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Abstract
Penile fracture with an associated urethral injury is a rare urological emergency resulting from trauma to the erect penis during vigorous sexual intercourse. The patient often presents with swelling of the penis, discoloration of the penile skin, localized pain, and hematuria with a typical history of sudden detumescence during intercourse. Subcoronal penile degloving incision has been conventionally described and is frequently used by many clinicians for the management of penile fracture-urethral injury. Here, we describe a case of complex penile fracture managed through the vertical penoscrotal incision. The penoscrotal approach confers excellent exposure to both the ruptured corpus cavernosum and urethra. This approach ensures successful outcomes in such an emergency procedure without having disadvantages of the degloving incision.
Keywords: Case report, male urological surgical procedure, penile disease, penile fracture
How to cite this article: Introduction 
Penile fracture is defined as the disruption of the tunica albuginea with rupture of corpus cavernosum.[1] Most penile fractures occur during sexual intercourse, usually due to the hitting of the penis to the perineal region and rarely due to masturbation and other sexual activities. It often presents with sudden detumescence after a typical cracking sound during sexual intercourse followed by the rapid development of swelling over the shaft of the penis and discoloration of local skin, pain, and penile deformity.[2] Penile fracture associated with urethral injury is quite rare. In Asian countries, the incidence of associated urethral injury is significantly lower (3%–6%) than in the western world (20%–25%).[3] An associated urethral injury should be suspected in patients with gross hematuria and also in patients with difficulty in micturition.[4] Early and immediate penile fracture repair has lower complication rates and better outcomes; however, recent studies have revealed that long-term outcomes of early versus delayed repair (up to 7 days) in patients without urethral involvement are similar.[5] However, penile fracture-urethral injury needs urgent exploration because of having more complications such as urine extravasation and stricture formation. In the present case, an early exploration was done to take care of corpora and urethra. The decision for penoscrotal incision was taken after localizing the tear, and the tunica and urethra repair were done through the same incision.
Case Report A 45-year-old male presented to emergency with complaints of swelling and discoloration of the penile shaft for more than 12 h after sexual intercourse. During intercourse, the patient felt a crackling sound followed by sudden detumescence. The patient developed pain and swelling associated with reddish-brown discoloration of the penile shaft and skin. These symptoms were associated with gross hematuria and pain during the micturition. The patient was evaluated and on examination, a defect on the right ventrolateral aspect of the penis was felt and a provisional diagnosis of penile fracture with urethral rupture was made. Emergency ultrasonography of the penis confirms the diagnosis of penile fracture but it was equivocal for urethral injury. The plan of urgent penile exploration was made.
After appropriate consent, the patient was taken to the operation room, and the flexible cystourethroscopy was done to confirm the associated urethral injury. On urethroscopy, a urethral defect on the right proximal penile region extending from 7 to 11 O'clock position was noted [Figure 1]. A 16 Fr silicone Foley catheter was placed over the guidewire gently. A decision of penoscrotal incision was taken and penile exploration was done. Penile structures opened in layers and a diffuse hematoma of size about 3 cm × 2 cm was noted [Figure 1]. The corpora cavernosa and corpus spongiosum were identified. The defect on tunica albuginea was identified in the ventral aspect of the right corpus cavernosum which was extending behind the urethra to the left cavernosum [Figure 2]. The urethra was mobilized from the right side (ruptured albuginea side), and a transverse partial tear of the urethra was noted as it was also noted in urethroscopy. After saline wash, watertight repair of the corpora was done with 3-0 delayed absorbable running suture. The urethral repair was done over the already placed silicone catheter with the same suture in an interrupted manner [Figure 2]. The wound was closed in layers and autism spectrum disorder was done. The patient was discharged on the next day with the Foley catheter in situ for 2 weeks in well and stable condition. The broad-spectrum antibiotic was advised for the next 7 days. The catheter was removed on day 14th and the patient voided well. At the 6-month follow-up, he is voiding well, having no erectile dysfunction (ED), no penile curvature, or nodule.
