What is Penile Fracture?

Penile fractures, which are quite rare, happen as a result of a blunt force to the penis, often during sexual activity. When the penis is erect and experiences a sharp blow, the pressure inside the penis can dramatically increase and, if it’s severe enough, cause the protective layer around the penis to rupture, which is known as a ‘penile fracture’.

If a penile fracture isn’t treated quickly, it can lead to long-lasting sexual problems. Because of the serious potential long-term effects of this injury, penile fractures are seen as real emergencies in urology, the area of medicine that focuses on urinary and sexual health. Therefore, it’s important to quickly identify, evaluate, treat, and manage penile fractures to prevent any lasting damage.

What Causes Penile Fracture?

A penile fracture usually happens due to physical injury to the penis during sexual activity. In a specific study, it was found that over half of the patients with confirmed penile fractures experienced this type of direct blow to the penis while it was erect during sex. The penis might inadvertently slip out of the vagina and hit the area between the anus and genitals, or the pelvic bone, due to vigorous movement. This can lead to a sudden increase in pressure inside the penis which is filled with blood during an erection. The boosted pressure ultimately leads to a rupture, and the resulting tear can cause a sudden loss of erection, swelling, bruising, changes in penis shape, blood clots, and instant pain.

There can also be complications like a tear in the urinary tract which leads to difficulty in passing urine. This happens in around 20% of the cases, and in up to 30% of cases, there can be damage to the spongy tissue inside the penis. The sexual positions most commonly associated with penile fractures are traditionally thought to be when the woman is on top or ‘doggy style’. However, studies show that no specific sexual position carries a higher risk.

Other causes of penile fractures can include injuries during masturbation, falling while having an erection, forcefully pivoting the penis for vigorous penetration, rolling over the penis while sleeping, and anal sex. In some Middle Eastern, North African, and Central Asian cultures, deliberately bending the erect penis downward to lose the erection quickly (known as ‘taqaandan’) is commonplace and can also lead to penile fractures.

Risk Factors and Frequency for Penile Fracture

Penile fractures primarily happen to men, especially those between the ages of 30 and 50. Although most of the time, these men are heterosexual, penile fractures can also occur in homosexual men. In fact, according to one study, about 1.8% of these injuries happen to homosexual men. Therefore, regardless of a man’s sexual orientation, if they report any form of injury to their sexual organ, the possibility of a penile fracture should be considered.

Interestingly, research indicates that these injuries happen more frequently during summer and on weekends. Every year in the United States, approximately 1 in every 175,000 men experience this kind of injury. In certain parts of the world where a procedure known as taqaandan is common, it’s usually the leading cause of penile fractures.

Penile fractures usually occur in men between ages 30 to 50 years old.
While mostly seen in heterosexual men, these injuries can also occur in homosexual men.
Regardless of sexual orientation, if a man reports an injury to their genital area, the possibility of a penile fracture should be considered.
These injuries are reported to occur more often during the summer and on weekends.
In the United States, annual rate of occurrence is about one case per 175,000 men.
In areas where a procedure known as taqaandan is common, it is often the most frequent cause of these injuries.

Signs and Symptoms of Penile Fracture

Penile fractures can often occur during sexual activity. Common symptoms that may indicate a penile fracture include:

Bending of the penis, typically away from the injury
An erect penis when the injury happened
Bruising and major swelling of the penis and the area around it
Sudden loss of erection
Genital pain
Hearing a “pop” or “snapping” sound (as reported by the patient)
Physical injury to the genitals

A doctor will generally conduct a thorough physical examination to confirm a suspected penile fracture. During this examination, they may observe:

A penis that is bent
A bruised shaft (often referred to as an “eggplant” deformity due to its color and shape)
A flaccid penis or an erection that is uneven
Significant swelling along the penis shaft
Tenderness of the penis

Testing for Penile Fracture

Penile fractures are usually identified by a doctor during a physical exam. The shape of the penis may look abnormal, like an eggplant, and lean away from the area of the fracture. It may not be immediately clear if there is also damage to the urethra, the tube that carries urine from the bladder.

