Received: 11 July 2018 Revised: 7 September 2018 Accepted: 13 September 2018

DOI: 10.1002/sono.12167

REVIEW ARTICLE

The role of ultrasound in the diagnosis of penile fracture

Donna Napier

Department of Medical Imaging, Royal

Brisbane and Women's Hospital, Herston,
Brisbane, Australia
Correspondence
Donna Napier, Department of Medical
Imaging, Royal Brisbane and Women's
Hospital, Herston, Brisbane, Australia.
Email: donnanapier@hotmail.com
Abstract
Although considered a relatively rare occurrence, penile fracture is nonetheless a
urological emergency. The importance of correctly identifying this pathology is essen-
tial when the long‐term sequelae of a delayed or misdiagnosis are considered. Due to
the stigma attached to this entity, it is assumed that its true incidence remains
underreported, and as such, literature on the sonographic evaluation of penile fracture
is rendered to be relatively scarce. The consequence of such an unusual referral
means that there is a gap in knowledge when it comes to attaining an accurate ultra-
sound diagnosis. This article will review the anatomy of the penis, the pathophysiol-
ogy contributing to penile fracture, and how an inherent understanding of both is
vital to the accurate sonographic grading of different fracture types. Although penile
fracture is still considered a clinical diagnosis, ultrasound provides critical information
in atypical or equivocal cases whereby multiple differential diagnoses cannot be
excluded. The possibility of an incorrect diagnosis based on inconclusive historical
and clinical findings therefore highlights not only the important role of ultrasound in
the facilitation of prompt surgical intervention but also its contribution to a favourable
patient outcome by way of correct management.

KEY W ORDS

emergency ultrasound, penile fracture, tunica albuginea rupture

1 | I N T RO D U CT I O N in contrast to surgical intervention necessary for penile fracture

Penile fracture is regarded as an infrequent occurrence, remaining
largely underreported because of patient embarrassment and/or the
stigma attached to this injury.1 Accurate statistics reflecting the occur-
rence rates of penile fracture are unknown, but it is thought to repre-
sent 1 in 175 000 hospital admissions.1,2
The first documented case of penile fracture was recorded in
Cordoba, Spain, more than 1000 years ago by Dr Abul Kasim1,3 and
in more modern times by Malis1,3 in 1924. As in the past, penile frac-
ture is still largely identified clinically in the present day; however, the
complications of an incorrect diagnosis can contribute to significant
4,5
patient morbidity. This is especially evident when the disparate
management pathways between penile fracture and other associated
aetiologies are compared, considering these can be clinically indistin-
guishable from a true fracture.6 An extra‐albugineal haematoma is a
commonly encountered differential that is managed conservatively,
repair.7,8 The literature, although limited, suggests that conservative
management of a penile fracture can be associated with a higher risk
of complication, including erectile dysfunction, male dyspareunia,
abnormal penile curvature, development of fibrotic plaques, and
urethrocutaneous or urethrocavernosal fistula formation.5 One such
study conducted by Amer et al9 concluded that postfracture complica-
tion rates occurred in 46% of the conservatively managed patient
group, as opposed to 20.6% of those who were managed surgically.
Alternately, ruptures of the penile vasculature can also mimic the clin-
ical appearance of penile fracture and as such expedite unnecessary
surgical exploration.10 This is significant when the consequences of a
circumferential degloving can encompass neurovascular injury and
skin necrosis.4
The fact that ultrasound is noninvasive, is cost‐effective, lacks the
use of ionising radiation, and can be performed at the patient's bed-
side makes it the obvious imaging modality to confirm or exclude a

Sonography. 2018;1–9. wileyonlinelibrary.com/journal/sono © 2018 Australasian Sonographers Association 1

