Introduction

A fractured penis is typically the result of a forceful bending trauma to an erect penis; not all trauma results in this rare urological emergency.^1,2 A tear in the tunica albuginea, in which the patient typically hears a “snapping” sound followed by sharp penile pain and prompt detumescence, characterizes this (fig. 1).^2-4 A hematoma-ecchymosis then develops, generating its characteristic eggplant deformity, and the penis typically pointing to the contralateral side of the injury (fig. 2).¹ Despite its diagnosis being customarily performed and confirmed on clinical findings and surgical exploration, respectively, penile ultrasound and magnetic resonance imaging (MRI) are useful especially in equivocal cases (fig. 3).^2,5,6

Figure 1. Horizontal tear of tunica albuginea, requiring dissection of neurovascular bundle for repair.

Figure 2. Eggplant deformity, with penis pointing to contralateral side of PF.

Figure 3. MRI demonstrating tear of tunica albuginea, confirming PF (purple arrow).

In Western culture, penile fractures (PFs) are routinely associated with missed intromission during sexual intercourse, while in other parts of the world such as the Middle East, penile manipulation, known as “Taghaandan,” is the most common culprit.^6,7 Unique scenarios can be encountered, such as post-intralesional injections of collagenase Clostridium histolyticum (CCH) and recurrent fractures, in which the algorithmic treatment may differ.

Recurrent PF

The occurrence of a recurrent PF is an even rarer event. In the literature it has been reported to occur in the same area of a previous fracture, in a different location in the ipsilateral corpora and even in the contralateral corpora.^8-14 After a PF has been repaired, the deposition of collagen is usually completed after 6 weeks; after this, collagen remodeling will occur and the final tensile strength of the tissue will continue to transpire for up to 2 years.⁹ Fractures that occur at the same site suggest that unwounded tissue will still have more strength than scarred tissue.^8,9 However, other authors have suggested that this fibrotic scar tissue can predispose to fractures at a different location in the ipsilateral corpora.^12,15 The reasoning for this is that the surrounding uninjured corpora could be considered weaker when compared to the inelastic scar overlying a previously healed fracture.¹² This inelastic scar tissue could also act as a source of unmatched axial pressure distribution within the corpora, leading to a fracture in the contralateral side.^8,13

Surgical repair for recurrent fractures is recommended. The use of a bovine pericardium patch to reinforce the sutured site has been reported with successful outcome.⁸

PF Post-Intralesional CCH Injection

PFs occurring after CCH injections usually occur at the site of injection.¹⁶ Although sexual trauma is the main cause of these fractures, they have also been reported with penile modeling, nighttime tumescence, and even with the use of a vacuum erection device.^16-18 These occur due to the ongoing degradation of tunica; therefore complete abstinence without any type of sexual activity is recommended for 4 weeks after starting each cycle due to the continuous effects of CCH on the tunica.^17,19 Therefore, any correction or surgical repair to the area of injury may be violated until penile tissue remodeling is completed.¹⁷

Conservative management should be considered in PF occurring post-intralesional CCH injection, especially in patients who are hemodynamically stable, without worsening hematoma or a urethral injury.^16,17 Compressive dressing, oral analgesics and penoscrotal elevation should be utilized in this specific scenario.¹⁷ When these fractures have been surgically repaired, poor tissue quality has been noted which could make appropriate tunical closure difficult, even requiring the use of a graft.¹⁹ It is important to note that no significant differences regarding erectile function, changes in penile curvature, and physician and patient satisfaction were noted among the group that underwent surgical exploration/repair and conservative management.¹⁹

Conclusion

Despite surgical management being the recommended management for PF, the final decision for care should be determined by the etiology and the circumstances in which the fracture occurred. In cases of recurrent fractures, immediate repair should be performed and a graft can be considered when the fracture occurs at the same site to further improve the strength in this area. In PF post-CCH therapy, conservative management should be considered. However, if there is concomitant urethral injury or expanding hematoma, surgical repair should be performed. If surgical intervention is to be performed, one can also consider a graft for repair, since the area at the injected site will continuously remodel and have weaker tensile strength.