Penile Fracture

How a penile fracture happens

The penis has no bone, so "fracture" refers to a rupture. During an erection, the corpora cavernosa fill with blood and the tunica albuginea stretches and thins, from about 2 mm to as little as 0.25 mm. A sudden bending force can tear it, and blood escapes into the surrounding tissue. In about 10 to 20% of cases, the urethra, the tube that carries urine and semen, is also torn (urethral injury).

Common causes

• sex, especially when the penis slips out and is thrust against the pubic bone or perineum
• forceful bending during masturbation
• rolling over onto an erect penis in bed
• deliberate bending to lose an erection (practiced in some regions of the Middle East)

Symptoms

• a cracking, popping or snapping sound
• sudden penis pain, which can range from moderate to severe
• immediate loss of erection
• rapid swelling and dark purple or black bruising, which may spread to the scrotum, groin and perineum
• the penis bending away from the side of the tear
• a palpable defect or tender lump at the tear site (the "rolling sign")
• with urethral injury: blood at the urethral opening, blood in the urine, difficulty urinating

Diagnosis

The diagnosis is usually clear from the history and examination. Tests may include:

• ultrasound to locate the tear, especially when the story is unclear
• MRI in uncertain cases
• retrograde urethrogram or cystoscopy to check for urethral injury, often done during surgery

When the classic history and examination are present, surgeons may proceed directly to repair. Other conditions can mimic a fracture, such as rupture of a superficial dorsal vein, which causes bruising without loss of erection and usually needs less extensive treatment.

Treatment

Surgical repair

Prompt surgery within 24 hours of injury is recommended by the American Urological Association. Under anesthesia, the surgeon:

1. makes an incision, often around the shaft just below the head (degloving) or directly over the tear
2. removes the blood clot
3. stitches the tear in the tunica albuginea
4. repairs any urethral injury

Most men go home within a day or two, sometimes with a urinary catheter for a few days, or longer if the urethra was repaired.

Non-surgical treatment

Conservative care with compression, cold packs and pain relief was used in the past but leads to much higher rates of curvature, painful erections and erectile dysfunction. It is now reserved for rare cases.

Recovery

• avoid sexual activity for about 4 to 6 weeks, or as advised
• medicines to reduce nighttime erections are sometimes prescribed
• swelling and bruising settle over several weeks
• follow-up to check healing, erectile function and urination

Complications

• erectile dysfunction
• penile curvature or a fibrous plaque, similar to Peyronie's disease
• painful erections
• urethral stricture after urethral injury
• infection or abscess

Complication rates are much lower with early surgery than with delayed treatment or conservative care.

Prevention

• take care with vigorous positions where the penis can slip out and strike the partner's body, especially partner-on-top and rear-entry
• use adequate lubrication
• stop if anything causes pain
• avoid forcibly bending an erect penis

Frequently asked questions

What are the symptoms of a penile fracture?

The classic symptoms are a popping or cracking sound during an erection, followed by sudden pain, immediate loss of erection, rapid swelling and dark bruising of the penis. The penis may bend to one side. Blood at the tip or trouble urinating suggests urethral injury.

How common is penile fracture?

It is uncommon, but probably underreported because of embarrassment. Most cases occur in men aged 30 to 50 during sexual activity. Anyone with symptoms should seek emergency care rather than wait.

Does a penile fracture need surgery?

Yes, in almost all cases. Surgical repair within 24 hours significantly lowers the risk of erectile dysfunction, curvature and painful erections compared with treating it without surgery.

Can you still have erections after a penile fracture?

Most men who have prompt surgical repair regain normal erections. A minority develop erectile dysfunction or curvature, which is more likely after delayed treatment or urethral injury. Treatments are available if problems persist.

How long after penile fracture surgery can I have sex?

Most surgeons recommend avoiding sexual activity, including masturbation, for about 4 to 6 weeks after repair. Your urologist will advise based on how the repair is healing.