons of postoperative functional results of the groups were performed using the 5-item version of the International Index of Erectile Function (IIEF-5) and the International Prostate Symptom Score (IPSS). Finally, among them, long-term penile complications including penile curvature, painful erection, palpable nodule, and paresthesia were assessed.

RESULTS

Fifty-three patients participated. Patients with urethral rupture (n = 8) were older (44.50 ± 10.69, 36.58 ± 10.33 years, p = 0.052). There was no significant difference in fracture etiology (p = 0.64). Urethral bleeding was present only in patients with urethral rupture (p < 0.001). Although no bilateral corpus cavernosum rupture was encountered in penile fracture patients without urethral rupture, this rate was significantly higher in those with urethral rupture at a rate of 62.5% (p < 0.001). The time from surgical repair to sexual activity was similar in both groups (p = 0.66). There was no significant difference in IPSS and IIEF-5 scores, the presence of erectile dysfunction and complication rates (p > 0.05).

CONCLUSIONS

Older age is a possible risk factor for a concomitant urethral rupture with penile fracture and it seems to be associated with urethral bleeding and bilateral corpus cavernosum involvement. Additionally, urethral rupture repair neither adversely affected functional outcomes nor increased penile complication rates.

Isolated rupture of the corpus spongiosum with urethral injury diagnosed by pre-surgical MRI

Introduction

Penile fracture is typically defined as the rupture of the corpus cavernosum.

Case presentation

A 61-year-old man presented with swelling, pain, and bruising of his penis, along with gross hematuria. He reported that he sustained this injury while having sex with his wife. We suspected a penile fracture and obtained magnetic resonance imaging, which showed a rupture of the ventral corpus spongiosum and clarified the appropriate approach for repair. We used a direct transverse incision to repair both the urethral injury and the corpus spongiosum. Surgery went well, without any significant intraoperative or postoperative complications. We removed the urinary catheter on postoperative day 8, and cystoscopy showed no urethral stenosis on postoperative day 17. The patient's postoperative erectile function was the same as before his injury.

Conclusion

Magnetic resonance imaging was useful for detect the site of rupture. Ventral direct transverce incision made him a good clinical course.

Consequences of penile fracture: Complications and long-term functional outcomes

INTRODUCTION

Penile fracture (PF) is a urological emergency with low incidence, and evidence of its long-term outcomes is scarce. This study focuses on postoperative complications and long-term functional outcomes in patients with PF and surgical repair at our center.

MATERIALS AND METHOD

Clinical records of patients undergoing urgent surgery for PF at a third level hospital between 2006 and 2020 were retrospectively reviewed. Functional outcomes were assessed with voluntary telephone interviews from June 2020 to February 2021. Lower urinary tract symptoms were screened by IPSS questionnaire, sexual function by EHS and IIEF-5 and morphological alterations by direct questions to patients.

RESULTS

A total of 41 patients underwent surgery for PF. Eleven of them also had urethral injury (higher incidence if there was bilateral corpora cavernosa injury, 19.4% vs. 80%, p < 0.05). Only 1 patient presented a Clavien-Dindo type 3a complication due to wound dehiscence, 4 (13%) type 2 and 9 (29%) type 1. Twenty-four patients underwent long-term follow-up, of whom 20 (83.3%) presented normal sexual function. Twelve patients (50%) had a palpable nodule at the fracture site, 8 (33.3%) had new onset penile curvature and 1 patient with previous urethral injury presented urethral stricture.

CONCLUSION

In cases of penile fracture, there is a higher incidence of urethral injury if both corpora cavernosa are affected. Long-term functional sequelae after surgical repair of a PF are rare.

Long term complications of penile fracture repair: Erectile dysfunction and penile curvature

OBJECTIVE

To determine the factors that cause erectile dysfunction and penile curvature after repair of penile fracture (PF).

METHODS

Data from 25 patients who underwent PF repair was retrospectively analyzed. PF was diagnosed by examining patients' medical histories and performing physical examinations. All patients underwent immediate PF repair. All patients filled out the International Index of Erectile Function (IIEF-5) form and penile curvature was examined.

