Penile fracture — disruption of the tunica albuginea with rupture of the corpus cavernosum — is a urologic emergency best managed by prompt surgical exploration and repair, which lowers the rates of erectile dysfunction, penile curvature, cavernosal diverticulum, and chronic pain. Clinical features and work-up are covered in the Trauma topic; this page is the operative reference. Repair within 7 days of injury does not adversely affect outcomes.
Indications
- Suspected penile fracture (a clinical diagnosis in most cases — a cracking/popping sound with immediate detumescence, swelling, ecchymosis, and a palpable tunical defect).
- Equivocal cases confirmed by ultrasound (preferred) or MRI before exploration.
- Evaluate the urethra (urethroscopy or retrograde urethrogram) when there is blood at the meatus, gross hematuria, or inability to void — urethral injury occurs in 10–22% of fractures (more with bilateral corporeal injury).
Approach
- Ventral vertical penoscrotal incision — usually preferred, giving direct exposure since most fractures are ventral or lateral.
- Distal circumcising (degloving) incision — used when the fracture location is uncertain, as it exposes all three penile compartments.
Equipment: 2-0 or 3-0 PDS, 3-0 Vicryl, 4-0 chromic; a Penrose drain as a tourniquet; injectable saline mixed with methylene blue; a 25-gauge butterfly needle; and local anaesthetic.
Surgical Steps
The steps below describe the distal circumcising (degloving) approach:
- Place a holding stitch on the dorsal glans near the coronal sulcus and hold the penis on stretch.
- Mark a circumferential incision ~2 cm proximal to the coronal sulcus (dry the skin so the ink takes).
- Incise down to Buck's fascia (taking care near the urethra) and place a holding stitch at 12 o'clock on the cut skin edge.
- Deglove the penis — use Metzenbaum scissors (closed-then-spread) to dissect the skin off the tunica albuginea, dividing attachments and using gauze for blunt dissection, until the fracture is exposed (stay alert near the urethra).
- Evacuate the hematoma within Buck's fascia.
- Identify the defect — the proximal corpora is the most common site; inducing an artificial erection with saline and methylene blue helps localise the (usually transverse) laceration.
- Repair the tunical defect with interrupted 2-0 or 3-0 PDS sutures.
- Repair any urethral injury — oversew a partial injury with fine absorbable suture over a catheter; debride, mobilise, and repair a complete injury tension-free over a catheter.
- Test the repair — apply a tourniquet proximal to the repair and inject saline–methylene blue via the 25-gauge butterfly needle into the corpus distal to the defect; place additional sutures if a leak is seen.
- Repair the overlying Buck's fascia, obtain hemostasis, reduce the foreskin, and reapproximate the skin with 4-0 chromic.
- Provide analgesia with a dorsal penile nerve block / ring block and apply a dressing.
Postoperative Care
- Broad-spectrum antibiotics.
- One month of sexual abstinence.
Key Exam Points
- Penile fracture = disruption of the tunica albuginea with rupture of the corpus cavernosum, usually during intercourse; the tear is typically transverse, unilateral, and ventral/lateral (the tunica is thinnest at 5–7 o'clock).
- An intact Buck's fascia produces an "eggplant deformity"; disruption causes a butterfly hematoma, and the penis deviates away from the tear.
- Diagnosis is usually clinical; ultrasound is the preferred imaging when equivocal (MRI is most accurate).
- Urethral injury occurs in 10–22% — evaluate it with blood at the meatus, gross hematuria, or inability to void.
- Prompt repair is preferred but can be undertaken up to 7 days after injury without worse outcomes.
- Repair the tunica with interrupted absorbable suture; confirm closure with an artificial erection; advise 1 month of sexual abstinence.