Introduction

Penile fracture is a rare urological emergency (1). Majority of the patients come to the emergency department immediately after the trauma and are operated for repair in a short span of time. History and clinical examination are essential for diagnosis. Detumescence, penile swelling, bruise and deformation are observed during the examination. In rare cases of uncertainty, radiological imaging methods are also used. These methods are magnetic resonance imaging (MRI), ultrasonography (US), cavernosography and urethrography (2). When penile fracture case reports are examined, penile trauma was found to be more common in Middle East and North Africa when compared to the rest of the world (3). Most of the fractures in the United States develop during the sexual intercourse as a result of dislocation of the penis from the vagina due to ‘faux pas du coit’ and as a result of hitting the perineum or the pubic bone (4,5). In this study, we aimed to present the early repair outcomes in patients who developed penile fracture during sexual intercourse.

Materials and Methods

Male patients, who underwent early surgical repair in our clinic due to penile trauma between June 2004 and December 2014, were evaluated retrospectively. Preoperative, perioperative and postoperative data were investigated upon the review of the patient records. The patients were evaluated in terms of age, height, weight, comorbidity, type and cause of trauma, erection hardness grade during sexual intercourse, pre-trauma International Index of Erectile Function-Erectile Function Domain Score (IIEF-ED), presence of fracture at physical examination, presence of urethral trauma, location of the fracture on the penis, fracture length, operation time, postoperative erectile dysfunction, postoperative IIEF-ED value, post-repair development of penile curvature and voiding dysfunction. Preoperative and postoperative IIEF-ED scores were compared with the use of the Wilcoxon test in order to predict the repair success. Furthermore, absence of postoperative erectile dysfunction, penile curvature and voiding dysfunction was considered as early surgical success. A p value of less than 0.05 was considered statistically significant.

Results

Twenty-six male patients, admitted to the emergency service due to penile trauma, were investigated. General characteristics of the patients (age, weight, height, body mass index) are given in Table 1. The patients applied with the complaint of hearing a sound during intercourse, development of detumescence, penile swelling and bruise. The mean time to admission of the patients was 6.4 (2-14) hours. Furthermore, three of the patients had blood in their external meatus. US was performed in two patients due to uncertainty in trauma diagnosis. The rest of the patients were diagnosed clinically. Early surgical repair was performed in all patients by using the degloving technique with incision from the circumcision scar. Physical examination and operative findings of the patients are given in Table 2. Four patients had only dorsal vein laceration without rupture of the corpus cavernosum, whereas the remaining 22 patients had rupture of the corpus cavernosum. In patients with dorsal vein laceration, dorsal vein ligation was applied following the degloving procedure. Primary repair was performed in 22 patients with a mean rupture of 16.7 (5-20) mm of the corpus cavernosum. While one patient had bilateral rupture of the corpus cavernosum, three of the patients had concomitant urethral injury. The mean operation time was 56.5 (30-120) minutes. Perioperative urethral catheter was inserted in all patients. The catheters were removed by the end of first day in patients without urethral injury and by the end of day 10 in those with urethral injury. Three of the patients developed erectile dysfunction postoperatively. These patients were over the age 45, one of them had bilateral corpus cavernosum rupture and two had concomitant urethral injury. Furthermore, penile curvature developed postoperatively in the patient with bilateral rupture, whereas none of the patients developed voiding dysfunction. Early surgery was found to be successful in nineteen of the 22 patients (86.4%). Furthermore, while the average pre-fracture erection hardness grade of the patients was 4.75 and IIEF-ED value was 28.6, the mean postoperative erection hardness grade was found to be 4.2 (1-5) and IIEF-ED value was 24.9 (1-30). There was no statistically significant difference between the preoperative and postoperative values (p>0.05) (Table 3).

Discussion

Two different surgical repair incision methods are generally defined in penile fracture repair. These are the degloving method with the degloving incision/circumcision incision and the ventral midline incision method (2). While postoperative complications have been reported to be higher with the ventral midline incision in the literature, no statistically significant difference was found (6). The degloving method was used in all the patients in our series and our postoperative complication rates were not statistically significant and were found to be lower than those reported in the literature. When the series of 300 patients reported from Tunisia is assessed, 60% of the fractures were reported to develop during masturbation and 5% of patients had concomitant urethral injury (7), whereas the rate of bilateral rupture of 10% has been reported and the rate of the presence of concomitant urethral ruptures was 18-38% according to the outcomes of the studies from the United States and Canada (1,6,8). When the outcomes of the studies from the Middle East countries are assessed, the success rate of early repair was found to be around 92-100% and the self-recovery was reported down to 40% (9,10). In series from Spain, Germany-Croatia and Switzerland, the number of patients was around 9-29 and the early repair success rate was to be around 80-95% (11,12,13). In one of the recent studies, postoperative success was reported to be 65%. However, in this series, ventral midline incision method was used (6). With 86.4% of early surgical success, our series seems to have similar outcomes when compared to the study, in which degloving method was applied. Our rates of bilateral corpus cavernosum and urethral rupture of 3.8%, are lower than that of 11.5% reported in other series. Besides the early surgical success rate, postoperative IIEF-ED value and mean erection hardness grades also contribute to the early surgical success, when compared to the values before the fracture. One of the major results of our study is that the main factor affecting surgical success is age and the extension of the fracture when the failing patients are assessed. In penile fracture cases, it is recommended to ask about the time to admission, age and pre-trauma erection quality and to identify the extension of the corpus cavernosum rupture and the presence of concomitant urethral trauma. The patient should be advised to have early fracture repair with the degloving method and be informed on the potential development of postoperative erectile dysfunction on the basis of the findings.

Conclusion

In conclusion, early repair with the use of the degloving method is identified as an effective method for the success of postoperative erection in sexual intercourse-induced penile fracture cases. Besides the early repair, other factors contributing to surgical success are the repair technique, age of the patient, pre-fracture erection hardness grade and IIEF-ED score, bilateral corpus cavernosum rupture, and the presence of urethral injury.

Ethics

Ethics Committee Approval: Ethics committee approval was not obtained because this was a retrospective study, Informed consent: Written informed consent was not obtained from patients because this was a retrospective study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: Serdar Çelik, Design: Serdar Çelik, Data Collection or Processing: Serdar Çelik, Sedat Karakoç, Analysis or Interpretation: Serdar Çelik, Ozan Bozkurt, Ömer Demir, Ahmet Adil Esen, Literature Research: Serdar Çelik, Sedat Karakoç, Ozan Bozkurt, Writing: Serdar Çelik.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.