2 NAPIER
clinically suspected penile fracture.11 This is especially relevant in
atypical or equivocal cases whereby diagnosis cannot be confidently
based on patient history and physical examination alone.8 This article
will review the anatomy and physiology of penile rupture, discuss
the sonographic technique, and outline the importance of not only
accurately grading the severity of fracture types but also differentiat-
ing a true penile fracture from common differentials. Successful out-
comes with minimal complications require an accurate diagnosis with
prompt surgical intervention,11 the use of ultrasound allowing both
to occur in a timely manner.
2 | A N A T O M Y OF TH E P E N I S
Located in the urogenital triangle, the penis is the male organ for
reproduction and urination.12 Globally, it is composed of three cylin-
drical bodies of endothelial trabecular tissue—two dorsal columns
known as the corpora cavernosa and one centrally located column
13,14
called the corpus spongiosum. Each corpus cavernosum conveys
the deep arteries of the penis and forms the crura proximally, which
attach onto the ischiopubic rami.14 The corpus spongiosum allows
for the passage of the urethra and is located in the penile midline. It
contributes to the glans penis located at the distal shaft and forms
the bulb of the penis proximally.14
Anatomically, the penis is composed of three regions—the root,
the body, and the glans.12 Its proximal attachment is known as the
root and is a collaboration of the bilateral crura, the bulb, and the
ischiocavernosus and bulbospongiosus muscles.12,14 The body refers
to the externally suspended portion of the penis and is composed of
the three corporal columns, spongy urethra, skin, supporting tissues,
and vasculature.12 At its furthermost region, the glans conveys the
urethral opening known as the penile meatus.12
An understanding of penile anatomy, especially the complexity of
its fascial planes, is essential in accurately grading the severity of
penile fracture as these layers influence the pattern of haematoma
extravasation following trauma.15 The fascial interfaces of the penis
can be categorised into three distinct layers—fibrous, loose facial,
and superficial connective tissue.
The fibrous layer called the tunica albuginea is a dense fibro‐elastic
sheath that encloses both cavernosa and is fused in the midline
between them14 (Figure 1). This layer incorporates a stratum com-
posed of longitudinally orientated fibres that attach onto the pubic
rami and a circular layer that contributes to the septum between the
cavernosa.15 It is considered to be the toughest fascia in the body
and the most important in the definition of a penile fracture.
Directly superficial to the tunica albuginea is a loose fascial layer
known as the Buck fascia (Figure 1). The Buck fascia envelops the
three corporal bodies and is a continuation of the deep perineal fas-
cia, the external spermatic fascia of the scrotum, and the penile
suspensory ligament.12,14 It also assists in attaching the base of the
penis onto the pelvic rami and the fascia of the perineal
membrane.15
Colles fascia is the collective name given to the layer of superficial
connective tissue of the penis. Also referred to as the superficial
dartos fascia, this areola mantle is located just deep to the skin surface
and encloses the superficial perineal space, communicating with the
scrotum and the perineum posteriorly.15 Anteriorly, the Colles fascia
merges with the Scarpa fascia of the anterior abdominal wall.15 Refer
to Figure 2 for these relationships in the sagittal section.
3 | U L T R A S O U N D A N A T O M Y OF TH E P E N I S
The sonographic appearance of a normal penis in the transverse sec-
tion is displayed in Figure 3A. Here, the corpora cavernosa appear as
two homogenous, hypoechoic, dorsal structures, with the ventrally
located corpus spongiosum appearing as a single, homogenous entity
that is usually more echogenic than the cavernous bodies.13 The
tunica albuginea is represented as a thin hyperechoic layer enveloping
both cavernosa, with the more subtle echogenic rim surrounding all
three corporal bodies indicative of the Buck fascia.13,16
FIGURE 1 Axial section of penis showing
the fascial planes
NAPIER
FIGURE 2 Sagittal section of penis and
perineum demonstrating the relationship of
the facial planes
FIGURE 3 A, Ultrasound image in the transverse plane of normal
penile anatomy. White line indicates the tunica albuginea. Light blue
line demonstrates the position of the Buck fascia. Dark blue oval
represents the superficial dorsal vein of the penis. Dark blue circle
indicates the deep dorsal vein of the penis, and the paired red circles
illustrate the deep arteries. B, Longitudinal ultrasound image of right
corpus cavernosum and corpus spongiosum. The spongiosum appears
more echogenic than the cavernosum
3
Figure 3B, a longitudinal representation, demonstrates the
hypoechogenicity of the right corpus cavernosum when compared
with the more echogenic spongiosum. The proximal portion of the
penile urethra can also be appreciated; however, it is important to
note that in the absence of pathology, the urethra is not readily visible
and a contrast medium such as gel or saline is required to widen the
urethra and allow an accurate assessment of the lumen.16
4 | P A T H O P H Y S I O L O G Y OF P E N I L E
FRACTURE
By its simplest definition, a penile fracture refers to the traumatic rup-
ture of the tunica albuginea of the corpora cavernosa; however, this
can extend to involve the corpus spongiosum, urethra, surrounding
fascial planes, and associated vasculature.17 Usually rupture of the
tunica albuginea is unilateral and transverse, commonly located ven-
trally at the base of the penis.5 The patient usually describes an audi-
ble “popping” noise in conjunction with the classic triad of pain,
detumescence, and haematoma.4,17
An erection renders the phallus more susceptible to injury, the
increased risk of rupture resulting when the tunica albuginea thins
from 2.5 mm in the flaccid state to 0.25 mm when rigid.18 Combining
this with increased intracavernosal pressures and the loss of elasticity
associated with an erection, the penis becomes vulnerable to forceful
manipulation by way of sudden blunt trauma and/or abrupt lateral
bending.7,18 The most common mechanisms of injury are coitus, mas-
turbation, and the act of penile manipulation so as to achieve
detumescence.19
Penile fractures can be classified as either simple or compound.19
A simple fracture indicates that the skin and urethra are intact, as
opposed to a compound fracture where both corpora cavernosa and
the penile urethra are compromised.19 The clinical appearance of the
anatomy can give an initial indication as to the severity of penile injury
4 NAPIER

