ADULT UROLOGY

CME ARTICLE

EVALUATION AND TREATMENT OF PENILE FRACTURES:

ACCURACY OF CLINICAL DIAGNOSIS AND THE VALUE OF
CORPUS CAVERNOSOGRAPHY
MELIH BEYSEL, ALI TEKIN, MESUT GÜRDAL, ERGIN YÜCEBAŞ, AND FERIDUN ŞENGÖR

ABSTRACT
Objectives. To assess the accuracy of clinical diagnosis and feasibility of treatment on the basis of cavern-
osographic findings in men with clinical features consistent with penile fracture.
Methods. Forty consecutive patients (mean age 32 years, range 18 to 65) who presented with a history of
blunt penile trauma and clinical signs and symptoms indicating penile fracture during the past 11 years were
included. The charts of the first 13 patients, who were seen between 1990 and 1994 and were treated
surgically on the basis of the clinical findings, were reviewed retrospectively. In the next 27 patients, a
prospective study was designed and treatment was determined according to their cavernosogram findings:
21 with evidence of corporal injury treated surgically and 6 with normal imaging treated conservatively. The
follow-up ranged from 3 to 32 months (mean 14).
Results. The clinical diagnosis of penile fracture was accurate in 11 of 13 patients and was false in 2 (15%).
In the prospective study, corporal injury as determined by cavernosography was confirmed surgically in all
cases. The cosmetic and functional results were satisfactory in all, including the patients treated conserva-
tively. No serious complication was reported.
Conclusions. In men with blunt penile trauma, the clinical presentation can be misleading and may result in
unnecessary surgery. The results also demonstrated that cavernosography is a useful investigation method
and may be helpful in selecting the treatment approach in these cases. UROLOGY 60: 492–496, 2002.
© 2002, Elsevier Science Inc.

P enile fracture is a dramatic and serious urologic

emergency. It almost always results from blunt
trauma to the erect penis.1–5 Patient history and the
appearance of the penis in this condition are typi-
cal. Patients commonly report hearing a cracking
or popping sound with a sharp pain followed by
rapid detumescence, swelling, discoloration, and
deviation of the penis.1–9 Although vaginal inter-
course is the most common cause,4,6 –9 manipula-
tion has been reported more frequently in some
geographic regions.1,3 Because the anatomic loca-
tion of the penis is suitable for physical examina-
tion, the clinical diagnosis of penile fracture is usu-
ally considered simple.1–3 However, definitive
diagnosis on the basis of clinical findings may
From the Department of Urology, Haydarpaşa Numune Educa-
tion and Research Hospital, İstanbul, Turkey
Reprint requests: Ali Tekin, M.D., Department of Urology,
Haydarpaşa Numune Education and Research Hospital, İstanbul,
Turkey
Submitted: January 14, 2002, accepted (with revisions): April
25, 2002
sometimes be difficult.6,9 A large hematoma may
impede palpation of a corporal rupture.6 A small
tunical tear also may not be palpated.9 Conversely,
various clinical conditions, including rupture of
the deep dorsal vein or artery and ruptured Mon-
dor’s disease, may mimic cavernous body inju-
ry.5,10 –12
The use of imaging techniques in the evaluation
of blunt penile trauma remains controversial. Be-
cause it is considered an easy technique, cavern-
osography is widely used in the diagnosis of penile
fractures. Some investigators have noted that cav-
ernosography is of value in confirming the clinical
diagnosis and defining the location and extent of
corporal rupture.5,13–16 Others have criticized it for
its invasive nature and false-negative results.1,3,6,8,9
However, most of these studies were reports of ret-
rospective observations on small patient se-
ries5,6,8,9,15,16 or even case reports.13,14 To our
knowledge, no prospective study has been pub-
lished to date to evaluate the value of cavernous
imaging in the management of penile fractures.