If there is blood at the opening of the urethra, in the urine, or if a person is having trouble urinating, this could indicate a urethral injury. Medical guidelines suggest testing for a urethral injury if it’s suspected, either during surgery, or before surgery with a kind of x-ray called a retrograde urethrogram. Some experts prefer the test during surgery to avoid false positives and delay in getting to surgery.

Other tests may be done before surgery to look for more injuries. If a penile fracture is suspected from just the person’s medical history, it is important to check for other injuries as well. There are many ways to identify penile fractures and diagnose urethral injuries.

Ultrasound is a commonly available method that can be done quickly in emergency rooms. However, its use in diagnosing specific injuries to the penis can be complicated because it depends on the experience of the operator and can be difficult to interpret, especially if there is notable bruising.

Computed Tomography (CT) scans can provide detailed information about the location and size of an injury. However, CT scans expose the patient to radiation, particularly to the genital area, and it also costs more. CT scans are not often used because they can delay getting the patient into surgery and don’t often affect how the surgery is done.

Magnetic Resonance Imaging (MRI), although not the fastest or cheapest option, can help doctors diagnose and manage penile fractures. One study found that an MRI could correctly identify all penile fractures with a high level of specificity.

Data from a procedure called cavernosography can also be helpful. However, like MRI and CT scans, this test is usually reserved for cases where the physical exam and medical history don’t provide enough information for a diagnosis, and a more detailed examination is required.

Treatment Options for Penile Fracture

When a penile fracture happens, the standard treatment is immediate surgery to repair the injury. Before the operation, antibiotics should be administered.

Surgeons start the procedure by making an incision, often around the head (or “crown”) of the penis. This allows the skin of the penis to be pulled back, giving surgeons a clear view of the damaged area.

Once the skin has been opened, the next step is to remove any blood that has collected in the space due to the injury. This is typically done to ensure that the layer surrounding the penile structures – the tunica – can be thoroughly examined for damage.

The surgeon will also check the tube where urine passes – the urethra – for any injuries. Even if no urethral damage was suspected before the operation, a check during surgery is standard procedure. If there is any uncertainty, an additional test using a scope might be performed.

A thin tube, called a Foley catheter, is often inserted during the operation, even if the urethra isn’t injured. This helps stabilize the penis during surgery and acts as a useful reference point for the surgeon. Normally, the catheter is taken out the day after surgery.

To mend the torn tunica, absorbable stitches are used. Stitches made on the sides of the wound are optional. Some surgeons may hide the stitches to reduce the chance of scarring after surgery.

To make sure the surgical repair was successful and that there are no unidentified injuries, a dye solution may be injected into the penis. This helps to identify any leaks or sewn areas. A rubber band-like device might be applied to the base of the penis for this test.

If another layer of tissue around the penis, known as Buck’s fascia, is torn, it should also be repaired during the procedure. If a collection of blood is formed in the scrotum, it needs to be drained out via surgery.

It’s crucial to perform the surgery as soon as possible after the fracture happens, to promote better healing and reduce complications. Studies show that waiting can raise the chances of long-term issues, such as erectile dysfunction.

However, in very limited cases, such as when the penis is weakened due to a certain type of injections for Peyronie’s disease, the fracture may be managed conservatively without surgery, especially if the urine tube is not injured.

If the urethra has been torn, it’s usually fixed with smaller, absorbable stitches. The Foley catheter should be left in place for at least two weeks, and a special urine test needs to be done before removing the catheter.

After surgery, it’s important to instruct patients on taking care of the surgery site and advising them on when to seek urgent medical care. Patients should also be informed to avoid sexual intercourse during the recovery period.

