What Is Penile Fracture? Signs and Why It Is an Emergency
Why is a fracture possible when there is no bone in the penis? How penile fracture occurs, its typical signs, why it needs urgent surgery and what can happen if treatment is delayed are covered here.
There is no bone in the penis; nonetheless, there is an injury known in medical terms as “penile fracture”. In this condition what breaks is not bone but the elastic sheath surrounding the erectile tissue, which stretches and thins during an erection (the tunica albuginea).
During an erection this sheath is stretched by internal pressure and approaches the limit of its strength. A sudden, forceful bend can tear it, and the blood inside escapes rapidly from the tissue. This is one of the injuries in urology where delay must be avoided; patients, however, often postpone seeking help out of embarrassment or in the hope that it will settle. This article covers how penile fracture occurs, how it presents, why it needs urgent assessment and what can happen if treatment is delayed.
How does penile fracture occur?
Penile fracture develops only during an erection; the injury is not expected in a flaccid penis. This is because the tunica albuginea stretches during an erection, its thickness decreases markedly and its resistance to a sudden bend falls.
The most common mechanism is a sudden bend at the wrong angle during intercourse. This usually happens when the penis misses the partner's body and strikes the pubic bone or the perineum. Certain sexual positions are known to be associated more frequently with this injury.
Other mechanisms include rolling onto the erect penis in bed, forcibly bending it by hand, or pressing on it in an attempt to end an erection.
What are the signs?
In most cases penile fracture presents with a distinctive picture that the patient can describe easily:
- An audible sound: A significant proportion of patients describe a cracking or snapping sound.
- Sudden, severe pain: Occurring at the moment of injury.
- Rapid loss of the erection: The penis becomes flaccid within a short time.
- Rapidly developing swelling and bruising: As blood collects under the tissue the penis swells markedly and takes on a deep purple appearance, described in medicine by a well-known analogy.
- Deformity: Curvature or asymmetry towards the side of the bleeding.
- Urinary findings: If the urinary channel is also affected, pain on passing urine, inability to pass urine or bleeding from the urethral opening may occur.
Where these findings are mild the patient may take the event for a simple strain. The presence of several of the above signs together, however, calls for assessment without delay.
Why is it an emergency?
In penile fracture, repairing the torn sheath early is decisive for the long-term outcome. Blood collecting at the site of injury and the tear healing on its own can lead to the formation of uncontrolled scar tissue.
The problems that can arise without early surgical repair are:
- Permanent curvature: Because scar tissue loses its elasticity, curvature can develop during an erection; this picture resembles that of Peyronie's disease.
- Erectile dysfunction: Disruption of tissue integrity and of the mechanism that retains blood.
- Painful erections: Discomfort due to stretching at the healing site.
- Palpable hardness: Permanent irregularity created by scar tissue.
- Urinary channel problems: A stricture can develop if the urethra is also injured and left unrepaired.
The message given to patients is therefore clear: rather than waiting after the injury, a healthcare facility should be attended without delay. Measures such as applying ice should not postpone presentation.
How is the diagnosis made?
In most cases the diagnosis is made from the history and examination. The patient's description of the moment of injury, together with the swelling, bruising and deformity found on examination, largely establishes it; in experienced hands the site of the tear can also be identified by palpation.
Imaging may be used in doubtful or borderline cases. Ultrasound and, where needed, magnetic resonance imaging help show the presence and location of the tear. The absence of findings on imaging does not preclude surgery where clinical suspicion is strong.
Further assessment is carried out in patients where a urethral injury is suspected; blood in the urine or difficulty passing urine increases that suspicion.
How is it treated?
The standard approach in penile fracture is surgical repair. During the operation the collected blood is drained, the torn area is exposed and the sheath is repaired with sutures. Any concurrent urethral injury is assessed in the same session.
Performing surgery early allows both a more precise repair and the prevention of long-term problems. A watch-and-wait approach is not preferred today; the results of surgical repair are accepted as better.
Swelling and bruising in the area take time to settle after surgery. Patients are advised to abstain from sexual activity for a period, with the duration specified by the surgeon according to how healing progresses. Temporary medication to suppress erections may be considered.
How does recovery progress?
Pain, swelling and discolouration are expected findings in the first days and settle over time. Patients are asked not to strain the area during this period, to take the medication advised and to attend follow-up appointments regularly.
Return to sexual activity is planned once healing of the tissue is complete. Strain in the early period can affect the repaired area.
In the long term the outcome is favourable in a significant proportion of patients. Depending on the extent of the injury and how soon the patient presented, however, some curvature, palpable hardness or change in erections may remain. Follow-up appointments therefore assess not only wound healing but also erectile function.
How can penile fracture be prevented?
This injury usually happens unexpectedly; even so, a few points can reduce the risk:
- Avoiding sudden, uncontrolled movements during intercourse
- Being mindful of circumstances that increase the risk of the penis suddenly bending at the wrong angle
- Being aware that control may be reduced under the influence of alcohol
- Not forcibly bending the penis by hand to end an erection
- Seeking help without delay where injury is suspected
Despite its name, penile fracture has nothing to do with bone: it is a tear in the sheath surrounding the erectile tissue and requires early surgical repair. A cracking sound, sudden pain, rapid loss of the erection and marked bruising are the typical findings; delay in this picture increases the risk of permanent curvature and erection problems. Assoc. Prof. Zülfü Sertkaya practises in urology and andrology in Istanbul; assessment and treatment planning after penile injury are carried out with individual assessment and confidentiality.