© 2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00

492 ALL RIGHTS RESERVED PII S0090-4295(02)01813-7
Therefore, in a prospective study of patients with
clinical features of penile fracture, we examined
the feasibility of treatment selection (conservative
versus surgical exploration) on the basis of the cav-
ernosographic findings. We also assessed the accu-
racy of the clinical diagnosis of penile fractures
retrospectively.
MATERIAL AND METHODS
A total of 40 consecutive patients with history, symptoms,
and physical examination findings indicative of penile fracture
presented to our emergency unit during the past 11 years. The
charts of the first 13 patients, who were seen between 1990
and 1994 and treated surgically on the basis of the clinical
findings, were retrospectively reviewed (group 1). In the next
27 patients (group 2) who presented thereafter, a prospective
study was designed and treatment determined according to
their cavernosographic findings; 21 patients with evidence of
corporal injury (filling defect or extravasation of contrast ma-
terial) were treated surgically and 6 with normal cavernoso-
graphic findings were treated conservatively. All patients in
group 2 provided written informed consent before evaluation
and treatment. The intraoperative findings were correlated
with those obtained from cavernosography in the surgically
treated patients in group 2. The cavernosography examination
was done under fluoroscopic control by the urology staff.15,17
No anesthesia was used during the investigation. Thirty to
seventy milliliters (mean 45) of nonionic contrast material
(150 mg/mL iohexol) was injected into the uninvolved corpus
cavernosum (opposite the deviation) until both corpora were
filled. Anteroposterior and oblique radiographs were ob-
tained. Early films were reviewed especially for a filling defect
at the suspected rupture site; delayed films obtained at 10 to 15
minutes were reviewed for extravasation of contrast materi-
al.15 Retrograde urethrography was carried out in patients
with blood at the urethral meatus and/or gross hematuria or
voiding difficulty.
During surgery, a 16F urethral catheter was first inserted in
patients without evidence of urethral trauma and a subcoronal
circumferential incision was made. After the penis was de-
gloved and the hematoma evacuated, careful exploration of
the cavernous bodies, corpus spongiosum, and urethra were
done. Any tunical tear was repaired with 2-0 Vicryl sutures.
Urethral rupture was repaired with 5-0 Vicryl sutures. The
urethral catheter was removed 24 hours after surgery, but was
left in place for 10 days after a urethral repair. Antibiotic treat-
ment was given preoperatively and postoperatively for 7 days.
Conservative management consisted of an elastic bandage and
cold compresses for 3 to 5 days and oral antibiotic and anti-
inflammatory treatment for 10 to 14 days. Sexual abstinence
was advised for 4 weeks. No medication was given for inhibi-
tion of penile erections during convalescence.
All patients were evaluated for voiding difficulty, erectile
potency, pain during intercourse, discomfort at the injury site,
penile deformity, and plaque formation at 1 and 3 months.
Then control visits were done every 6 months.
RESULTS
The mean patient age was 32.1 years (range 18 to
65). The time elapsed between trauma and presen-
tation ranged from 1 to 48 hours (mean 7). The
etiology was vaginal intercourse in 28 patients
(70%), penile manipulation in 8 (20%), a fall on an
erect penis in 3 (8%), and rolling over on an erect
UROLOGY 60 (3), 2002
FIGURE 1. Cavernosography film showing massive ex-
travasation and depicting the extent of a right-sided
tunical rupture.
penis during sleep in 1 (3%). All patients reported
that they heard a cracking sound and felt a sharp
pain with a sudden loss of the erection. Penile dis-
tortion, swelling, and ecchymosis at presentation
were obvious in all cases.
In group 1, the clinical diagnosis of penile frac-
ture was accurate in 11 (85%) of the 13 patients. A
palpable defect was noted in 8 cases (62%). Cav-
ernous body rupture was one-sided in 10, and two-
sided in 1 patient. An incomplete urethral rupture
was also identified in this case. The mean length of
rupture was 17 mm (range 5 to 35). The clinical
diagnosis of penile fracture was false in 2 cases
(15%) in group 1. A palpable tunical defect was
noted in one of these patients. However, both cor-
pora cavernosa and spongiosum were intact at ex-
ploration in both cases. A partial disruption and
thrombosis of the deep dorsal vein was docu-
mented in one of the patients. No specific abnor-
mality was identifiable in the other patient.
In group 2, corporal injury was demonstrated
intraoperatively in all 21 patients with radio-
graphic evidence of rupture. Figure 1 is a cavern-
osogram showing massive extravasation of con-
trast material. The tunical laceration was one-sided
in 19 cases and bilateral in 2. The mean length of
rupture was 17.5 mm (range 5 to 30). A palpable
tunical defect was noted in 12 of the cases (57%).
Tunical laceration was palpable in only one side in
both patients with bilateral trauma. Four (19%)
had blood at the urethral meatus and/or hematuria
at hospital admission. Urethrography revealed a
partial urethral rupture in only two of these pa-
tients. The findings of urethrography were con-
firmed surgically.
Even though the 6 patients treated nonopera-
tively had clinical features similar to the others, the
cavernosography study was negative. A palpable
493
FIGURE 2. Typical appearance of penis with deformity,
swelling, and discoloration 1 hour after trauma, sug-
gesting penile fracture.
defect was reported in one of these patients (17%).
Figure 2 demonstrates the typical “eggplant defor-
mity” of the penis in 1 case. No tunical injury was
evident in his cavernosography study. The etiology
was vaginal intercourse in all 6 patients. The inter-
val between trauma and presentation was 1 to 19
hours (mean 10.5) in these cases.
The average hospital stay after surgery was 2.5
days (range 1 to 4). The patients treated conserva-
tively were discharged after an observation period
of 5 to 7 hours provided that they were able to void
spontaneously. No early complication was en-
countered, including in the patients treated con-
servatively. Also, complications related to radio-
graphic evaluation, such as allergic reaction,
priapism, or infection, were not reported. At 1
month, a slight penile angulation was noted in one
of the patients treated conservatively (Fig. 3). Four
patients (one conservative observation, three sur-
gical repair) reported a moderately painful erec-
tion. No necrosis or infection was noted in any of
the patients. Micturition was normal in all patients.
At 3 months, the cosmetic and functional results
were satisfactory in all patients, including those
treated conservatively (Fig. 4). The mean fol-
low-up was 14 months (range 3 to 32). No late
494
FIGURE 3. Slight penile angulation with complete res-
olution of hematoma at 4 weeks after conservative
management.
complication developed, and erectile potency was
preserved in all patients within the study period.
COMMENT
The erect penis is relatively more prone to injury.
A sudden and abrupt increase in intracavernosal
pressure may exceed the tensile strength of the al-
ready thinned tunica albuginea of the erect penis.18
Penile fracture affects only the cavernous bodies in
most cases. However, urethral injury may also de-
velop in 1% to 48% of the cases, possibly depend-
ing on the mechanism and severity of the trau-
ma.1,6
Controversy on the optimal management of pe-
nile fractures remains. Currently, early surgical re-
pair is considered the most appropriate treatment
for penile fractures.1–7 Many investigators also be-
lieve that the clinical findings are sufficient for a
definitive diagnosis and do not consider imaging
necessary.1,3 In a recent report, Zargooshi1 re-
ported that he was able to document penile frac-
ture in all patients in whom the diagnosis was
based on history and physical examination. How-
ever, false-positive clinical findings were a concern
in another report.5 Penile distortion may develop
because of a hematoma in the absence of corporal
UROLOGY 60 (3), 2002