RESULTS

The median age of patients at the time of surgery and the median follow-up duration were 46 years (22-60 years) and 95 months (12-156 months), respectively. Two of the patients had concomitant urethral injury. At the final follow up, erectile dysfunction (ED) was present in 13 patients (52%). Among these patients, 9 patients (36%) had mild ED and 4 patients (16%) had moderate ED. With a univariate analysis, age and penile curvature were significantly associated with ED (p=0.008 and p=0.039, respectively). With a multivariate analysis, age was independently associated with ED (p=0.048, odds ratio=1.104, 95% confidence interval 1.000-1.218). The IIEF-5 scores correlated with age (p=0.009, r=0.510). Seven patients (28%) had penile curvature and one patient underwent penile plication surgery.

CONCLUSION

After PF repair, age is the only risk factor for ED and penile curvature rarely requires surgical treatment.

Penile fracture with urethral rupture: The feasibility of repair through penoscrotal approach

Penile fracture with an associated urethral injury is a rare urological emergency resulting from trauma to the erect penis during vigorous sexual intercourse. The patient often presents with swelling of the penis, discoloration of the penile skin, localized pain, and hematuria with a typical history of sudden detumescence during intercourse. Subcoronal penile degloving incision has been conventionally described and is frequently used by many clinicians for the management of penile fracture-urethral injury. Here, we describe a case of complex penile fracture managed through the vertical penoscrotal incision. The penoscrotal approach confers excellent exposure to both the ruptured corpus cavernosum and urethra. This approach ensures successful outcomes in such an emergency procedure without having disadvantages of the degloving incision.

Penile Fractures: Evaluation and Management

Penile fracture is a urologic injury with an etiology that varies based on the cultural milieu. Diagnosis can be made based on history and physical examination alone. Patients should be evaluated with RUG or cystoscopy when urethral injury is suspected. Ultrasound or MRI is a helpful adjunct when the diagnosis is unclear, and can assist in identifying the location of the rupture. Surgical management is favored over conservative measures to improve outcomes. Delayed surgical repair may not be inferior to immediate intervention.

Bilateral Corpus Cavernosum and Complete Urethral Rupture: A Double Trouble

Penile fracture is a rare urologic emergency. The main finding is a partial disruption of one or both cavernosal bodies due to blunt trauma of the penis during an erection. Complete or partial injury of the urethra may accompany the penile fracture but complete urethral rupture is rarely encountered. In this study, we present the management of a penile fracture case with disruption of both corpus cavernosum with total urethral rupture.

European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease

OBJECTIVE

To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of male urethral stricture disease.

EVIDENCE ACQUISITION

The panel performed a literature review on these topics covering a time frame between 2008 and 2018, and used predefined inclusion and exclusion criteria for the literature to be selected. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on a review of the available literature and after panel discussion.

EVIDENCE SYNTHESIS

Management of male urethral strictures has extensively been described in literature. Nevertheless, few well-designed studies providing high level of evidence are available. In well-resourced countries, iatrogenic injury to the urethra is one of the most common causes of strictures. Asymptomatic strictures do not always need active treatment. Endoluminal treatments can be used for short, nonobliterative strictures at the bulbar and posterior urethra as first-line treatment. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques, and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates.

CONCLUSIONS

Management of male urethral strictures is complex, and a multitude of techniques are available. Selection of the appropriate technique is crucial, and these guidelines provide relevant recommendations.

PATIENT SUMMARY

Injury to the urethra by medical interventions is one of the most common reasons of male urethral stricture disease in well-resourced countries. Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. These guidelines, developed based on an extensive literature review, aim to guide physicians in the selection of the appropriate technique(s) to treat a specific type of urethral stricture.

Complete urethral injury in the penile fracture: a case report and literature review

Penile fracture is described as a traumatic rupture of the tunica albuginea caused by blunt injury to the erect penis. It usually occurs as a single rupture of the tunica albuginea in one of two corpora cavernosa; a rupture with urethral injury is an extremely rare condition. Although its diagnosis is usually clinical, ultrasound plays an important role in confirming diagnosis and identifying the site of the injury. Here, we presented a case of penile fracture with complete urethral injury. A 43-year-old male was admitted to the hospital because of trauma to the genital and dysuria following sexual intercourse. After admission, the patient was diagnosed with double penile fracture and complete urethral injury after the physical and B-ultrasound examinations. Emergency surgery to remove the hematoma and repair the urethra was performed. The patient recovered smoothly and was discharged on the third day after operation. After two months’ follow-up, the patient urinated smoothly and achieved an adequate erection without other complications. In this case, consistent with previous studies, emergency surgery for penile fracture is necessary and can preserve the urethral function and sexual function. In addition, there are two lesions in tunica albuginea in this case, so careful search for the penile shaft during the surgery is important to avoid the missed injuries. This report provides evidence of an uncommon and underreported clinical case.