Figure 1: (a) Urethroscopy showing tear of the urethra between 7 and 11 O'clock position (green arrow), (b) hematoma noted after exploration through the penoscrotal incision (arrow)
Figure 2: (a) Rupture of right tunica albuginea with a tear in right corpora (arrow), (b) repair of albuginea and corpora with running delayed absorbable suture (green arrow) and urethra with interrupted suture (blue arrow) Discussion Penile fracture is a rare urological emergency it implies the rupture of tunica albuginea in an erect penis due to an excessive external bending force during sexual activities.[6] A meta-analysis study done by Amer et al. found sexual intercourse as a cause of fracture penis in 46% of the patients followed by forced flexion (21%) and masturbation (18%) in a pooled data of over 3000 patients. In the present case, also the culprit was violent sexual intercourse. The increased risk of penile fractures during tumescence is related to the stretching and thinning of tunica albuginea which is the thinnest at the ventral aspect of the penis (0.5 mm as compared to 2 mm at other sites).[3],[6]
Penile fracture most of the time presents with isolated rupture of tunica albuginea and corpora cavernosa. The association of urethra rupture is ranging from 1% to 38% in different literature. An associated urethral injury should be suspected if there is blood at meatus, microscopic, or gross hematuria, with or without voiding difficulty.[7] Diagnosis of penile fracture is mainly clinical, although there may be an absence of typical signs and symptoms. Associated urethral injuries may or may not present with hematuria and at times can pose a challenge to complete diagnosis. Therefore, an adequate history and good physical examination are cornerstones of the diagnosis of penile injury complex.
Our patient presented with typical history, signs and symptoms with gross hematuria leading to a diagnosis of penile fracture with urethral injury. Physical examination findings were corroborated with ultrasound (US) findings. Most cases reported in the literature describe imaging modalities being used to exclude the presence of a concomitant urethral injury and to delineate the exact location of the albuginea rupture. Various imaging modalities have been used to aid in the diagnosis, such as cavernosography, retrograde urethrography, ultrasonography-color Doppler, and magnetic resonance. Cavernosography is an invasive method that is rarely used. Ultrasonography is the most commonly used modality because of its cost and easy availability. Magnetic resonance imaging (MRI) is the most accurate method to localize lesions, but its use is limited due to cost, availability, and time consumption. The role of imaging is largely limited to unclear cases with equivocal findings or unreliable history.[4],[8] It is also believed that retrograde urethrography is not needed in the era of flexible cystoscopy, which provides an accurate view of urethral patency. With the combination of a thorough history, clinical examination, and flexible cystoscopy, other diagnostic methods such as US, MRI, or cavernosography might not be required.[9] In the present case, because of strong suspicion of urethral injury, we did on-table flexible cystoscopy, and the tear on the urethra is delineated very well. By doing on-table flexible cystoscopy, we could avoid contrast extravasation and other complications of retrograde urethrogram.
The management of the penile fracture is mainly early exploration and surgical repair but variables outcomes of early and delayed repair are mentioned in the presently available literature. Fewer complications were noted with patients managed surgically, with 88.6% reporting sufficient erections for intercourse with no voiding dysfunction or penile curvature compared to 66.7% of those managed conservatively. The benefits of surgical management over conservative therapy are well proven and universally accepted. A systematic review and meta-analysis done by “Wongal” et al. identified no statistical difference between the timing of penile fracture repair ([early <24 h from the time of injury to presentation/surgery] vs. delayed [≥24 h]) and rates of ED and tunical scar formation. Although the gold standard for penile fracture is surgical repair, they suggested that a brief delay may be acceptable in select patients.[5]
Several techniques for the surgical repair of penile fractures have been proposed, most commonly used is penile degloving (with a circumferential or subcoronal incision) followed by penoscrotal incision and longitudinal incision directly over the hematoma. The classical subcoronal degloving incision is useful in cases with significant penile swelling or extensive hematomas, as well as in cases where the location of tunical rupture cannot be determined clinically or by the US, or the rupture is located dorsally.[10] Disadvantages of the penile degloving incision are the extensive dissection of Buck's fascia, it is often required circumcision, and risk of distal penile/preputial skin necrosis. The advantages of penoscrotal incisions are an easy exploration of the base of both corpora cavernosa where most penile fractures statistically occur and also direct access to the penile urethra in cases of urethral injuries. With this incision, there is always a possibility of extending the incision if necessary and it also leads to avoidance of unnecessary extensive dissection in Buck's fascia, which is the case with the “degloving” technique.[10] In the past 4 years, we repaired eight cases of penile fracture-urethral injury through the same vertical penoscrotal exposure. In all the cases, exposure to the corpora and urethra were excellent and none of the patients required circumcision.
Conclusion Immediate surgical repair of penile fracture with or without associated injuries gives better anatomical and psychosocial outcomes. The penoscrotal approach is reliable, reproducible, and suitable for the most penile fracture and it gives adequate exposure to deal with associated urethral injury also.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Research quality and ethics statement
The authors followed applicable EQUATOR Network (http://www. equator-network. org/) guidelines, notably the CARE guideline, during the conduct of this report.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
References 
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CheckDOI: 10.4103/jets.jets_154_21
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