Penile Fracture | |
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Penile fracture | |
Specialty | Urology |
Symptoms | Immediate pain and swelling of the penis, rapid erection loss, discoloration of the penile shaft [1] |
Complications | Gangrene, erectile dysfunction, Peyronie's disease |
Causes | Blunt trauma to an erect penis |
Risk factors | Sexual intercourse, masturbation |
Diagnostic method | Based on symptoms, ultrasound |
Differential diagnosis | Testicular torsion |
Treatment | Emergency surgery |
Prognosis | ~10–50% of people develop erectile dysfunction or Peyronie's disease [2] |
Frequency | ~1 per 175,000 men per year [3] |
Penile fracture is rupture of one or both of the tunica albuginea , the fibrous coverings that envelop the penis's corpora cavernosa . It is caused by rapid blunt force to an erect penis, usually during vaginal intercourse, or aggressive masturbation. [4] It sometimes also involves partial or complete rupture of the urethra or injury to the dorsal nerves, veins and arteries. [5]
A popping or cracking sound, significant pain, swelling, immediate loss of erection leading to flaccidity, and skin hematoma of various sizes are commonly associated with the sexual event. [4] [6]
Penile fracture is a relatively uncommon clinical condition. [7] Vaginal intercourse and aggressive masturbation are the most common causes. [4] A 2014 study of accident and emergency records at three hospitals in Campinas, Brazil, showed that woman on top positions caused the greatest risk with the missionary position being the safest. The research conjectured that when the receptive partner is on top, they usually control the movement and are not able to interrupt movement when the penis suffers a misaligned penetration. Conversely, when the penetrative partner is controlling the movement, they have better chances of stopping in response to pain from misalignment, minimizing harm. [7]
The practice of taqaandan (also taghaandan) also puts men at risk of penile fracture. Taqaandan, which comes from a Kurdish word meaning "to click", involves bending the top part of the erect penis while holding the lower part of the shaft in place, until a click is heard and felt. Taqaandan is said to be painless and has been compared to cracking one's knuckles, but the practice of taqaandan has led to an increase in the prevalence of penile fractures in western Iran. [8] Taqaandan may be performed to achieve detumescence. [9]
Ultrasound examination is able to depict the tunica albuginea tear in the majority of cases (as a hypoechoic discontinuity in the normally echogenic tunica). In a study on 25 patients, Zare Mehrjardi et al. concluded that ultrasound is unable to find the tear just when it is located at the penile base. In their study magnetic resonance imaging (MRI) accurately diagnosed all of the tears (as a discontinuity in the normally low signal tunica on both T1- and T2-weighted sequences). They concluded that ultrasound should be considered as the initial imaging method, and MRI can be helpful in cases that ultrasound does not depict any tear but clinical suspicions for fracture are still high. In the same study, authors investigated accuracy of ultrasound and MRI for determining the tear location (mapping of fracture) in order to perform a tailored surgical repair. MRI was more accurate than ultrasound for this purpose, but ultrasound mapping was well correlated with surgical results in cases where the tear was clearly visualized on ultrasound exam. [10] The advantage of ultrasound in the diagnosis of penile fracture is unrivaled when its noninvasive, cost-effective, and nonionising nature are considered. [11]
Penile trauma can result from a blunt or penetrating injury, the latter being rarely investigated by imaging methods, almost always requiring immediate surgical exploration. In the erect penis, trauma results from stretching and narrowing of the tunica albuginea, which can undergo segmental rupture of one or both of the corpora cavernosa, constituting a penile fracture. [2]
In the ultrasound examination, a lesion of the tunica albuginea presents as an interruption in (loss of continuity of) the echoic line representing it (Figure 4). Small, moderate, or broad hematomas demonstrate the extent of that discontinuity. Intracavernous hematomas, sometimes without the presence of a tunica albuginea fracture, can be observed when there is a lesion of the smooth muscle of the trabeculae surrounding the sinusoid spaces or the subtunical venular plexus. [2]
In 10–15% of penile traumas, there can be an accompanying urethral lesion. When blood is observed in the urethral meatus, contrast-enhanced evaluation of the urethra is necessary. In cases in which the ultrasound findings are inconclusive, the use of magnetic resonance imaging can facilitate the diagnosis and is recommended by various authors. [2]
Penile fracture is a medical emergency, and emergency surgical repair is the usual treatment. Delay in seeking treatment increases the complication rate. Non-surgical approaches result in 10–50% complication rates including erectile dysfunction, permanent penile curvature, damage to the urethra and pain during sexual intercourse, while operatively treated patients experience an 11% complication rate. [4] [12]
In some cases, retrograde urethrogram may be performed to rule out concurrent urethral injury. [12]
In the United States, the case of Doe v. Moe , 63 Mass. App. Ct. 516, 827 N.E.2d 240 (2005), tested liability for a penile fracture injury caused during sexual intercourse. The court declined to find duty as between two consensual adults. The plaintiff in this case, a man who suffered a fractured penis, complained that the defendant, his ex-girlfriend, had caused his injury while she was on top of him during sexual intercourse. The court ruled in her favor, determining that her conduct was neither legally wanton nor reckless.
Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.