A Modified Endoscopic Primary Realignment of Severe Bulbar Urethral Injury

Purpose: Male urethral injury is a common urologic emergency in developing countries. Whether early or late treatment of urethral injuries is often multifactorial and controversial. The goal of this study is to determine whether early realignment can reduce postsurgical complications and evaluate the clinical feasibility of emergency endoscopic urethroplasty using single rigid ureteroscopy in the treatment of bulbar urethral severe injury. Patients and Methods: Between September 2013 and March 2019, 15 male adult patients (mean age 35 years; from 21 to 62 years) with severe bulbar urethral injury were enrolled into the current study. The patients mainly presented with dysuria or painful urination (15/15, 100%), urethral bleeding (13/15, 86.7%), and urinary retention (11/15, 73.3%). Six of them had swelling of perineal or scrotal soft tissue, while four had testicular contusion. No pelvic fracture was found in all cases with CT scanning of the pelvic cavity. The bulbar urethral at grade IV was confirmed to be completely ruptured in all cases by endoscopy during operation. The modified endoscopic primary realignment was performed. Results: This new urethral repair technique was effectively performed in all patients and none converted to open operation. Mean operation time was 42.3 ± 11.5 minutes (28-52 minutes) and the mean Foley catheter indwelling time was 34.5 ± 6.9 days (28-42 days). During a follow-up of 41.3 ± 22.8 months (12-64 months), mild urethral strictures (grade I) (19.7 ± 9.5 weeks, 10-27 weeks postsurgery) developed in 8 patients (53.3%) and then were all improved 2.1 ± 0.8 months (1.3-2.9 months) after periodic dilatations of the urethra (4-10 times). Erectile dysfunction (ED) occurred in three patients (20%) after surgery, who recovered from mild ED to normal by administration with oral sildenafil (100 mg, three times a week) for 12 weeks. The International Index of Erectile Function-5 (IIEF-5) score was significantly improved after surgery (M ± SD, 25 ± 3) compared with before (16.4 ± 3.5) (p < 0.05). No incontinence and other complications occurred in all cases. Conclusions: Early endoscopic realignment via suprapubic puncture cystostomy by single rigid ureteroscopy provides an effective, feasible, and safe procedure for severe bulbar urethral injury.

The Management of Penile Fracture: a Review of the Literature with Special Consideration for Patients Undergoing Collagenase Clostridium Histolyticum Injection Therapy

PURPOSE OF REVIEW

To review the current literature on acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie's disease.

RECENT FINDINGS

The immediate repair of traumatic penile fracture injury is associated with significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury. Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.

Repair of urethral injury associated with penile fracture using buccal mucosa graft: A novel therapeutic approach for complex cases

Penile fracture is a rare urological emergency caused by blunt trauma to the erect penis and it may be accompanied by urethral injury. Complete urethral rupture is very uncommon and is usually managed by primary anastomosis. However, these patients are more likely to develop post-operative complications such as urethral strictures. Buccal mucosa graft is commonly used for substitution urethroplasty in management of urethral strictures, but its use has not been reported for immediate treatment in the setting of penile fracture. We report a patient with rupture of both corpora cavernosa, as well as the rupture of the urethra, after sexual intercourse. Buccal mucosa graft was used for surgical repair of urethral injury. At 36-month follow-up patient did not experience erectile or voiding problems. The application of this technique could possibly reduce the incidence of urethral strictures in these patients and further prospective studies with larger samples should be conducted.

Penile fracture in a Peyronie’s disease patient: a case report

Background

Penile curvature in men with Peyronie’s disease (PD)—caused by tunica anchoring plaques with loss of focal fiber elasticity—theoretically increases the risk of penile fracture during sexual activity. Penile fracture is the result of tearing of the tunica albuginea of one or both corpora cavernosa, usually during sexual intercourse, and is among the most serious urological emergencies. Generally, a patient presented to a surgical emergency within 48 h of injury can be handled successfully with minimum complications. Immediate surgical treatment is the current standard of care and has a relatively low risk of late complications.

