Rosen & Barkin's 5-Minute Emergency Medicine Consult (521 page)

BASICS

• Traumatic rupture of the corpus cavernosum and the encompassing tunica albuginea
  
• May involve the corpus spongiosum and urethra
  
• Hematoma formation occurs at rupture site.
  
• Injury is usually unilateral and transverse.
  
• Most common fracture site is the proximal shaft of the penis.
  
• During erection, pressure within the corpus cavernosum is maximal, close to arterial pressure, increasing the volume in each corpus to maximum, which thins the tunica albuginea, making it susceptible to rupture.
  
• Penile erection stretches the spongiosum to the limit, which limits movement vertically while allowing lateral movements; this forms a bend at the base of the penis, making it vulnerable to lateral swing and rupture of corpus cavernosum.
  
• 25–30% have associated urethral injury, which may be partial or complete.
  
• Caused by blunt trauma to erect penis during:
  
  • Sexual intercourse
    
  • Manipulation
    
  • Fall on erect penis
    
  • Entanglement in clothing
    
  • “
    Taghaandan
    ”—Middle Eastern practice of forcefully bending the erect penis to cause detumescence
    

• Peyronie disease
  
• Urethritis in past
  
• Surgical procedure on corpus cavernosum or trauma to corpus cavernosum resulting in weak scar tissue
  

DIAGNOSIS

• Loud popping or crunching sound heard at the time of injury
  
• Immediate detumescence
  
• Severe penile pain
  
• Deviation of the penis away from the side of injury
  
• Penile swelling and ecchymosis
  
• There may be blood at the urethral meatus if there is a urethral injury.
  
• May have dysuria, inability to void, or an increase in the size of the swelling with voiding due to extravasation of urine
  

• Cause of the injury
  
• Sudden painful sensation in erect penis during sexual intercourse or soon after with loss of erection
  
• Blood at the urethral meatus after intercourse
  
• Problems with poor erections after the injury if presentation is delayed
  
• Penile deviation with erection
  
• Urinary retention or weak urinary stream
  

• Swelling and blue-black discoloration at base of penis, usually on one side
  
• Ecchymosis may also involve scrotum.
  
• Penis flaccid and edematous with angulation away from the side of tear
  
• Defect in the penile shaft may be palpable at the site of the tear.
  
• Blood at tip of penis or frank hematuria suggests an associated urethral injury.
  
• Urethrocavernous or urethrocutaneous fistulas may be present as late complications of a penile fracture.
  

• Urinalysis
  
• PT/PTT
  
• Retrograde urethrography if urethral trauma is suspected
  

Urinalysis to evaluate urethral trauma:

• May have frank blood or microscopic hematuria
  
• PT/PTT if patient is on Coumadin or has a history of bleeding disorder
  

• Retrograde urethrography—recommended in all cases of suspected urethral trauma:
  
  • Should be done with low pressure during injection, before urethral catheterization
    
• Cavernosography and MRI of penis may be needed to confirm diagnosis and site of tear.
  
• Ultrasonography may also be done to confirm a suspected tear.
  

Diagnostic exploration of the penis is recommended when cavernosography is negative but clinical suspicion of a fracture is high.

• Cellulitis of penis
  
• Contusion of penis
  
• Lymphangitis of penis
  
• Neoplasm of penis
  
• Paraphimosis
  
• Trauma because of constrictive ring or other structure
  
• Urethral injury
  
• Vasculature rupture, especially superficial or deep dorsal vein or dorsal artery
  

TREATMENT

• Other injuries take precedence in the setting of multiple trauma.
  
• Local treatment: Ice packs to the penis; splinting of the penis with tongue blade
  
• Elevate the area to reduce swelling.
  

• Pain control
  
• Needle suprapubic cystostomy in patients with urethral trauma and a full bladder to relieve patient discomfort
  

• Combined efforts of ED physician and urologist are aimed toward restoration of normal shape of penis and sexual and urinary functions.
  
• ED treatment is directed to reducing hemorrhage, preventing further complications.
  
• Prophylactic antibiotic use is unnecessary.
  
• Urethral catheterization in all cases after excluding urethral trauma
  
• Urologic evaluation and early surgical treatment are essential to prevent complications such as erectile dysfunction, impotence, penile deformity, urethral stricture.
  
• All patients with suspected or definite diagnosis
  must
  have early urologic evaluation.
  

• Diazepam: 2–5 mg IV q1–6h PRN anxiety
  
• Fentanyl: 0.05–0.2 mg IV q1h PRN pain
  
• Hydromorphone: 0.5–1 mg IV q1–2h PRN pain
  
• Lorazepam: 0.5–1 mg IV q1–6h PRN anxiety
  
• Morphine sulfate: 0.1 mg/kg IV q1h PRN pain
  

FOLLOW-UP

If immediate urologic consultation and treatment are unavailable, patient may be transferred to a suitable hospital after initial stabilization and transfer criteria have been met.

Follow up with urologist to ensure adequate repair and return to normal sexual and urinary function.

• Penile fracture is not a rare occurrence.
  
• Coitus and penile manipulation are the most common causes.
  
• Delay in seeking treatment is the major cause of morbidity.
  
• Mainly a clinical diagnosis:
  
  • Cavernosography, MRI, and US may be used to confirm the diagnosis.
    
  • Early surgical repair is important.
    

• Ekwere PD, Al Rashid M. Trends in the incidence, clinical presentation, and management of traumatic rupture of the corpus cavernosum.
  J Natl Med Assoc
  . 2004;96(2):229–233.
  
• El-Assmy A, El-Tholoth HS, Abou-El-Ghar ME, et al. Risk factors of erectile dysfunction and penile vascular changes after surgical repair of penile fracture.
  Int J Impot Res.
  2012;24(1):20–25.
  
• Kamdar C, Mooppan UM, Kim H, et al. Penile fracture: Preoperative evaluation and surgical technique for optimal patient outcome.
  BJU Int
  . 2008;102(11):1640–1644.
  
• Kervancioglu S, Ozkur A, Bayram MM. Color Doppler sonographic findings in penile fracture.
  J Clin Ultrasound
  . 2005;33(1):38–42.
  
• Muentener M, Suter S, Hauri D, et al. Long-term experience with surgical and conservative treatment of penile fracture.
  J Urol
  . 2004;172(2):576–579.
  
• Sawh SL, O’Leary MP, Ferreira MD, et al. Fractured penis: A review.
  Int J Impot Res.
  2008;20:366–369.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Urethral Trauma
  
• Paraphimosis
  

CODES