Fractured Penis

A urological emergency: rupture of the tunica albuginea of the corpus cavernosum, almost always from direct blunt trauma to an erect penis. The tunica normally withstands intracavernosal pressures up to ~1,500 mmHg, but thins from 2mm to 0.25mm when fully engorged — the ventral surface next to the urethra, its weakest point, is where most ruptures occur, which is why urethral injury often accompanies it (more likely when both corpora rupture).

Mechanism

Most commonly sexual intercourse (the erect penis slipping from the vagina and striking the perineum or pubic bone), also masturbation injuries, falls onto an erect penis, or deliberate forceful bending to hasten detumescence (taqaandan, practised in some Middle Eastern, North African and Central Asian cultures).

History

A sudden, audible snapping or cracking sound at the moment of injury, with immediate loss of erection (detumescence). Extensive bruising and swelling develop rapidly in the penis, scrotum, and lower abdomen.

Examination

The classic “eggplant deformity” — ecchymosis, swelling, and angulation of the penis, usually deviating away from the side of the rupture. Check for blood at the meatus, haematuria, or voiding difficulty, which raise suspicion of an associated urethral injury.

Investigations

Diagnosis is primarily clinical. Imaging rarely changes management and can delay theatre — don’t let it hold up surgical referral:

• Ultrasound — readily available, but operator-dependent and can be obscured by a large haematoma.
• MRI — more accurate (one study: 100% sensitivity, 78% specificity for tunica rupture) but not first-line given availability/cost.
• Retrograde urethrogram or intraoperative cystoscopy if urethral injury is suspected — international urology guidelines differ on preference (intraoperative cystoscopy avoids the urethrogram’s higher false-positive rate and avoids delaying theatre).

Management

Urgent urology referral for prompt operative repair — evacuation of the haematoma, direct inspection and suture repair of the tunica defect, with urethral repair over a Foley catheter if injured. Delay worsens outcomes: one study found a delay of ~8 hours substantially increased postoperative erectile dysfunction. Conservative management carries a significantly higher rate of long-term erectile dysfunction than immediate repair, except after collagenase (clostridium histolyticum) injection for Peyronie’s disease, where conservative management is preferred if the urethra is intact.