Case presentation

We present a case of penile fracture in a male with a history of PD referred to the emergency department with severe pain. Clinical history assessment and physical examination revealed a penile fracture with underlying PD. He underwent emergency surgical exploration via subcoronal incision. Penile plication was not necessary for our case because the angulation of the penis was less than 15° after examination of artificial erection.

Conclusion

Penile fracture in a patient with underlying PD is a rare urological emergency that should be treated surgically with fracture repair as early as possible. Penile plication might be necessary in severe cases (angulation > 60°).

Penile Fracture during masturbation - a case report

Penile fracture is a well-recognized but uncommon urological emergency. It is a tear in the tunica albuginea with rupture of corpus cavernosum. It may be associated with injury to corpus spongiosum and urethra. Diagnosis is usually clinical and Urethral injury should be suspected in penile fracture, especially in those cases with urethral bleeding and bilateral cavernosal rupture. Penile fracture is most commonly caused by injury during sexual intercourse. It has also been described with masturbation, rolling over or falling onto the erect penis, and other scenarios. A cracking or popping sound followed by pain, rapid detumescence, discoloration and swelling of penile shaft and urethral bleeding are common presenting symptoms. Prompt surgical intervention with closure of tunica albuginea is the treatment of choice with satisfactory cosmetic and functional results. We report a case of fracture penis in a 25-year-old male who came to emergency department of our hospital.

A case of traumatic penile fracture with simultaneous rupture of both corpora cavernosa and complete urethral transection

Penile fracture is a rare injury to the penis caused by blunt trauma. The presence of urethral injuries sustained during fracture is less than 10%, but very few cases involve complete circumferential urethral transection. We present a case of a patient who presented with traumatic penile fracture involving bilateral corporal cavernosa injury and complete urethral transection.

Lessons learned after 20 years' experience with penile fracture

Objective:

To report our experience over the past 20 years in the diagnosis and surgical treatment of penile fracture (PF).

Materials and methods:

Between January 1997 and January 2017, patients with clinical diagnosis of PF were admitted to our facility and retrospectively assessed. Medical records were reviewed for clinical presentation, etiology and operative findings. Postoperative complications, sexual and urinary function were evaluated.

Results:

Sexual trauma was the main etiological factor, responsible for 255 cases (88.5%): 110 (43.1%) occurred with the “doggy style” position, 103 (40.3%) with “man on top” position, 31 (12.1%) with the “woman on top” position and 11 (4.3%) in other sexual positions. The most common findings in the clinical presentation were hematoma, in all cases and detumescence in 238 (82.6%). Unilateral corpus cavernosum injuries were found in 199 (69%) patients and bilateral in 89 (31%) patients. Urethral injuries were observed in 54 (18.7%) cases. Nine (14.7%) patients developed erectile dysfunction and eight (13.1%) had penile curvature. Only two (3.7%) patients had complications after urethral reconstruction.

Conclusions:

PF has typical clinical presentation and no need for additional tests in most cases. Hematoma and immediate penile detumescence are the most common clinical findings. Sexual activity was the most common cause. The ‘doggy style’ and ‘man-on-top’ was the most common positions and generally associated with more severe lesions. Concomitant urethral injury should be considered in cases of highenergy trauma. Surgical reconstruction produces satisfactory results, however, it can lead to complications, such as erectile dysfunction and penile curvature.

Urethral injury in penile fracture: a narrative review

Objective

To present the evolution and the recent data on the etiology, diagnosis, management and outcomes of penile fracture (PF) with concomitant urethral injury.

Materials and Methods

We searched the Pubmed database between 1998 and 2019 using the following key words: “penile fracture”, “fracture of penis”, “trauma to penis”, “rupture of corpora cavernosa”, “urethral injury”, “urethral rupture” and “urethral reconstruction”.

Results

The incidence of urethral lesion in patients with PF varies by geographic region and etiology. Blood in the meatus, hematuria and voiding symptoms are highly indicative of urethral rupture. The diagnosis of PF is eminently clinical and complementary exams are not necessary. The treatment consists of urethral reconstruction and the most common complications found are urethral stenosis and urethrocutaneous fistula.

