The erectile tissue fills with blood during arousal, causing the penis to stiffen (erection). If the penis is suddenly strongly bent or compressed during sexual intercourse (for example, if it accidentally slips out of the vagina), the connective tissue capsule surrounding the erectile tissue (tunica albuginea) can tear.
Schematic representation of a penile rupture
A penile fracture isnot a break or fracture in the strict medical sense, as the penis does not consist of bone but of soft tissue such as connective tissue, ligaments and blood vessels. The 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 is always a medical emergency that requires immediate assessment by a doctor.
The typical symptoms of a penile fracture are
- cracking sound during tearing
- Bruising (haematoma) with dark red-bluish discoloration of the penis
- swelling
- Severe and stabbing pain
A cracking sound can often be heard during the tearing of the erectile tissue. The penis immediately goes limp (detumescence) and there is pronounced pain in the injured area.
This is followed by massive bruising and visible swelling, which can also affect adjacent organs such as the testicles, epididymis or spermatic cords. The bruising causes the penis to turn a dark red to bluish color.
The usually transverse tear in the connective tissue capsule surrounding the erectile tissue can be felt in some cases. The penis often shows an unnatural curvature (deviation) to the non-ruptured side due to the hematoma. If blood oozes from the urethral orifice (meatus urethrae), this may indicate an additional injury to the urethra.
As a rule, a penile fracture can be diagnosed on the basis of the typical symptoms. The differential diagnosis must be differentiated from a ruptured vein. In addition, the exact location and extent of the rupture should be determined and possible involvement of neighboring structures should be ruled out. The following examinations can be used for this purpose:
- Ultrasound examination of the penis (sonography)
- Cavernosography (X-ray examination of the erectile tissue after contrast medium administration)
- Magnetic resonance imaging
An ultrasound examination of the penis can be used to visualize the tear in the connective tissue capsule and the hematoma on the penis shaft and scrotum (scrotum).
In doubtful cases, radiographic imaging of the corpora cavernosa can clearly rule out a penile rupture. Magnetic resonance imaging can be used to clearly localize the penile fracture.
The following therapeutic measures are available
- conservative therapy
- Surgical exposure of the penile shaft
Conservative therapy
Conservative therapy consists primarily of physical rest, cooling and compressive bandages as well as medication against possible erections (antiandrogens, sedatives). Antibiotic treatment is also often recommended to prevent bacterial infections.
Purely conservative treatment is statistically associated with more complications than surgery. For this reason, emergency surgery or elective surgery is generally recommended. Conservative measures are then only used on a temporary basis. An operation is described as elective if its timing can be freely determined - in contrast to an emergency operation that has to be performed immediately.
In the literature, emergency surgery is often recommended for penile fractures. This is probably not necessary, as elective surgery also leads to good results. In any case, however, affected men should visit the emergency room immediately to minimize the risk of complications later on.
Surgical exposure of the penile shaft and suturing of the lesion
As part of the surgical procedure, the tears in the erectile tissue are closed. If the location of the tear is uncertain, an access to the penile shaft is created by circumcising the foreskin (circumcisional approach); if the location is certain, a lateral access is created. The attending physician then sutures the affected erectile tissue with absorbable suture material.
If the urethra is involved, it is also treated and a bladder catheter is inserted, which takes over the function of the urethra until it has healed (three to seven days).
Once the penis is closed, it is bandaged to prevent further swelling. To avoid painful erections and to protect the cavernous suture, the patient is given additional medication (e.g. the anti-androgen bicalutamide or sedative benzodiazepines).
A four-week period of sexual abstinence is also recommended.
With appropriate treatment, a penile fracture heals well, although erectile dysfunction may occur as a result of the trauma. Conservative treatment measures lead to more complications than surgery. They can be accompanied by a curvature of the penis (penile deviation) and subsequent pain in the affected area.
More rarely, expanding haematomas (increasing bruising) and swelling that does not subside or diverticula (protrusions in the erectile tissue) may occur. There is a risk of urethral stricture (narrowing of the urethra), particularly if the urethra is involved. This in turn can lead to bladder and kidney problems.