|Year : 2004 | Volume
| Issue : 2 | Page : 123-125
Penile fractures: Results of delayed repair
Manohar Shetty, RB Nerli, Shailesh Kamat, Abhinandan Sadalge, Vinay K Patil, Shrishailesh Amarkhed
Department of Urology, KLE Society's Hospital and Medical Research Centre, Belgaum, India
Department of Urology, KLES Hospital and MRC, Nehrunagar, Belgaum - 590 010
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objectives : To assess the results of delayed repair of penile fractures.
Methods: The patients presenting with penile fractures constituted study group. Those who have come after 24 hours of sustaining , penile injury are considered as delayed presentation. Five of the total 7 patients were in delayed group. All the patients were treated by surgical correction.
Results: Except for mild wound infection in 2 patients, there were no bothersome complications. The results were as good as with early repair and there was no increased risk of erectile dysfunction in penile fractures.
Conclusions: The surgical correction need not be deferred in delayed presentation of penile fractures.
Keywords: Fracture penis, tunica albuginea. delayed repair, erectile dysfunction.
|How to cite this article:|
Shetty M, Nerli R B, Kamat S, Sadalge A, Patil VK, Amarkhed S. Penile fractures: Results of delayed repair. Indian J Urol 2004;20:123-5
| Introduction|| |
"The harder the penis is, the more vulnerable it is to injury". Fracture penis (rupture of the tunica albuginea or corpus cavernosum) is a rare but probably under-reported entity and it truly represents an urological emergency.  Penile fractures occur to the erect penis as a result of blunt trauma commonly during coitus or masturbation.  Fracture is normally manifested by a cracking sound accompanied by immediate severe pain and detumescence, followed by rapid swelling and widespread echymosis.  A palpable tunical defect and a hematoma with a "rolling sign" are pathognomonic features.  All recent reports favor early surgical repair due to the adequate functional and cosmetic results with minimal complications and this is in contrast to old reports favoring conservative management.  This is because conservative treatment is associated with very high complication rates reaching as high as 53% of patients.  However, the timing of repair from the time of injury has never been well defined, although most series indicate that repair is needed as soon as the patient presents; but unfortunately due to the social and personal scenario surrounding the occurrence of these events some men may delay seeking medical help immediately.  This is more so in developing countries due to poverty, ignorance, living in remote places, poor transportation, etc. There are very few reports available on the results of delayed repair of penile fracture. We have evaluated our own experience with 7 patients of penile fractures, majority of whom underwent delayed repair.
| Patients and Methods|| |
Over a period of 7 years between 1996 and 2002 we have treated 7 patients with penile fractures. Among them, 5 patients presented to us 24 hours after sustaining penile injury. All the 7 patients were treated by surgical exploration because of the presence of significant hematoma. The repair was done with subcoronal circumferential degloving incision with evacuation of hematoma and repair of the laceration using 3-0 vicryl suture material with interrupted, inverting knots. Watertight closure was confirmed at the end of repair by artificial induction of erection by saline injection. The skin was approximated using 3-0 catgut. The patients were discharged second day onwards depending on the wound status. The follow up period ranged from 7 weeks to 2 years during which the history was taken regarding erectile activity, pain, sexual performance, presence of nodule/plaque and angulation followed by physical examination of the penis. Details of the patients are summarized in Table.
| Results|| |
Five out of 7 patients underwent repair 24 hours after sustaining penile injury which we considered as delayed repair. The dissection in these patients was not difficult except in 1 wherein the delay was 8 days. The tear size ranged from 1.0 x 0.5 cm to 2.5 x 1.5 cm. The patients were discharged if the wound was found healthy. Three patients were discharged on 2nd postoperative day, 2 on 3rd , 1 on 5th and another on 8 th postoperative days (average 3.6 days). Two patients developed mild postoperative wound infection, which was treated with antibiotic and wound dressing. In the follow-up period, 2 patients complained of slight bend of the penis to the affected side but with no sexual problem. On artificial induction of erection in these 2 patients there was only minimal deviation of the penis to the side of repair without any chordee. There was no history of erectile dysfunction in any of the patients.
| Discussion|| |
Penile fracture, even though uncommon, is an urologic emergency that may have devastating physical and psychological consequences. The prompt diagnosis and expedient surgical correction of the condition gives excellent results. The rupture of tunica albuginea occurs due to its marked thinning from a resting thickness of 2 mm to 0.25-0.5 mm on erection together with the associated marked short-term pressure increases (intracaversonal pressures exceeding 450 mm Hg), which approach or exceed the tunica tensile strength during acute abrupt loading or bending of the erect penis.  The classical pathological injury to the erect penis is usually a transverse tunical rupture of one corporal body, but the involvement of both corpora, corpus spongiosum and urethra can occur. , Small injuries to the tunica albuginea that go unrecognized may result in Peyronie's disease and/or impotence.  However, recent reports suggest that penile fracture is not associated with an increased risk of erectile dysfunction. ,
Immediate surgical correction of the tunical defect is recommended which not only decreases the length of hospital stay but also allows early resumption of sexual activity, , minimizes the risk of complications like fibrous tissue formation, chordee, painful erection and other psychosocial problems.  But due to various reasons patient may present to us after days of sustaining penile fracture. There is no clear description of what is delayed repair. Even though Cummings et al  have described delayed repair defined as more than 8 hours after injury, we have considered a delay of more than 24 hours as delayed repair. There are few reports of delayed repair. In a report by Anselmo et al  two patients underwent delayed repair at 2 and another at 8 days of injury with latter patient having a good result and the other had a, mild chordee with a fibrous area. Cummings et al  in their report of 3 patients with a delay of 24-40 hours found good results with normal straight erections postoperatively. Cendrom et al  also observed similar encouraging results in their series.