The urethra is the tube that connects the mammalian urinary bladder to the urinary meatus. In placental mammals, the urethra transports urine through the penis or vulva during urination and semen through the penis during ejaculation.
Peyronie's disease is a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis. Specifically, scar tissue forms in the tunica albuginea, the thick sheath of tissue surrounding the corpora cavernosa, causing pain, abnormal curvature, erectile dysfunction, indentation, loss of girth and shortening.
A urethral stricture is a narrowing of the urethra, the tube connected to the bladder that allows the passing of urine. The narrowing reduces the flow of urine and makes it more difficult or even painful to empty the bladder.
Hypospadias is a common malformation in fetal development of the penis in which the urethra does not open from its usual location on the head of the penis. It is the second-most common birth defect of the male reproductive system, affecting about one of every 250 males at birth, although when including milder cases, is found in up to 4% of newborn males. Roughly 90% of cases are the less serious distal hypospadias, in which the urethral opening is on or near the head of the penis (glans). The remainder have proximal hypospadias, in which the meatus is all the way back on the shaft of the penis, near or within the scrotum. Shiny tissue or anything that typically forms the urethra instead extends from the meatus to the tip of the glans; this tissue is called the urethral plate.
Chordee is a condition in which the head of the penis curves downward or upward, at the junction of the head and shaft of the penis. The curvature is usually most obvious during erection, but resistance to straightening is often apparent in the flaccid state as well. In many cases but not all, chordee is associated with hypospadias. This is not the same condition as Peyronie's disease, which involves curvature of the shaft of the penis most commonly due to injury during adult life.
Urethral sounding is the practice of inserting objects into the urethra for sexual gratification. Urethral dilatation is a urological procedure that uses probes called sounds to enlarge the inside diameter of the urethra and locate obstructions in the urethra, or as a treatment for urethral strictures.
Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.
Radical retropubic prostatectomy is a surgical procedure in which the prostate gland is removed through an incision in the abdomen. It is most often used to treat individuals who have early prostate cancer. Radical retropubic prostatectomy can be performed under general, spinal, or epidural anesthesia and requires blood transfusion less than one-fifth of the time. Radical retropubic prostatectomy is associated with complications such as urinary incontinence and impotence, but these outcomes are related to a combination of individual patient anatomy, surgical technique, and the experience and skill of the surgeon.
Testicular rupture is a rip or tear in the tunica albuginea resulting in extrusion of the testicular contents, including the seminiferous tubules. It is a rare complication of testicular trauma, and can result from blunt or penetrating trauma, although blunt trauma is more likely to cause rupture.
Urethroplasty is the surgical repair of an injury or defect within the walls of the urethra. Trauma, iatrogenic injury and infections are the most common causes of urethral injury/defect requiring repair. Urethroplasty is regarded as the gold standard treatment for urethral strictures and offers better outcomes in terms of recurrence rates than dilatations and urethrotomies. It is probably the only useful modality of treatment for long and complex strictures though recurrence rates are higher for this difficult treatment group.
A retrograde urethrography is a routine radiologic procedure used to image the integrity of the urethra. Hence a retrograde urethrogram is essential for diagnosis of urethral injury, or urethral stricture.
Diphallia, penile duplication (PD), diphallic terata, or diphallasparatus is an extremely rare developmental abnormality in which a male is born with two penises. The first reported case was by Johannes Jacob Wecker in 1609. Its occurrence is 1 in 5.5 million boys in the United States.
The mechanics of human sexuality or mechanics of sex, or more formally the biomechanics of human sexuality, is the study of the mechanics related to human sexual activity. Examples of topics include the biomechanical study of the strength of vaginal tissues and the biomechanics of male erectile function. The mechanics of sex under limit circumstances, such as sexual activity at zero-gravity in outer space, are also being studied.
Bulbar urethral necrosis is a problem that can occur after a pelvic fracture associated urethral distraction defect (PFUDD).
The septum glandis, also septum of the glans, refers to the fibrous partition of the ventral aspect of the glans penis that separates the two glans wings in the ventral midline. The septum extends from the urethral meatus through the glanular urethra and ends in the tunica albuginea of the human penis. Externally it is attached to the frenulum which extends lower on the neck of the penis.
Genital trauma is trauma to the genitalia.
A penile injury is a medical emergency that afflicts the penis. Common injuries include fracture, avulsion injury, strangulation, entrapment, and amputation.
Rupture of the urethra is an uncommon result of penile injury, incorrect catheter insertion, straddle injury, or pelvic girdle fracture. The urethra, the muscular tube that allows for urination, may be damaged by trauma. When urethral rupture occurs, urine may extravasate (escape) into the surrounding tissues. The membranous urethra is most likely to be injured in pelvic fractures, allowing urine and blood to enter the deep perineal space and subperitoneal spaces via the genital hiatus. The spongy urethra is most likely to be injured with a catheter or in a straddle injury, allowing urine and blood to escape into the scrotum, the penis, and the superficial peritoneal space. Urethral rupture may be diagnosed with a cystourethrogram. Due to the tight adherence of the fascia lata, urine from a urethral rupture cannot spread into the thighs.
Penile ultrasonography is medical ultrasonography of the penis. Ultrasound is an excellent method for the study of the penis, such as indicated in trauma, priapism, erectile dysfunction or suspected Peyronie's disease.