Conclusion

PF is an uncommon urological emergency, particularly in cases with urethral involvement. Urethral injury should be suspected in the presence of suggestive clinical signs, and diagnosis is usually clinical. Urgent urethral reconstruction is mandatory and produces satisfactory results with low levels of complications.

[Ambulatory treatment of penile fracture at teaching hospital in Lomé]

OBJECTIVES

To study the feasibility of outpatient management of fractures of the penis and to identify factors that promote their occurrence.

MATERIALS AND METHOD

This were a prospective, monocentric study of patients who received emergency treatment for fractured penises. It took place from January 2016 to January 2019. The data analyzed were circumstances of occurrence, time elapsed before management, clinic, type of anesthesia, functional outcomes (assessment based on IIEF5 questionnaire) and complications.

RESULTS

Seven cases were recorded. The average age of the patients was 35 years. The diagnosis was clinical and surgical treatment in all our patients. Management was outpatient in 6 patients. Sexual function was normal in six patients with an IIEF-5≥21 with a normal erection and no pain at intromission. No complications were objectified.

CONCLUSION

Emergency surgical management of patients with clinical and confirmed per-operative penis fractures may be outpatient without negative impact on functional outcomes and regardless of the cause of fracture.

LEVEL OF EVIDENCE

3.

Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes

INTRODUCTION

The epidemiology of penile fractures in the emergency setting is not well described.

AIM

Examine the incidence, evaluation, management, risk factors predicting surgical repair or hospital transfer, and use of financial resources in patients presenting with penile fractures to the emergency departments (ED) nationwide in the Unites States.

METHODS

ED visits with a primary diagnosis of penile fractures (International Classification of Diseases, Ninth Edition codes) between 2010-2014 were abstracted from the Nationwide Emergency Department Sample.

MAIN OUTCOME MEASURE

Penile fracture incidence, disposition, hospital, and clinical factors which were associated with immediate surgical repair or transfer to another institution, and cost were investigated.

RESULTS

8,029 ED visits for penile fracture in the United States were observed, which represents a national incidence of 1.02 per 100,000 male subjects per year. No meaningful trends in incidence were observed over the 5-year period. 63.9% were treated non-surgically or discharged from the ED, 25.7% underwent surgical repair, and 10.3% were transferred to other institutions. Hospital factors which predicted surgical repair included Northeast region, teaching hospital status, trauma hospital status, high volume ED, and urban location. Clinical risk factors which predicted surgical repair included hypertension, smoking, alcohol dependence, drug abuse, erectile dysfunction, hematuria, urethral injury, and urinary retention. Factors leading to patient transfers included non-academic, rural and non-trauma hospitals, low economic income and low emergency department volume. In addition, weekend and spring presentation were associated with higher transfer rates, while summer presentation was associated with surgical repair.

CLINICAL IMPLICATIONS

A large proportion of penile fractures are discharged from the ED, indicating possible health care access disparity.

STRENGTHS & LIMITATIONS

This is one of the first population-based study of penile fracture incidence, disposition, risk factors which predict surgery or transfer, and cost in the US ED setting. The unexpected high number of discharges may be a result of misdiagnosis; alternatively these data may reveal previously under-reported management patterns in the community.

CONCLUSION

This large retrospective study of penile fractures in the US ED setting demonstrates a stable incidence of penile fractures presenting to the US emergency departments. A quarter of patients undergo immediate surgical repair, 10% are transferred to other institutions and 63.9% of patients are discharged home. The high proportion of ED discharges may be due to access to health care disparities. Rodriguez D, Li K, Apoj M, et al. Epidemiology of Penile Fractures in United States Emergency Departments: Access to Care Disparities May Lead to Suboptimal Outcomes. J Sex Med 2019;16:248-256.

Surgical reconstruction for penile fracture: a systematic review

Penile fracture is a rare condition that describes the rupture of the corpus cavernosum following direct, high-pressure trauma to the erect penis. There is no standardized management algorithm for these patients. We performed a systematic review of the past 10 years regarding management of penile fractures. A complete PRISMA-P 2015 checklist was performed where we reviewed English articles published over the past 10 years to identify 105 articles, where 63 articles were of relevance and subsequently narrowed to a total of 28 articles into the final review for this study. We determined that immediate penile exploration and tunica repair is considered the most common and current management of penile fractures with experts demonstrating that it leads to the fastest in recovery in erectile function and positive cosmetic outcomes. However, we also determined that the specific algorithm can be variable-down to the suture material, use of catheterization, urethroplasty when involved, and length of recovery/follow-up. In the last several decades, men with penile fracture have been treated, in most cases, with immediate surgical intervention. This review highlights the varying practices regarding surgical exploration, injury repair, and postoperative management in men with a penile fracture. Immediate penile exploration and tunica repair have been the mainstay approach of management.

