A 36-year-old man heard a sudden popping sound during intercourse with a woman in the reverse coitus position and immediately developed pain in the penis, swelling, and detumescence of the penis.
The swelling was confined to the length of the penis, and blood was observed at the meatus. The base of the penis was tender to palpation. A Foley catheter was gently advanced into the meatus and clear urine was obtained. The patient was advised, but refused, admission to the hospital, and penile exploration was initially refused. Several days later, the patient presented to the ER with profuse bleeding from the meatus (Figure 1) and consented to exploration of the penis and repair of the injuries.
The patient was brought to the operating room and exploration was conducted through a degloving incision of the penis. The Foley catheter was removed and replaced with a sterile 18 French Foley catheter intraoperatively. Exploration revealed a torn right corpus cavernosum approximately 300° circumferentially, with a torn urethra also about 300° circumferentially (Figure 2).
The left corpus cavernosum was intact. The right corpus cavernosum was repaired with a running 3-0 monocryl suture. The urethra was completely mobilized from the underlying corpora cavernosa for 1 to 2 cm proximal and distal to the injury and then repaired with an interrupted 3-0 monocryl suture over the Foley catheter. Some of Buck’s fascia was interposed between the urethral repair and the corpus cavernosum repair to help prevent future fistula formation.
Penile fracture is defined as a disruption or tear of the tunica albuginea of the corpus cavernosum in the penis. The mechanism for this injury is most commonly the erect penis slipping out of the vagina and thrusting against the perineum or the pubic bone, causing a sudden bending of the penis and resulting in a buckling injury to the penis and a tearing of the tunica albuginea of the corpus cavernosum. The tensile strength of the tunica albuginea can resist tearing until the intracavernous pressure exceeds 1500 mm Hg.1 When intracavernous pressure of the penis exceeds the tensile strength of the tunica albuginea with the sudden bending of the penis, the result is shearing of the tunica albuginea. The most common causes include reverse coitus–woman on top, doggy style intercourse, anal intercourse, masturbation, rolling over on the erect penis, and the self-inflicted bending of the penis practiced in Iran and called taqaandan.2 The most common signs and symptoms of penile fracture include a cracking or popping sound, sudden penile pain, rapid detumescence of the penis, and sudden swelling and discoloration of the penis.
For the surgical repair, I recommend using synthetic absorbable sutures, either 3-0 or 4-0. A circumcising degloving incision gives access to all three corporal bodies and the entire penile shaft and allows for separation of the neurovascular bundle if necessary. However, midline penoscrotal, inguinoscrotal, and lateral penile incisions have been used by other urologists. It is advisable to circumcise all men at the end of the procedure to prevent phimosis postoperatively. The corpus cavernosum and spongiosum injuries are almost always at the same level. It is advisable to interpose Buck’s fascia or another soft tissue flap between the two corporal injuries to help prevent fistula formation between the corporal bodies. If a urethral injury is repaired, a Foley catheter should be left indwelling for 7 to 10 days. To help prevent a missed cavernosal injury, the urologist can create an artificial erection by mixing saline with indigo carmine, creating a tumescence that will allow for evaluation of the repair and identification of any other corporal injuries. Finally, for evaluating urethral injuries in patients presenting with blood at the urethral meatus, flexible cystoscopy in the operating room is preferable because significant false-negative rates have been reported with retrograde urethrography.2 Flexible cystoscopy allows direct visual evaluation of the urethra prior to placement of the Foley catheter. A Foley catheter is a good idea intraoperatively to help identify the urethra and prevent inadvertent injuries to the urethra during the dissection.