When a doctor is trying to diagnose a penile fracture, they need to rule out a number of other conditions that could cause similar symptoms. Here are some conditions they might consider:

Anasarca, a general swelling of the whole body
Coagulation disorders, which affect blood clotting
Dorsal vein rupture, a broken vein along the top of the penis
Dependent penile edema, or penis swelling due to fluid build-up
Paraphimosis, an uncomfortable penis problem
Pelvic trauma, or injury to the pelvic area
Penile cellulitis, a bacterial skin infection
Penile contusion, or a penis bruise
Priapism, which is a long-lasting and often painful erection
Thrombocytopenia, a lower-than-normal number of platelets in the blood
Urethral tear, a tear or rupture in the tube where urine travels from the bladder out of the body

Each of these conditions requires different treatments, so it’s important for the doctor to make the correct diagnosis.

What to expect with Penile Fracture

If a penile fracture is quickly identified and repaired, the outlook is typically excellent. However, there is a chance of long-term effects on sexual function due to the injury. Immediate surgical repair of the fracture and any related injuries to the urethra can reduce the chances of complications.

Institutions that regularly handle such injuries generally report better patient outcomes.

Possible Complications When Diagnosed with Penile Fracture

Penile fractures can cause a range of complications. The most noticeable is sexual dysfunction, which all patients will experience to some degree. In most cases, it occurs right after surgery but can often last longer. Following a fracture, patients often experience anxiety about their sexual performance. This can lead to changes in sexual behavior due to fear of getting injured again. Professional counseling may help patients cope with these psychological effects and minimize sexual dysfunction.

Surgical complications can include lumps and scar tissue, curvature of the penis, erectile dysfunction, painful erections, infection, the need for further surgery, narrowing of the urethra, hardening of the penis, formation of cysts in the penis, swelling around the wound, and urinary problems. These can be more noticeable if non-absorbable stitches are used during the surgery.

Another potential risk is a possible injury to the urethra, the tube through which urine and semen are expelled from the body. This requires careful action during surgery to avoid any problems. If such an injury isn’t noticed and addressed, it could lead to:

Abscess, or pocket of pus forming on the penis
Curvature of the penis
Erectile dysfunction
Extravasation, or leak of body fluid outside where it should go
Fibrosis and formation of plaque
Formation of abnormal connections between blood vessels and the urethra
Blood in urine
Formation of lumps at the injury site
Painful erections
Painful intercourse
Narrowing of the urethra
Difficulty in emptying the bladder
Formation of a urinoma, or pool of urine that’s collected outside the bladder
Weak flow of urine

Without surgical treatment, penile fractures are associated with more complications, specially in relation to erectile dysfunction. Moreover, patients might have excessive scarring that results in a curved penis, painful erections, and loss of penile length during erections. Therefore, taking into account these risks and benefits, timely operation to fix the fractures is generally the best approach, and this should be openly discussed with patients.

Recovery from Penile Fracture

It’s crucial for patients to get easy-to-understand instructions for after-surgery care, as this knowledge can significantly aid in their recovery. For example, patients need to be aware of the importance of looking after their Foley catheter, which is likely to stay in place for around two weeks. This catheter is critical in safeguarding any repairs that might have been made to the urethra during surgery.

In addition, they should also be informed about how to properly care for the surgical cut, or the incision, on the penis and when they can resume sexually related activities. Maintaining cleanliness of the wound and avoiding contamination is important. Patients must also not shave around the wound area and should keep it dry unless advised otherwise by their healthcare provider.

Preventing Penile Fracture

It’s important that patients are educated about the usual causes of injury to the penis. This education should include the importance of safe sexual habits. Patients should be advised to avoid sexual positions that are too intense or unusual, as these can lead to injuries to the penis. Furthermore, the cultural practice of forcefully bending an erect penis, known as taqaandan, followed in some Middle Eastern, African, and Central Asian cultures, should be discouraged for its potential harm.

Those who have had surgery should be taught how to take care of their surgical wound. They should be given clear step-by-step instructions about what to do after the operation and when to come back for a check-up.