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Penile fracture or rupture is a rare event, however one that requires emergency diagnosis and intervention. It is a rupture of the penile tunica albuginea of the corpora cavernosa or spongiosum caused by trauma to an erect penis, most commonly during sexual intercourse. The urologist needs to know whether the tunica albuginea is ruptured and if the rupture extends to the urethra to determine if an emergent surgical exploration is indicated.
Patients typically have a characteristic history of trauma in an erect penis: a 'crack' may be heard with associated severe pain, loss of erection (detumescence) and a suddenly swollen penis 7,8. The characteristic bruising and swelling that develops has been described as the 'eggplant' or 'aubergine' deformity or sign 7,8. Additionally, gross evidence of urethral injury may also be present, such as blood at the meatus, hematuria, or difficulty voiding 8.
During an erection the tunica albuginea thins and thus it is susceptible to mechanical injury. The corpora cavernosa is injured as soon as tunica albuginea is breached. However, urethral injury is associated only with a very severe injury.
In the West, it is assumed that most penile rupture is due to trauma during sex, however in the Middle East, taqaandan is not uncommon 7:
- sexual intercourse: generally occurs when the erect penis hits against the perineum or pubic symphysis
- during vaginal sexual intercourse is most common cause in Western populations
- non-sexual trauma involving an erect penis (e.g. rolling over in bed onto an erect penis)
- the practice of 'taqaandan': manually bending the erect penis to achieve detumescence
- a more common etiology in Middle Eastern populations
- animal bites
Fractures usually occur in distal two-thirds of the penis 1, and is usually unilateral, being more common on the right 7.
Shukla et al. 5 proposed an ultrasound-based grading system of penile rupture that is helpful in defining the extent of the injury.
Emergency ultrasound is usually the initial imaging modality, but because the penis is often markedly swollen and painful, it may not be worthwhile. MRI of the penis is the most useful study to determine the extent of injury. A retrograde urethrogram may be of use in the post-operative period particularly if there is urethral involvement.
The tunica albuginea is usually seen as a hyperechoic linear band in the penis covering the corpora cavernosa and the corpus spongiosum. A hypoechoic breach in this band of fibrous tissue may be seen especially along the penile longitudinal axis. An associated collection or hematoma may also be seen alongside the breach.
Tunica albuginea is a hypointense band on all sequences. A tear can be seen as T2 hyperintense breach. MRI can accurately determine if the fracture is transversely or longitudinally oriented. It can also accurately depict the depth and extent of the tear.
This invasive interventional procedure is often avoided but may depict the tear in corpora cavernosa.
Urethral rupture or post-traumatic stricture can be depicted by this imaging.
Treatment and prognosis
If there is no tunica albuginea rupture, the injury can be managed non-operatively with cold compresses and simple analgesia 7. However, in cases of tunica albuginea rupture, it is better to explore surgically and repair the tunica, to reduce the chances of fibrous plaque formation or angulated penis 1. Urethral injury should always be chosen for exploration and urethral repair as early as possible.