with five main appearances used to describe the presence of a likely to minimise further patient discomfort, the penis is examined as it lies
penile defect—eggplant deformity, rolling sign, butterfly pattern by way of either a dorsal or ventral approach.
ecchymosis, anterior abdominal wall haematoma, and bleeding from The dorsal approach is utilised when the penis is lying on the
the penile meatus.2,5,15 anterior scrotal wall, the dorsal surface of the penis being continuous
The eggplant deformity is a result of a ruptured tunica albuginea, with the anterior wall of the abdomen. This is usually the preferred
with the haematoma collecting deep to an intact Buck fascia.2 As a method of approach as it allows sufficient representation of all three
consequence, swelling is confined to the penile shaft only, with devia- corporal bodies.16 In the representative image, the cavernosa are
tion of the penis away from the site of rupture due to the mass effect visualised in the near field, with the spongiosum located centrally in
2
of the encroaching haematoma. Skin discolouration is also a hallmark the far field.16
7
of this appearance. The rolling sign is encountered when the penis is A ventral approach is undertaken when the penis is positioned on
manually examined in order to isolate the site of tunical tear.4 A pos- the anterior abdominal wall, as the ventral aspect of the penis is con-
itive rolling sign is confirmed when the penile skin is rolled over a hard tiguous with the anterior surface of the scrotum. This approach pro-
4
and immobile haematoma by a palpating finger. vides the best visualisation of the spongiosum and the urethra along
Butterfly ecchymosis is associated with a more severe defect and is the entirety of the penile length22 and is located in the near field of
indicative of a disruption to the Buck fascia, allowing haematoma to the representative image. Care should be taken however to use mini-
extravasate around an intact Colles fascia.2 The disruption of the Buck fas- mal transducer pressure so as prevent compression of the corpus
cia allows for the formation of a perineal haematoma and is characterised spongiosum and/or the urethra.16 If confusion still exists in regard to
2,15
by a butterfly pattern of bruising. As the Colles fascia encloses the
superficial perineal space, disturbance of this layer manifests in a
haematoma extending into the anterior abdominal wall and the scrotum.15
The identification of blood at the penile meatus is significant of
urethral involvement, the incidence of concomitant urethral injury5,17
being between 10% and 39%. Urethral injury should be suspected in
the presence of bilateral cavernosa rupture and is associated with
increased morbidity rates because of its severity.17
It is important to acknowledge however that these common clinical
appearances can also be consistent with less severe penile injuries
resulting from the same mechanism of injury.6 Ruptures of the superficial
dorsal vein, deep dorsal vein, and arteries or nonspecific dartos bleeding
can contribute to extra‐albugineal haematoma and thus resemble
ecchymosis associated with penile fracture, despite the tunica albuginea
remaining intact.6,10,20 Unlike in true penile fracture whereby detumes-
cence is immediate, injury to the penile vasculature is usually associated
with delayed detumescence, although this is not always the case.20

