Double penile fracture without urethral injury presenting after 7 days.

Penile fracture is the sudden rupture of the tunica albuginea of an erect penis due to blunt trauma. It is an uncommon uropathology which characteristically occurs when one or both of the turgid penile corpora cavernosa forcefully snap under an abrupt blunt trauma, usually during an aggressive sexual intercourse or noncoital manipulation. In the majority of cases, diagnosis is clinical. Surgical repair irrespective of the time of presentation results in accelerated recovery, reduced morbidity, and fewer short and long-term complication rates. We report the case of a 35-year-old banker who sustained a bilateral rupture of the tunica albuginea without urethral injury during a heterosexual intercourse. He presented 7 days after the trauma to our facility following the persistence of symptoms despite conservative management with herbal medicine. Following a clinical diagnosis of penile fracture, he had penile exploration under regional anesthesia using a degloving subcoronal incision. He subsequently had repair of both corporal tear after clot evacuation. The postoperative period was uneventful, and he was discharged on the 3rd day after the surgery. He had been followed up for 2 years with good erectile and functional outcomes. This case report reiterates the fact that late presentation is not a barrier to surgical management and good outcome.

INTRODUCTION

Penile fracture is an acute urologic condition resulting from an abrupt rupture of the tunica albuginea of one or both corpora cavernosa following blunt trauma to the erect penis. Penile fracture is comparatively rare and frequently underreported.[1] The etiology of the trauma ranges from vaginal intercourse to noncoital causes.[1234] The predominant cause depends greatly on the geographical location of the report.[3] The attendant pathological lesion is a tear of the tunica albuginea of one or both corpora cavernosa with occasional extension into the corpus spongiosum and the urethra. Characteristically, patients volunteer a history of a snapping or popping sound during sexual activity, followed immediately by pain and a sudden penile detumescence. Besides, there is a resultant occurrence of substantial edema and hematoma, giving rise to the phenomenal “eggplant deformity.”[15]

The diagnosis is usually clinical.[156] However, a meta-analysis of penile fracture cases by Amer et al.[7] in 2016 revealed that radiological studies may be indicated in some complex cases. Prompt surgical exploration and repair of albugineal tears and associated injuries is the standard management as it is associated with minimal complications.[58]

This case report is aimed at highlighting the need for surgical exploration and repair despite delayed presentation as well as shed some light on the factors responsible for delayed presentation in the sub-Saharan Africa.

CASE REPORT

A 35-year-old married banker presented to our facility with penile pain and swelling of 7 days’ duration following a traumatic sexual intercourse. He was having sexual intercourse with his wife in a male-dominant position when his penis slipped out of the vagina and forcefully thrust against her perineum. Following this, he heard a “pop” sound followed by a sharp distressing penile pain and immediate detumescence. Shortly after, he developed a gradual swelling of his penis. There was no history of bleeding per urethra and had no difficulty with voiding. He denied the use of performance-enhancing medications and does not ingest alcohol or take hard drugs in any form. He had no curving of the penis before the trauma. Following the above, he immediately applied a warm compress and took some over-the-counter medications for 24 h. With worsening of symptoms, he sought help in an herbal home where the penis was “splint” with thin strips of wood tied around it and was given some herbal concoctions to ingest. He presented to our facility, 7 days after the trauma, on account of the persistence of symptoms.

Examination revealed a swollen penis in favor of the left side and angulated to the right [Figure 1]. The penile shaft had a palpable defect on the left proximal portion with a positive rolling sign, but the scrotal sac was unremarkable. His urinalysis revealed no microscopic hematuria.

Figure 1

Typical penile “eggplant” deformity

The diagnosis of penile fracture was made on account of the above clinical findings. The penis was explored under regional anesthesia using a degloving subcoronal incision and the blood clots [Figure 2] were removed. A 2.5-cm defect in the left corpus cavernosum at the proximal penile shaft and a 0.5-cm tear in the right corpus cavernosum around the midportion were noted following clot evacuation. The urethra was spared. Both defects were repaired with 3/0 vicryl sutures [Figure 3]. A urethral catheter was passed to temporarily divert urine. He had a straight penis following surgery [Figure 4]. Ciprofloxacin was given prophylactically, and low-dose ketoconazole (200 mg daily) was given for 5 days to prevent immediate postoperative erections following a normal liver function test. The patient had a hitch-free postoperative period. The urethral catheter was removed 2 days after the surgery, and he was discharged on the 3rd day. He was told to avoid sex for 8 weeks.

Figure 2

The fracture sites with clotted blood

Figure 3

Both tears repaired

Figure 4

Immediate straightening of the penis just after surgery

He was followed up for 2 years, and had no signs of erectile dysfunction, pain, or deformity during erection. This was corroborated by the wife when questioned separately in one of the clinic visits.

DISCUSSION

Penile fracture is a comparatively rare genitourinary trauma worldwide. A recent work by Amer et al.[7] noted a total of 3213 cases globally. In Nigeria, it is uncommon and often underreported due to the embarrassment associated with the condition. Of the 1331 cases reported in the literature across the globe in 2001 by Eke,[3] only 11 were from Nigeria.

Penile fracture is more common in younger males, with mean ages mostly in the third and fourth decades of life.[15] The age of this patient falls within this age range and that of other reported mean ages in the literature.[16] The frequency of this pathology at this age bracket may be attributed to the attendant bizarre sexual escapades and experimentation associated with this highly sexually active age group.

The etiology of penile fracture in this patient was vaginal intercourse in the male-dominant position. This conforms with the findings of Barros et al.[1] in Latin America and Amer et al.[7] in Europe, but at variance with those of Salako et al.[5] in Nigeria and Zargooshi[6] in Iran. This buttresses the fact that the chief cause of penile fracture is determined by the geographical location of the report.[3]

The clinical presentation of penile fracture is classical in the majority of patients and except for some complicated cases, investigations only lead to delay in presentation-to-intervention time.[156] This patient presented with features that are typical of penile fracture with no findings suggestive of urethral injury, obviating the need for imaging studies. Imaging investigations should be done for cases in which the clinical history and examination findings are at variance or for those with complications such as urethral injuries.[157]

Most patients in our environment now present early probably due to increased awareness and health-seeking behavior.[245] This patient, however, presented after 7 days due to ignorance. Other authors have reported shame and embarrassment as some reasons why patients delay in presenting to health units.[5] The dearth of urological surgeons and inaccessibility of the few available experts are other factors encouraging delayed presentation by patients with penile fracture, especially in the sub-Saharan Africa.

The patient in the present study had postoperative erection suppressed with a 5-day course of low-dose oral ketoconazole (200 mg daily) after a normal liver function test. The effectiveness of ketoconazole in preventing postoperative erection, though recently being frowned at because of its hepatotoxicity particularly at high dose, has been variously reported.[910] Other commonly used drugs include cyproterone acetate and antiandrogens.[3]

Despite the delayed presentation, the patient had penile exploration and repair of the bilateral corporal tears. The recovery of erectile function despite delayed presentation buttresses the fact that surgical repair provides excellent outcomes at all times.

CONCLUSION

Penile fracture is a rare genitourinary trauma. Ignorance, shame, embarrassment, and relative inaccessibility of urological services in the remote parts of the sub-Saharan Africa, still play major roles in delayed presentation. Surgical repair of corporal tear offers excellent functional and erectile outcomes even in late presentation and should be the first-line management option for all patients with penile fracture irrespective of the time of presentation.

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 initial will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.