Suspected penile fracture: to operate or not to operate?

Optimal timing of surgical intervention for penile fracture: a narrative review of the modern literature

INTRODUCTION

Penile fracture is traditionally considered a surgical emergency warranting immediate repair with the goal to maximize long-term erectile function and minimize penile curvature. Nonetheless, consensus on the optimal timing for penile fracture repair remains to be elucidated and is the subject of continued research efforts.

OBJECTIVES

This review aims to summarize the contemporary literature pertaining to optimal timing of penile fracture repair and associated outcomes.

METHODS

We queried PubMed/MEDLINE and Google Scholar for relevant articles published between 2012 and 2022 to evaluate the most recent literature on the queried topic of early vs delayed intervention for penile fracture. All examined review articles were published within the last decade but may have included analyses of studies published prior to 2012. Reference lists of articles and reviews were manually reviewed to identify additional relevant articles.

RESULTS

We identified 16 articles that met inclusion criteria: 12 primary articles and 4 systematic reviews or meta-analyses. Importantly, definitions of early and delayed intervention varied greatly among studies, making quantitative comparison challenging. In summary, 6 primary studies and 2 systematic review articles favored early intervention. There were also 6 primary studies and 2 systematic review articles suggesting equivocal outcomes between early and delayed repair. No articles demonstrated improved outcomes with delayed repair relative to early intervention.

CONCLUSION

Surgical intervention for penile fracture remains the gold standard, with superior long-term sexual and functional outcomes when compared with conservative management. Optimal timing of penile fracture repair remains to be elucidated with data limited by low incidence, resulting in small case series and a lack of randomized controlled trials. Nonetheless, recent data suggest that a brief delay in surgical intervention for patients presenting with penile fractures does not affect long-term sexual and functional outcomes.

Risk Factors for Penile Fracture After Intralesional Collagenase Clostridium histolyticum in Peyronie's Disease

OBJECTIVE

To evaluate risk factors leading to corporal rupture after Collagenase Clostridium histolyticum (CCh). Peyronie's disease (PD) is a fibrotic condition of the penis characterized by abnormal plaque formation. Intralesional CCh is the only FDA-approved medication for PD, however, it can lead to corporal rupture, a potential surgical emergency.

METHODS

We retrospectively reviewed medical records from Veterans diagnosed with PD who were under treatment with CCh using the Veterans Administration Informatics and Computing Infrastructure (VINCI). Using International Classification of Diseases and Current Procedural Terminology codes, we identified men who suffered a corporal rupture after CCh. Individual charts were reviewed to determine potential risk factors and events leading to corporal rupture.

RESULTS

We identified 17,647 veterans who were diagnosed with PD, of which 8.7% (1541) received at least one injection of CCh for PD. Of them, 0.7% (11/1541) veterans suffered corporal rupture. Within these 11 patients, the median number of CCH injections was 6 with a median initial curvature of 35°. Fracture occurred at a median of 8days after CCH injection. The majority of fractures were secondary to spontaneous erections or sexual intercourse. Finally, six patients had their fracture repaired surgically while the remaining were managed conservatively.

CONCLUSION

Most fractures occurred within 2weeks of CCh injections and were associated with sexual intercourse and spontaneous morning erections.

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: 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.

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.

Penile Fracture: Delayed Presentation, Primary Urethral Repair and Satisfactory Outcome

Penile fracture is a relatively rare condition warranting emergency intervention. The commonest etiological factor remains coital activities, which explains why it is being underreported. Presentation is usually delayed and up to 38% of cases present with associated urethral injury. Prompt surgical intervention and primary urethral repair are associated with a good outcome. We present a 30-year-old male with unilateral penile fracture and associated urethral injury following sexual intercourse.