In our group of 7 patients, 5 (71%) attended our hospital more than 24 hours after sustaining injury and in all the patients surgical corrections were performed. We have used subcoronal circumferential degloving incision for all patients. The average size of the tunica albuginea lacerations was 1.7 x 1.0 cm [Figure - 1]. Such large tears are also noted by Cummings et all (1.5, 2 and 3 cm), Cendron et al' (2, 3 and 3 x 2 cm) and Kundu et al" (1-2.5 cm). In all likelihood, this much large defects would have healed with a significant scarring if treated conservatively leading to development of chordee. The wide separation of the transversely torn edges of tunica albuginea is probably due to the retraction of the longitudinally arranged elastic fibers in it. The presence of hematoma may add to the local fibrous reaction. So, the evacuation of hematoma and approximation of torn edges of the tunica albuginea should give much better results than conservatively managed patients irrespective of the time of repair. The generally accepted procedure in delayed presentation of penile fractures is to do surgery only if there is extensive/increasing hematoma or extravasation of contrast on cavernosogram and in others a conservative management is suggested. With our experience this is to be questioned and we suggest surgical correction in all cases of fracture penis irrespective of the time of seeking treatment. Javaad Zargooshi.  in his review of 170 cases, has concluded that there is no relationship between the time of repair and the development of complications, and no difficulty in dissecting the penis in delayed cases and hence there is no optimum time and no emphasis on immediate surgery. Even though, ours is a small number of patients, the observation supports that of Zargooshi. A large proportion of patients (71 %) presented late to us after sustaining penile fracture. This is probably because this center is a referral hospital and caters to a large number of rural population who defer the treatment for various reasons. Although patients can be discharged within 24 hours of surgery, our patients were discharged after 48 hours as the patients were from remote places and preferred to stay back for wound observation. All of our patients were in the younger age group ranging from 22-36 years: a period of maximum sexual activity. Surgical correction in the patients provides a shorter period of hospital stay, early resumption of work and sexual activities and thus less psychological trauma.
| Conclusions|| |
The penile fractures mostly consist of a significant laceration of tunica albuginea with wide separation of torn edges. Surgical exploration can be considered in all cases of fracture penis to evacuate hematoma and repair tunica albuginea to minimize the subsequent scarring process that could ultimately lead to penile deformity. The procedure is simple with minimal morbidity even in delayed cases. The `time lag' factor need not be considered in planning the treatment for penile fracture. There is no evidence of increased risk of erectile dysfunction in patients with penile fracture, undergoing delayed surgical repair.
| References|| |
|1.||Cedron M, Whiemore KE, Carpiniello V, Kurzwell SJ, Hanno PM, Snyder HM et al. Traumatic rupture of the corpus cavernosum: evaluation and management. J Urol 1990; 144: 987-91. |
|2.||El-Bahansawy MS, Gomha MA. Penile fractures: the successful outcome of immediate surgical intervention. Int J Imp Res 2000; 12: 273-7. |
|3.||Gontero P. Sidhu P, Muir GH. Penile fracture repair: assessment of early results and complications using color doppler ultrasound. Int J Imp Res 2000: 12: 125-9. |
|4.||Narayansingh V, Raju JC. Fracture of the penis. Br J Surg 1985; 72: 309-16. |
|5.||Kalash SS. Young JD. Fracture of the penis: controversy of surgical versus conservative treatment. Urology 1984; 24: 21-4. |
|6.||Cummings M. Parra RO, Boullier JA. Delayed repair of penile fracture. J Trauma 1998; 45: 153-4. |
|7.||Penson DF. Seftel AD, Krane RJ, Frohrib D, Goldstein I. The hemodynamic pathophysiology of impotence following blunt trauma to the erect penis. J Urol 1992: 148: 1171-80. |
|8.||Javaad Zargooshi. Penile fracture in Kermanshah, Iran: The longterm results of surgical treatment. Br J Urol 2002; 89: 890-4. |
|9.||Asgari MA, Hossein SY, Safarinejad MR. Samadzedeh B, Bardideh AR. Penile fractures: evaluation, therapeutic approaches and longterm results. J Urol 1996; 155: 148-9. |
|10.||Anselmo G. Fandell A, Faggiano L, Merlo F. Maccatrozzo L. Fractures of the penis: therapeutic approach and long-term results. Br J Urol 1991: 67: 509-11. |
|11.||Kundu AK. Ghosh G, Kaviraj SP. Fracture penis: A complication of sildenafil citrate! Ind J Urol 2002; 18: 143-5. |
[Figure - 1]
[Table - 1]