|Year : 2002 | Volume
| Issue : 2 | Page : 143-145
Fracture penis : A complication of sildenafil citrate!
Anup Kumar Kundu, Goutam Ghosh, Sankar Prasad Kaviraj
Department of Surgery and Radiology, North Bengal Medical College & Hospital, Siliguri, India
Anup Kumar Kundu
4, P.C. Sarkar Sarani, Hakimpara. Siliguri - 734 401
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Our experience with 6 consecutive cases of fracture penis, a rare urological injury, in normal male without any erectile dysfunction, who consumed Sildenafil Citrate for prolonged sexual enjoyment out of curiosity. All of them were properly worked up and treated surgically resulting in excellent recovery of function.
Keywords: Fractured Penis; Trauma; Sildenafil Citrate; Colour Doppler; Ultrasonography.
|How to cite this article:|
Kundu AK, Ghosh G, Kaviraj SP. Fracture penis : A complication of sildenafil citrate!. Indian J Urol 2002;18:143-5
| Introduction|| |
Rupture of tunica albugenia or better known entity of `Fracture' of Penis is a rare urological emergency. , The first reported case is attributed to an Arab physician, Abul Kasem in Cordoba, about a thousand years ago, with subsequent reports in 1770 A.D. by Charles Bordon in London and in 1900 A.D. by Lipa Bay  in Cairo.
This article is concerned with the cause, diagnosis, treatment, and long-term outcome of fracture penis. The injury is due, most often, to the erect organ being pushed forcibly downwards, either during coitus, masturbation or otherwise, resulting in a flaccid, painful, bruised and swollen organ. We document our experiences with 6 cases after consuming sildenafil citrate by normal subjects for sexual gratification. In most of the reported cases of fracture penis in the literature the workup has been limited to using clinical findings, urethrogram to assess the injury to the corpora spongiosum and urethra, cavarnosography to assess damage to the corpora cavarnosa. Derks and Hawkins  described the use of ultrasonography for preoperative demonstration of penile haematoma caused by rupture of corporal body. The vascular integrity of the fracture penis was demonstrated by Colour Doppler Ultrasonography of the cavarnosal arteries and penile veins.  All these cases were surgically managed with good results like others. 
| Materials and Methods|| |
6 consecutive cases of fractured penis managed in the span of 3 weeks. All these patients were referred from international border adjoining subdivisional town of North Bengal. The patients ranged from 19 years to 36 years of age and presented from 18 hours to 29 hours after injury, all occurring during sexual intercourse. All of them had a swollen, flaccid penis without urethral injury and were able to pass urine freely.
The diagnosis is based on patients' narrative, clinical findings, ultrasonography (7.5 mhz) and Colour Doppler study of penis.
All these patients illustrated trauma to the erect penis associated with severe pain and immediate detumescence. Snapping sound heard by the patient is one of the clues for this diagnosis.
Physical examination revealed typical features of rupture tunica albugenia, i.e., diffusely swollen penis, discolouration, tenderness and flaccid penis with deviation to the opposite site.
Ultrasonography (7.5 mhz) performed in both longitudinal and transverse axis of penis showed normal texture of corpora cavarnosa with disruption of tunica albugenia, along with ill-defined hypoechoic area (haematoma) representing the site of disruption [Figure - 1]a, b. Urethral continuity was maintained.
Cavarnosal artery showed normal flow pattern in the disrupted area, no high flow region was seen in Colour Doppler Study of penis [Figure - 2]a, b.
All these patients were easily catheterized as a preoperative preparation.
Emergency exploration of the corpora cavarnosum was carried out in all 6 cases through degloving sub-coronal circumferential incision. Haematoma of considerable size was evacuated on each occasion. The tear in the tunica albugenia measured on an average 1.0-2.5 cm in length. The repair of the tunica was performed with 3-0 interrupted atraumatic catgut sutures. The urethral catheters were kept for 48 hours. All these patients received a full antibiotic cover for 7 days and appropriate analgesics.
Immediate postoperative recovery was uneventful in each case with sound healing of the wound and no urinary retention. All of them were discharged on the 4 th postoperative day.
On retrograde evaluation and counseling it was found that all these gentlemen had taken sildenafil citrate without prescription for "sexual gratification". All of them on regular follow-up on 3 rd ,6 th ,12 th ,18 th and 24 th weeks, state a normal and straight erection without visible deformity and fibrosis. Postoperative Ultrasound and Colour Doppler delineate normal anatomy.
| Discussion|| |
Fracture penis is a rare urological emergency caused by blunt trauma to erect penis resulting a tear in the tunica albuginea - so a misnomer. The injury occurs mainly during sexual intercourse or as a result of forceful manipulation of erect penis. The diagnosis is based mainly on clinical findings. But ultrasonography is able to identify the exact site and extent of injury , and some surgeons made surgical incision at the site of tear, it also help to avoid negative surgical exploration. Martinz et al  state that ultrasono graph i c evaluation revealed a haematoma in the corpora cavarnosa or hypoechogenic areas alone, the tunica albugenia. It also showed the tear in tunica albugenia or discontinuity of the tunica.  Colour Doppler Ultrasonographic evaluation demonstrated the integrity of the arteries and cavernous veins,  which corroborate with our study.
Sildenafil citrate is the magic drug of choice for erectile dysfunction patients. The complications of this drug are well known. i.e., facial flushing in 33.5% of cases, headache in 23.4%, nasal congestion in 12.6%, dyspepsia 10.1 % and dizziness in 10.8%. 10% of the population suffer from the above side effects but all these events are short-lived and mild in nature.  But sildenafil citrate may be fatal in heart patients  therefore contraindicated in patients taking organic nitrates.
But no one till today described any patients developing penile fracture like ours after consuming sildenafil citrate. Sildenafil has changed the scenario of erectile dysfunction since its introduction in world market and saved lots of marriages. It is the drug for patients with erectile dysfunction. But in our series all the patients are normal persons and they consumed the drug for enjoyment. All of them confessed that they had enjoyable vigorous intercourse resulting in fracture of their penis, after consuming this drug.
The treatments in all these cases are operative and they had good erection like other patients in the postoperative period. ,,,,,
This story illustrates that irrational use of drugs (sildenafil citrate) for sexual enjoyment by normal male people with active sexual habits may result in a rare urological complication, ie., fracture penis.
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[Figure - 1], [Figure - 2]