5 | U L T RA S O U N D T E C H N I Q U E

In 1983, Dierks and Hawkins first described the use of high frequency
ultrasound as a method to evaluate corpus cavernosum rupture.21
Some authors consider a limitation of this modality to be its
operator‐dependant nature, with an accurate diagnosis reliant on the
knowledge and skill of the practitioner.17,21 The advantage of
ultrasound in the diagnosis of penile fracture, however, is unrivalled
when its noninvasive, cost‐effective, and nonionising nature are
considered. This coupled with its ability to provide superior resolution
of superficial structures such as the penis makes it an obvious
imaging choice.
Because of the sensitive nature of this examination and taking
into account the possibility of patient embarrassment, a thorough
explanation of the examination should be provided by the sonogra-
FIGURE 4 A, Schematic diagram of penis in transverse section used
pher prior to beginning. Ultrasound of the penis is undertaken using
by sonographer to indicate location of fracture and/or haematoma.
a high‐resolution linear array transducer on a relevant superficial pre- B, Schematic diagram of penis in the longitudinal section used by
set.16 An increased volume of gel may be required so as to ensure sonographer to indicate position of fracture and/or haematoma
optimal contact of the transducer interface with the skin.2,16 In order along shaft
NAPIER 5

the anatomical surfaces of the penis, a good rule is to associate the
dorsal surface as that being closest to the head and the ventral surface
as that closest to the feet.12
Irrespective of the scanning approach, a survey scan in the trans-
verse and longitudinal planes should be performed prior to the docu-
mentation of static images. In the transverse section, the penile shaft
should be evaluated from base to glans and from right to left in the
TABLE 1 Grades of penile fracture and their characteristics 27
longitudinal plane.22 The value of a survey scan (including cine loop
capture) not only provides for a thorough assessment of the extent of
injury but also allows for the exclusion of coexisting pathology such
as calcified plaques, abnormalities of the cavernosa, and/or penile vas-
culature.16 Disruption to the hyperechoic line of the tunica albuginea,
coupled with the presence of a haematoma, is diagnostic of penile frac-
ture.2 Particular attention should be paid to the corpus spongiosum
because identification of the urethra is indicative of injury. Visualisation
of the urethra is rendered difficult in a normal penis as the lumen is void
of contents and thus compressed.22 A survey scan in the transverse
plane from the penile base to glans can adequately assess for a

Fracture
distended urethral lumen containing echoes while assessment in the
Grade Characteristics longitudinal section can identify any disruption to its contiguity. Pano-
Grade 0 Normal tunica albuginea, with or without ramic imaging in the longitudinal plane can also demonstrate the length
‐deep dorsal artery/vein rupture of the spongy urethra. Transperineal placement of the transducer is rec-
‐superficial dorsal vein rupture
ommended to assess the internal urethral components.22
Grade 1 Defect in tunica albuginea with cavernosal involvement
Representative B‐mode images in the transverse section should
Grade 2 Defect in tunica albuginea with perialbugineal and
cavernosal haematoma include the three corporal bodies, with an image documented proxi-
Grade 3 Defect in the tunica albuginea, Buck fascia, and corpus mally at the base of the penis, at midshaft, and at its distal end proxi-
spongiosum mal to the glans.16 Representative images in the longitudinal plane
Grade 4 Disruption to the urethra with or without vascular should display each corporal body parallel to its length. Here, pano-
malformation
ramic imaging techniques can be useful in displaying each corpora in

