Penile Fracture, Penile Break, or Penile Rupture - Specialists & Information

During sexual arousal, the erectile tissues fill with blood, causing the penis to stiffen (erection). If the penis is suddenly bent sharply or compressed during sexual intercourse (for example, if the penis accidentally slips out of the vagina), the connective tissue capsule surrounding the corpora cavernosa (tunica albuginea)—a firm layer of connective tissue—can tear, particularly during sexual intercourse in certain positions, such as the cowgirl position. In rare cases, a penile fracture can also occur during masturbation.

Schematic representation of a penile fracture

A penile fracture is therefore not a fracture in the strict medical sense, since the penis consists not of bone but of soft tissues such as connective tissue, ligaments, and blood vessels. The technically correct term would therefore be corpus cavernosum rupture.

With an incidence (frequency) of 1 in 175,000 new hospital admissions, a penile fracture is a very rare condition. However, it always constitutes a medical emergency that requires immediate medical evaluation.

The typical symptoms of a penile fracture are:

• a snapping sound during the rupture
• Bruising (hematoma) with a dark red-bluish discoloration of the penis
• Swelling
• severe, stabbing pain
• In severe cases, blood in the urine
• Pain when urinating

A cracking sound can often be heard as the erectile tissue tears. The penis immediately loses its erection (detumescence), and severe pain occurs in the injured area.

This is followed by the formation of a massive hematoma and visible swelling, which may also affect adjacent organs such as the testicles, epididymis, or spermatic cords. Due to the hematoma, the penis turns dark red to bluish in color.

The tear in the connective tissue capsule surrounding the corpus cavernosum—which usually runs transversely—can be palpated in some cases. Often, due to the hematoma, the penis exhibits an unnatural curvature (deviation) toward the side that is not torn, a condition clinically described as penile curvature. If blood is coming out of the urethra (meatus urethrae), this may indicate an additional injury to the urethra.

As a general rule, a penile fracture can be diagnosed based on the typical symptoms. Differential diagnosis requires ruling out a venous rupture. In addition, the exact location and extent of the tear should be determined, and involvement of adjacent structures should be ruled out. The subsequent course of treatment depends on the severity of the injury. The following examinations may be used for this purpose:

• Ultrasound examination of the penis (sonography)
• Cavernosography (X-ray examination of the corpora cavernosa after administration of a contrast agent)
• Magnetic resonance imaging (MRI)

An ultrasound examination of the penis can visualize the tear in the connective tissue capsule as well as bruising on the penile shaft and scrotum.

In cases of uncertainty, an X-ray examination of the corpora cavernosa can definitively rule out a penile fracture. Magnetic resonance imaging can be used to precisely locate the penile fracture.

The following therapeutic measures are available for treating a penile fracture:

• Conservative therapy
• Surgical exposure of the penile shaft

Conservative therapy

Conservative therapy primarily consists of physical rest, cooling and compression bandages; medications are also prescribed to prevent possible erections (antiandrogens, sedatives). To prevent bacterial infections, the administration of an antibiotic is often recommended.

Statistically, purely conservative therapy is associated with more complications than surgical intervention. Therefore, emergency surgery or a so-called elective procedure is generally recommended. Conservative measures are then used only as a temporary measure. A procedure is considered elective if its timing—unlike an emergency requiring immediate surgery—can be freely determined.

The medical literature often recommends emergency surgery for a penile fracture. This is likely unnecessary, as elective surgeries also yield good results. In any case, however, affected men should seek immediate care at the emergency room to minimize the risk of later complications.

Surgical Treatment

In surgical treatment, the tears in the corpora cavernosa are closed during the procedure. To do this, if the location of the tear is not clearly identified, an incision is made through the foreskin (circumcision approach); if the location is clearly identified, an incision is made laterally on the shaft of the penis. The treating physician then sutures the affected corpus cavernosum using absorbable suture material.

If the urethra is involved, it is also treated, and a urinary catheter is inserted to take over the function of the urethra until complete healing occurs (three to seven days).

After the incision in the penis is closed, a dressing is applied to prevent further swelling. To avoid painful erections and to protect the sutures in the corpus cavernosum, the patient is prescribed additional medications (such as the antiandrogen bicalutamide or sedative benzodiazepines).

In addition, four weeks of sexual abstinence is recommended.

With appropriate treatment, a penile fracture heals well, although erectile dysfunction or sexual dysfunction may occur as a result of the trauma. Conservative treatment methods lead to more complications than surgical intervention. They may be associated with penile curvature (penile deviation) as well as subsequent pain in the affected area. Without treatment, it may become impossible to achieve an erection.

Less commonly, further expanding hematomas (enlarging bruises) as well as persistent swelling or diverticula (protrusions in the erectile tissue) may occur. Particularly when the urethra is involved, there is a risk of urethral stricture (narrowing of the urethra). This, in turn, can lead to bladder and kidney problems. In rare cases, the condition may also progress to induratio penis plastica (scarring of the connective tissue capsule surrounding the corpora cavernosa).