FIGURE 4. Appearance of penis with complete recov-
ery at 3 months.
injury.5 Rupture of the dorsal penile veins5,10,12 and
arterial injuries mimicking corpus cavernosum in-
jury have also been reported.11 In our study, the
pathologic condition that resulted in a clinical pre-
sentation mimicking penile fracture was a rupture
of the deep dorsal vein in 1 patient. If penile frac-
ture had been excluded preoperatively, these pa-
tients would have been spared unnecessary sur-
gery. Conversely, false-negative results may also be
possible in many conditions. Palpation of the rup-
ture line may be difficult because of the small size
of the rupture,9 delayed presentation, or a large
hematoma localized against the rupture site. Some
of the clinical findings typical for penile fracture
could not be demonstrated in many of our cases.
For instance, a palpable defect was identifiable in
only one half of the patients with documented cav-
ernosal injury in group 2.
A tunical laceration demonstrated by cavern-
osography was confirmed surgically in all cases in
our study. More importantly, the treatment strat-
egy as determined by the cavernous imaging find-
ings did not result in any untoward sequelae. It was
evident in our studies and others5,6,9,13–16 that pos-
itive cavernosographic findings (ie, filling defect or
extravasation) is highly diagnostic of penile frac-
ture. Regarding the negative predictive value of the
technique, there are few and conflicting reports in
UROLOGY 60 (3), 2002
published studies.5,6 In the study by Mydlo et al.,6
the cavernosographic findings were falsely nega-
tive in 2 of the 7 cases with penile fracture. Possible
reasons for false-negative results according to the
investigators were a “ball valve” effect of the un-
derlying hematoma or a suboptimal technique for
imaging.6 On the other hand, Karadeniz et al.5 doc-
umented the absence of corporal injury in both of 2
cases with normal cavernosographic findings.
The practical use of cavernosography in the man-
agement of penile fractures was first reported by
Dever and coworkers.15 They achieved a favorable
outcome after conservative management on the ba-
sis of a negative cavernosogram in 1 patient with
atypical clinical findings. Similarly, we did not at-
tempt to confirm the normal cavernosography
findings by surgical exploration. Rather, from a
practical point of view, we assessed the feasibility
of nonoperative management of acute blunt penile
trauma as determined by normal cavernous imag-
ing. Our study represents the unique prospective
study in the literature in this regard and provides
further supportive data to the preliminary conclu-
sions by Dever et al.15 Although conservative man-
agement has not been recommended19 because of
the high complication rates of the earlier series, a
recent report with encouraging results20 has again
raised interest in the nonoperative treatment of pe-
nile fractures. We believe that the main clinical
implication of our study is that cavernosography
may be helpful in patient selection for conservative
management.
Other imaging techniques that are under inves-
tigation for their use in the preoperative diagnosis
of penile fractures are ultrasonography8,9 and mag-
netic resonance imaging.9 Ultrasonography is op-
erator dependent and may not be able to detect
small tears.9 The rupture line can be shown excel-
lently by magnetic resonance imaging on both T1-
weighted and T2-weighted images.9 However, be-
cause of its high cost and restricted availability, it
currently is not considered a routine part of the
evaluation of penile fractures.17
CONCLUSIONS
In men with blunt penile trauma, the clinical
presentation can be misleading and may result in
unnecessary surgery. Our results also indicate that
cavernosography may be helpful in selecting the
treatment approach in these cases.
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UROLOGY 60 (3), 2002