20 Urology seminar

Penile fracture:
diagnosis and management
MOHAMMAD MASARANI AND MICHAEL DINNEEN
Penile fracture is an uncommon urological emergency that can have significant complications. Patients usually
present to the accident and emergency department, but may seek advice from GPs. Immediate surgical repair is
the treatment of choice, with fewer complications, shorter hospital stays, better outcome and increased patient
satisfaction compared with conservative therapy.

Mr M. Masarani, MSc, FRCS, Dip(Urol), Staff Grade Urologist; Mr M.

ed cases of penile fracture occurred in the Middle
Dinneen, MD, FRCSI(Urol), Consultant Urological Surgeon, Chelsea & East.3 In the western hemisphere, the injury most com-
Westminster Hospital, Imperial College, London. monly occurs during vigorous sexual intercourse when
the penis slips out of the vagina, hitting the perineum

Fbothracture of the penis, faux pas du coit, is defined as a

traumatic rupture of the tunica albuginea of one or
of the corpora cavernosa affecting the erect penis.
or the pubic symphysis. Most coital fractures involve
consensual heterosexual vaginal intercourse. The cases
from the Middle East resulted mainly from penile
The rupture may extend to affect the corpus spongio- manipulation, often involving kneading the penis to
sum and the urethra. The first documented report of achieve detumescence.
this condition is credited to an Arab physician, Abul
Kasem, in Cordoba more than 1000 years ago.1 Pathophysiology
The tunica albuginea (Figure 1) is one of the toughest
Aetiology of penile fracture fascias in the body. As the penis changes from a flaccid
The condition is under-reported, and certainly not as to an erect state, the tunica albuginea thins from 2mm
rare as has been claimed.2 More than half of the report- to 0.25–0.5mm, loses elasticity and becomes vulnerable
to rupture during sudden acute bending, such as may
Superficial dorsal vein happen during sexual intercourse or manipulation.
Deep dorsal vein Dorsal artery Following the fracture, a haematoma forms. If this is
confined within the Buck’s fascia, the ecchymosis will
be limited to the penile shaft. When the fascia is dis-
rupted, the haematoma extravasates around Colles’ fas-
cia, giving rise to the ‘butterfly’ pattern of ecchymosis
in the perineum, scrotum and lower abdominal wall.
Rupture of the tunica albuginea is usually unilateral
and transverse. The rupture occurs more often in the
proximal shaft and is located ventrally in coital injuries.
The incidence of concomitant urethral injury is 10–38
per cent.4 Urethral injury occurs more commonly with
Cavernosal artery a bilateral cavernosal tear. However, the frequency of
urethral involvement was between 0 and 3 per cent in
Tunica albuginea the Middle Eastern studies.3
Corpora
cavernosum Buck’s fascia Presentation of penile fracture
Corpus Those affected are often reluctant to report the injury
spongiosum Dartos’ fascia (becomes because of embarrassment. They may be reticent in
Colles’ fascia posteriorly) their history, but usually present early. The clinical pic-
ture of penile fracture is usually fairly straightforward.
Figure 1. Cross-section through the penis, showing normal anatomy. Most affected patients report penile injury coincident

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 Urology seminar 23

with sexual intercourse. A popping, cracking or snap-

ping sound that is followed by sudden detumescence is
described. Pain is a variable symptom.
Findings at presentation include penile swelling,
ecchymosis and deformity (the so-called ‘eggplant’ or
‘aubergine’ sign; Figure 2). The penis is often deviated
away from the site of the tear secondary to the mass
effect of the haematoma. The clinician might be able to
illustrate the ‘rolling sign’, which is the palpation of the
localised blood clot over the site of rupture. The pres-
ence of blood at the urethral meatus, gross haematuria
or voiding difficulties may indicate a urethral rupture,
but their absence does not exclude such an injury.
Delayed presentation may result in complications such
as erectile dysfunction, penile deviation and plaques
resembling those of Peyronie’s disease.
The principal differential diagnosis is a tear of the
deep dorsal vein of the penis, which can be clinically
indistinguishable from penile fracture.