FIGURE 5 A, Schematic diagram of grade 0 subtype resulting from rupture of the deep dorsal vein or arteries. Haematoma represented by green
shading contained beneath Buck fascia. B, Schematic diagram of grade 0 subtype resulting from rupture of the superficial dorsal vein. Haematoma
is located outside of Buck fascia within the subcutaneous tissues. C, Transverse ultrasound image taken from the ventral aspect. The tunica
albuginea is intact with a right‐sided haematoma (star) located superficial to it
6 NAPIER
its entirety. Dual imaging can be incorporated into the series to pro-
vide comparative imaging.16
Accurate documentation of pathology is of upmost importance to
not only assist the radiologist in providing a comprehensive report but
also help the urologist with surgical planning. A defect in the tunica
albuginea, Buck fascia, or corpora should be described according to
the side on which it is located and whether it is on the dorsal or ven-
tral aspect of the penis.23 Its position along the penile shaft, whether
proximal, mid, or distal, should also be conveyed and the length of
the defect measured.24 A mark placed on the skin surface indicative
of the fracture location can be helpful to the treating urologist. Like-
wise, when a haematoma is identified, its position on the side and
aspect of the penis should be recorded as well as its size in three
dimensions.23 A description as to whether it is intracavernosal or
extracavernosal provides additional information.24 An example of
schematic diagrams that can be utilised by the sonographer in demon-
strating the location of pathology is illustrated in Figure 4.
Colour Doppler assessment should be undertaken to examine a
defect in the tunica albuginea or Buck fascia. Compression of the
penis can instigate a flush of blood, thus assisting in the detection of
small tears in the tunica albuginea.2 Colour Doppler is also helpful in
FIGURE 6 A, Schematic diagram representative of grade 1 penile
fracture in the transverse section. Orange triangle denotes structures
affected in this subtype—tunica albuginea with corpus cavernosum
involvement. B, Transverse ultrasound image of grade 1 penile
fracture. An anechoic region is displayed in the left corpus cavernosum
(arrow).
assessing ruptures of the dorsal veins and arteries as well as identify-
ing the presence of any arteriovenous malformations posttrauma.22
6 | GRADES OF PENILE FRACTURE
Although the characterisation of fracture is important, emphasis
should initially be placed on the sonographic discrimination of a true
penile fracture from a vasculature disruption resulting in haematoma
formation within the superficial tissues. Differentiation between a
tunical tear and a vascular injury can therefore influence the manage-
ment pathway that is undertaken.8 According to Metzler et al,25 two
ultrasound findings—the presence of a tunical defect in conjunction
with an intracavernosal haematoma—conclusively diagnose a penile
fracture and thus expedite surgical intervention. In the absence of
these two entities, conservative management is recommended.25
Once a tunical defect has been detected, accurate grading of penile
fracture is imperative to not only comprehend the severity of injury but
also guide the urologist as to the best surgical approach required to cor-
rect the abnormality.24 This is especially evident when a complete
degloving of the penis can be replaced by a less invasive, modified
FIGURE 7 A, Schematic diagram representative of grade 2 penile
fracture in the transverse section. Orange triangle denotes structures
affected in this subtype—tunica albuginea and corpora cavernosum,
with a peri‐tunical haematoma represented by the green circle. B,
Transverse ultrasound image of grade 2 penile fracture. A defect is
noted in the right tunica albuginea (arrow) with haematoma of mixed
echogenicity demonstrated on either side (stars), contained by an
intact Buck fascia
NAPIER
incision over the rupture site.24 The use of ultrasound can thus custom-
ise the surgical procedure by way of its ability to accurately locate
tunical defects and renders exploration via the traditional circumferen-
26
tial degloving method unnecessary. The grading system can also be
used to influence the timing of surgical repair. Generally, it is expected
that penile fracture is surgically corrected within 24 hours so as to avoid
long‐term sequelae, commonly involving evacuation of the haematoma,
corporal debridement, closure of tunical defects, and ligation of any
compromised vasculature.4 Those fractures involving the urethra
require immediate intervention and are addressed by way of suture, pri-
mary reanastomosis, or graft interposition.4
In 2015, Shukla et al27 composed a grading system of penile dis-
ruption based on the most common sonographic appearances encoun-
tered in their clinical experience. This grading system identified four
main subtypes ranging from 0 to 4, each being outlined in Table 1
and discussed as follows.
Grade 0: Normal tunica albuginea without defect. This subtype also
includes haematoma of the soft tissues of the penis due to rupture
