Injured Penis: The Fracture

It's perhaps the greatest irony of a man's sexual life: The harder the penis is, the more vulnerable it is to injury.

Fractures to the penis, although uncommon, do occur when an abnormal force is applied to the erect penis. The 'fracture' is actually a tear in the tunica albuginea, the thick fibrous coat surrounding the corpora cavernosum tissue that produces an erection. It is not a common injury to the penis during sexual intercourse, but it can happen. Penile fracture can only occur with an erection.

Most cases (75 per cent) occur only on one side, but sometimes the injury affects both sides. Also, a small portion of the injured penis population tear extends into the urethra.

Penile fractures can also happen during masturbation. Although, most injuries that result from masturbation come from forcibly hiding an erection without care and fracturing it.

There is one common scenario/position that results in many penis fractures. In this scenario, the female partner is on top during intercourse, as the penis thrusts in and out it becomes dislodged from the vagina and when attempting to reinsert it, the partner comes down hard on the penis, striking the female pelvic bone, and creating a sudden bending of the penis. A sure sign is a loud snap and excruciating pain following the injury, as well as the rapid development of a hematoma or bruise. These injuries are not difficult to diagnose, and symptoms will depend upon the severity of the fracture.

Men with penile fractures will be in excruciating pain and notice black-and-blue marks in close proximity to the injured area on the penis. When the diagnosis is equivocal (a large bruise, but no obvious distortion or destruction) the penis is evaluated with corporal cavernosography. This is the procedure where urologists or radiologists place a fine needle into the corporal body of the penis and inject contrast material in order to examine the shape of the corporal bodies and to test for leakage. If there is a question of urethral injury, a retrograde urethrogram is also performed in which contrast material is instilled down the urethra via a small tube or catheter to test for leakage. Urethral injury is usually evident with blood in the urine.

Historically, conservative therapy was considered the treatment of choice for penile fractures. Conservative therapy consisted of cold compresses, pressure dressings, penile splinting, anti-inflammatory medications, fibrinolytics, and suprapubic urinary diversion with delayed repair of urethral injuries.

However, this concept has fallen into disfavor due to the high complication rates (29-53%) of non-operative therapy. Complication rates of conservative management included missed urethral injury, penile abscess, nodule formation at the site of rupture, permanent penile curvature, painful erection, painful coitus, erectile dysfunction, corporourethral fistula, arteriovenous fistula, and fibrotic plaque formation. Also, another problem with conservative management is that fibrosis of the lining of the corporal body can create a bend and poor healing, similar to the effects of maltreated broken arm. Additionally, complications from expanding blood clots, such as a blood clot accumulation or a hematoma, or an infection of the hematoma can occur as well.

Because of the risk of major complications stemming from penis fractures, surgery is the best treatment for the serious injury. These days, primary goals of surgical repair are to expedite the relief of painful symptoms, prevent erectile dysfunction, allow normal voiding, and minimize potential complications from delay in diagnosis. The faster the torn tissues can be re-approximated, the sooner the healing process can begin. The men with penile fractures caused from sexual intercourse are typically young, sexually active, and highly motivated to resume sexual activity as soon as the healing process is complete. This means that surgery is often the best choice and the best treatment.

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