Diagnosis of penile fracture

The diagnosis of penile fracture can usually be made
solely on clinical grounds, and most authors report
accurate diagnoses without imaging studies. Where the
history indicates a possible injury but the physical
examination findings are equivocal, imaging studies
may be used. Cavernosography and ultrasonography
are used for the detection and evaluation of the exact
site of the tear. Magnetic resonance imaging is the most
accurate modality for evaluating patients with acute
penile trauma.5 It can accurately demonstrate the
extent and location of the tunical tear and associated
injuries to the corpus spongiosum and urethra. The
addition of any investigative tool may extend the time
before definitive treatment can be delivered.
Urethrography is recommended when a urethral injury
is suspected.
Management of penile fracture
Historically, conservative management was considered
the treatment of choice for penile fractures.
Conservative therapy consisted of cold compresses,
pressure dressings, anti-inflammatory agents and
antibiotics. This approach has fallen into disfavour
because of the associated high complication rate.
Currently, immediate surgical repair is the favoured
treatment, with fewer complications, shorter hospital
stays, better outcome and increased patient satisfac-
tion. The repair has been performed under local or
spinal anaesthesia, but is most commonly carried out
under general anaesthesia.
Figure 2. Penile fracture, showing swelling, ecchymosis and deformity (the so-called ‘egg-
plant’ or ‘aubergine’ sign).
The principles of surgical management are:
• evacuation of the haematoma (Figure 3a);
• identification of the site of fracture (Figure 3b);
• closure of the defect in the tunica albuginea;
• restoration of the urethral integrity (if required).
Absorbable and non-absorbable sutures have been
used; the latter are particularly recommended for
recurrent cases.6 Although it is advocated that patients
should abstain from penile manipulation for six to
eight weeks to prevent re-fracture, some authors have
reported no recurrence in patients who resumed sexu-
al activities within two weeks of treatment.7 The use of
sedatives and oestrogens (such as stilboestrol) to sup-
press spontaneous erections during convalescence is
probably unnecessary, as painful stimuli are usually suf-
ficient to prevent such erections, and these medications
should be saved for recurrent cases.
Complications
Complications of penile fracture occur in patients man-
aged both conservatively and surgically. However, those
receiving conservative therapy have a significantly high-
er incidence of complications than those receiving
prompt surgical treatment,8 and some of these compli-
cations have devastating physiological and psychologi-
cal consequences (Box 1). Wound infection, penile
haematoma, penile abscess and penile skin necrosis

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24 Urology seminar

a b

Glans penis Haematoma Urethra Penile fracture Urethra

Figure 3. Penile fracture repair. (a) A circumscribing–degloving incision is made and the haematoma is evacuated. (b) A unilateral, transverse fracture in the right
corpus cavernosum is identified.

have been reported as complications in the immediate
postoperative period.
Conclusion
Penile fracture is a urological emergency that may have
devastating physiological and psychological conse-
quences. However, with prompt diagnosis and expedi-
ent surgical management, outcomes are excellent and
complications minimal.
References
1. Taha SA, Sharayah A, Kamal BA, et al. Fracture of the penis:
surgical management. Int Surg 1988; 73: 63-4.
2. Cendron M, Whitmore KE, Carpiniello V, et al. Traumatic rupture
of the corpus cavernosum: evaluation and management. J Urol
1990; 144: 987-91.
3. Zargooshi J. Penile fracture in Kermanshah, Iran: report of 172
cases. J Urol 2000; 164: 364-6.
4. Sant GR. Rupture of the corpus cavernosum of the penis. Arch
Surg 1981; 116: 1176-8.
5. Zaman ZR, Kommu SS, Watkin NA. The management of penile
fracture based on clinical and magnetic resonance imaging
findings. BJU Int 2005; 96(9): 1423-4.
6. Kattan S, Youssef A, Onuora V, et al. Recurrent ipsilateral fracture
of the penis. Injury 1993; 24: 685-6.
7. Uygur MC, Gulerkaya B, Altug U, et al. 13 years’ experience of
penile fracture. Scand J Urol Nephrol 1997; 31: 265-6.
8. Muentener M, Suter S, Hauri D, Sulser T. Long-term experience
with surgical and conservative treatment of penile fracture. J Urol
2004; 172: 576-9.
Further reading
Eke N. Fracture of the penis. Br J Surg 2002; 89: 555-65.

Box 1. Complications of penile fracture. KEY POINTS

• Abnormal penile curvature • Penile fracture is an uncommon but under-reported urological

• Painful erection/male dyspareunia emergency.
• Erectile dysfunction • The diagnosis of penile rupture can usually be made solely on
• Formation of fibrotic plaques clinical grounds.
• Penile abscess
• Urethrocutaneous fistula • Investigations might delay the definitive treatment.
• Urethrocavernosal fistula • Immediate surgical repair is the treatment of choice.
• Urethral stricture • Conservative management leads to a significantly higher
• Psychiatric disturbance incidence of complications than surgical treatment.

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