of specific penile vasculature.10 A rupture of the deep dorsal vein
or artery results in haematoma being contained beneath the Buck
20
fascia and thus confined to the penile shaft, as shown in
FIGURE 8 A, Schematic diagram representative of grade 3 penile
fracture in the transverse section. Orange triangle demonstrates the
structures commonly affected—tunica albuginea, corpus cavernosum,
corpus spongiosum, and Buck fascia. B, Transverse ultrasound image
of a grade 3 penile fracture. A defect is noted in the right Buck fascia
(arrow), with a heterogeneous haematoma (stars) restrained by an
intact Colles fascia
7
Figure 5A. Alternately, injury to the superficial dorsal vein, which
is located outside the Buck fascia, allows ecchymosis to extrava-
sate throughout the subcutaneous tissues of the penis.20 Refer
to Figure 5B.
Grade 1: This subtype represents minimal disruption wherein there
is a defect in the tunica albuginea as well as disruption to the
adjacent corpus cavernosum,27 as shown in Figure 6A. Figure 6B
illustrates a hypoechoic defect in the tunica albuginea with the
injury encroaching into the left corpus cavernosum.
Grade 2: Also associated with minimal disruption, this subtype
describes a defect in the tunica albuginea and corpora
cavernosum with associated perialbugineal and cavernosal
haematoma formation27 (Figure 7A). Figure 7B demonstrates a
defect in the echogenic tunica albuginea and a haematoma of
mixed echogenicity on either side of the tunica albuginea, in
the right corpus cavernosum and deep to an intact Buck
fascia.27
Grade 3: Indicative of moderate fascial plane disruption, involvement
encompasses the tunica albuginea, Buck fascia, and the corpus
spongiosum,27 as illustrated in Figure 8A. Ultrasound representation
of this subtype displays haematoma on either side of a
FIGURE 9 A, Schematic diagram representative of grade 4 penile
fracture in the transverse section. Orange triangle denotes injury
commonly incorporating—tunica albuginea, corpus cavernosum,
corpus spongiosum, Buck fascia, and urethra. B, Longitudinal
ultrasound image of the corpus spongiosum. Echoes noted in urethra
lumen representative of blood
8 NAPIER
disrupted Buck fascia, but contained by an intact Colles fascia
(Figure 8B).
Grade 4: This is the most serious grade, indicating major disruption
with the spongiosum and urethra being compromised,27 as
demonstrated in Figure 9A. Under normal circumstances, the ure-
thra is not readily identified on ultrasound because the lumen is
free of pathological entities. Figure 9B displays a urethral lumen
containing echoes representative of blood, in association with a
haematoma of the corpus spongiosum. In addition to this, urethral
disruption can also be evident sonographically when a discontinua-
tion of the lumen, the presence of air in the cavernosal bodies, and
oedema or haematoma of the corpus spongiosum are identified.8
7 | L I M I T A T I O NS A N D P I T F A L L S
The literature conveys that the most common limitation of ultrasound
in the detection of penile fracture is its operator‐dependant nature,
the diagnosis determined by the examiners level of clinical knowledge
and technical skill.21,24 Because of the rarity of this entity, inexperi-
enced operators are at a higher risk of missing subtle lesions, espe-
cially those obscured by haematoma and/or oedema.21 Furthermore,
the presence of haematoma or swelling at the site of fracture can ren-
der the visualisation of a tunical tear difficult, especially if the defect is
24
small in dimension.
A study conducted by Mehrjardi et al24 concluded that another
significant limitation of ultrasound in displaying a true positive result
was the location of the tunical defect. Fractures located at the base
of the penis detected at magnetic resonance imaging (MRI) and surgi-
cal intervention had been an oversight by ultrasound examination in
12% of the sample volume.24
8 | C O N CL U S I O N
Considering that increased patient morbidity can result from injuries
masquerading as a true penile fracture,6 the role of ultrasound in
accurately differentiating equivocal cases is paramount. This is
particularly important when delays in diagnosis and surgical interven-
tion can contribute to poor patient outcomes and long‐term complica-
tions. Rupture of penile vasculature and extra‐albugineal haematoma
are entities that can closely resemble the appearance of a penile
fracture clinically, but the superior resolution of ultrasound can reduce
the likelihood of an incorrect diagnosis and an inappropriate
management strategy. As ultrasound is noninvasive, cost‐effective,
and a readily accessible modality, it should play a pivotal role in
confirming or excluding a clinical suspicion of penile fracture.
ACKNOWLEDGEMEN TS
The author acknowledges the contribution of William Troy and Ellen
Wilson in the creation of the graphics used in this review article.
FUND ING
None.
CONFLIC T OF INT E RE ST
None.
ORCID
Donna Napier http://orcid.org/0000-0002-1585-9614
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https://doi.org/10.1002/sono.12167