Penile fracture in a patient with Ehlers-Danlos syndrome: A case report

The association of penile fracture with Ehlers-Danlos syndrome (EDS) has never been described. Our patient is a 41-year-old male with EDS who presented with a traumatic penile fracture, ten days following sexual intercourse. This report recognizes the possible heightened risk of structural penile injury in patients with connective tissue disorders such as EDS and emphasizes a need for a high index of suspicion of occult urethral injury and special considerations in surgical management of these complex cases.

Traumatic cervical spine injury during sexual activity

Sexual activity is unlikely to result in spinal injuries. We present the first case of a cervical fracture-subluxation and spinal cord injury following sexual activity. This 31-year-old female presented to the emergency room with neck pain and quadriparesis, following sexual activity in an extreme position. Imaging revealed a hyperflexion cervical fracture-subluxation injury, requiring reduction by traction, followed by circumferential surgical fixation. At 6 months postoperatively, she reported baseline return of function. This case demonstrates that sex-induced spinal injuries are possible and may require urgent surgical treatment.

Case Report: Double penile fracture

Penile fracture is an underreported surgical emergency. It usually occurs as a single rupture of the tunica albuginea in one of two corpora cavernosa; a rupture of both masses is an uncommon finding. We report a case of a young male who presented to the emergency department two hours after sustaining penile trauma. Prompt surgical exploration was performed four hours post-injury. He was found to have one fracture on each corpora cavernosa, without urethral injury, which were repaired successfully. The patient had a favorable recovery and was discharged on the third postoperative day without complications. The aim of this report is to highlight the importance of complete degloving of the penile shaft for a meticulous search during surgery to avoid missed injuries. This approach will ensure a successful outcome avoiding physical and psychological disabilities.

Bilateral fracture of corpora cavernosa with complete rupture of the anterior urethra: Case report and review of recent findings for surgical management

Introduction: Penile fracture is a rare urological emergency associated in up to 30% of cases with injury to the anterior urethra. Recent data suggest that early surgical intervention is the best treatment strategy. This investigation describes a case of bilateral corpora cavernosa injury associated with complete rupture of the anterior urethra and presents current concepts about its management.Case presentation: 39-year-old man with bilateral corpora cavernosa injury and complete rupture of the anterior urethra, who received early surgical treatment with satisfactory early clinical outcomes. A literature review was made in PubMed and Embase, limiting the search to scientific articles published in the past 10 years using the MeSH terms “Penile diseases”, “Genital diseases, male”, “Wounds and injuries”. Some references were included given their clinical relevance. In this case, similar to international experiences, early surgical management of corpora cavernosa fractures allowed achieving adequate clinical outcomes in the patient.Conclusions: The diagnosis of penile fracture is based on clinical findings. Early surgical management should be considered as a therapy of choice. Conservative management has a higher complication rate versus early surgical management. The case described here had an adequate clinical evolution after 3 months of follow-up.

Recurrent Penile Fracture-Case Report and Alternative Surgical Approach

Introduction

Penile refracture is an exceedingly rare event, with very few published studies. To the best of our knowledge, this is the first documented case in the literature of penile fracture with 3 same-site recurrences.

Aims

To describe the case of a 25-year-old Caucasian man with recurrent penile fracture ultimately treated with resuture and patch reinforcement.

Methods

Patient history (clinical and surgical) and literature review.

Results

After the 3rd same-site recurrence, patch reinforcement over the sutured area was performed. The patient had an uneventful recovery and no recurrences to date.

Conclusion

There is no evidence indicating the superiority of non-absorbable sutures. Bovine pericardium reinforcement over the sutured area was used to minimize the chance of another recurrence. More studies are necessary to investigate its safety and efficacy in this scenario.

Nascimento B, Guglielmetti GB, Miranda EP, et al. Recurrent Penile Fracture—Case Report and Alternative Surgical Approach. Sex Med 2018;6:263–266.