The clinical presentation of PF is frequently quite clear, even with superficial physical examination [9]. In the majority of the cases, patients report to have had the injury while the female partner was up straddling the penis during a sexual intercourse, or while having sex on particular surfaces or object such as desks or other types of furniture. The injury is frequently felt with a popping, cracking, or snapping sound immediately followed by detumescence.

Upon physical examination, the penis appears clearly deformed, with a significant welling of internal soft tissue, penile ecchymosis, and hematoma formation. The deformity might be so severe that the penis appears s-shaped, associated with a clear deviation from the side of the injury due to the mass effect of the hematoma. Blood might be present in the meatus if the urethra has also been damaged. The Buck fascia usually remains intact, but if this too have been damaged, swelling and ecchymosis can be seen in Colles fascia. If this circumstance occurs, ecchymosis appears over the perineum, scrotum and abdominal wall with a typical “butterfly-patter”. Furthermore, a localized blood clot can be observed over the site of the injury, over which the penile skin can be rolled (the so called “roling sign”).

Many patients might also experience concomitant urethral trauma, usually associated with periurethral hematoma. These subjects might show acute urinary retention due to the urethral injury itself, which might appear as a late sign. Other signs of urethral injury include blood at the meatus and dysuria.

• Vascular Disease

  None of our patients had ED before the penile trauma and only two of them had risk factors for systemic vascular diseases, such as diabetes mellitus (one patient) and hypertension (one patient). [ncbi.nlm.nih.gov]

• Periodontitis

  Necrotizing cavernositis secondary to periodontal abscess. J Urol. 1993; 149 :1137–8. [ PubMed ] [ Google Scholar ] 2. Shah DK, Paul EM, Meyersfield SA, Schoor RA. False fracture of the penis. [ncbi.nlm.nih.gov]

• Self-Mutilation

  Cases are typically associated with self-mutilation related to acute psychotic episodes or gender dysphoria. Felonious assaults account for the remainder of cases. Penetrating injury Gunshot wounds account for 35% of all genital injuries. [emedicine.medscape.com]

• Self-Mutilation

  Cases are typically associated with self-mutilation related to acute psychotic episodes or gender dysphoria. Felonious assaults account for the remainder of cases. Penetrating injury Gunshot wounds account for 35% of all genital injuries. [emedicine.medscape.com]

• Paresthesia

  Complications occurred in eight patients (4.7%), of whom seven developed a mild (four) to moderate (three) penile curvature; five had penile nodules and four reported mild paresthesia over the scar line. [ncbi.nlm.nih.gov]

• Painful Erection

  In Group II, the most common complication was painful erection (in 4 of 37 patients, 10.8 %), whereas in Group I, 80 % (4/5 patients) suffered complications such as wound infection, painful erection, penile nodule and curvature, and erectile dysfunction [ncbi.nlm.nih.gov]

• Penile Pain

  A 38-year-old man with history of repaired penile fracture presented with rapid detumescence, penile pain, and ecchymosis during vaginal sexual intercourse concerning for recurrent fracture. [ncbi.nlm.nih.gov]

  A healthy 42-year-old man presented to the emergency department after the acute onset of penile pain during sexual intercourse. The erect penis had inadvertently collided with his partner's perineum. [nejm.org]

• Urethral Discharge

  The patient denied any history of urethral discharge, intracorporeal therapy or instrumentation. Physical examination revealed edema, redness, ulceration and discharge of thick, yellowish pus from the proximal penile shaft [ Figure 1 ]. [ncbi.nlm.nih.gov]

  Urethral rupture must be suspected in any case of penile fracture presenting with bloody urethral discharge. Standard treatment is immediate surgical repair. [nature.com]

• Edema of the Penis

  Physical exam revealed significant edema of the penis and foreskin as well as the so-called ‘eggplant deformity’ commonly associated with penile fractures (Figure 1 a). [criticalultrasoundjournal.springeropen.com]

The primary diagnostic method for PF in undoubtedly physical examination. This can be integrated by several laboratory studies, whose choice should be considered case by case. The laboratory studies to use in the diagnosis of PF can include electrolytes, complete blood count, coagulation studies, and urinalysis, which might also be accompanied by urine culture if an urinary tract infection is suspected.

Imagine studies can be useful, although not frequently employed due to the high medical costs associated with them. In any case, these should be considered when an injury is suspected but not evident after simple physical examination. The imagine studies used in the diagnosis of PF include:

• Retrograde urethrography, performed when urethral injury is suspected.
• Penile cavernosography, especially to detect damages of the tunica albuginea.
• Penile magnetic resonance imaging, which thanks to its excellent definition provides clear images of the tunica tears, urethral injury and their shape and orientation.

The main goals of the treatment of PF is to make sure the penis is restored to its pre-injury state, avoiding as much as possible erectile dysfunction and allowing normal voiding [10] [11] [12]. A surgical procedure is the most important treatment, that should be optimized so that the hematoma can be evacuated, the injury identified, the defect of the tunica albuginea corrected, and the possible urethral injury repaired. Experts disagree on the antibiotics to use, even though the most frequently administered are the broad-spectrum intravenous antibiotics such as cefazolin.

The prognosis of PF is usually excellent and complications are minimal [7] if medical treatment is promptly given. The complication rate, in fact, is directly proportional with the delay in seeking medical attention, going from a percentage of 10-50% when medical treatment is delayed to 11% when this is prompt [1] [8].

In general, erectile function is preserved in up to 86% of the patients who receive microvascular reanastomosis of the dorsal arteries. Penile sensation too is frequently maintained, in up to 82% of the patients, although it might turn out to be slightly diminished. Other important complications include:

• Urethral strictures, occurring in about 20% of the cases.
• Skin loss, occurring in about 50% of the cases, although this is usually superficial.
• Formation of fibrotic plaques
• Penile abscess
• Urethrocutaneous fistula
• Corporourethral fistula
• Painful nodules, generally appearing along the site of the injury.

In the cases which show higher levels of damage amputation might be needed, although this circumstance is less frequent.

In the Western culture penile fracture usually occurs during sexual activities, for example when during a vigorous vaginal intercourse the penis slips out of the vagina and violently hits the surrounding regions such as perineum or pubic symphysis. PF is particularly frequent when the woman is on top on the man, since she is not aware of the harm she is causing to the erected penis with her movements. Other possible causes include the already mentioned vigorous masturbation, or accidental events like turning over in bed, occasional forced bending, and hastily removals or applications of cloths on the penis when this is erected.

The prevalence of PF is particularly high in Eastern cultures, when the practice of detumescence, the forced subsidence of a swollen organ like penis, is very common and widespread [6]. Very famous is the example of the Iranian practice Taqaandan, a pastime in which the top part of the erected penis is sharply wrenched to one side and then abruptly popped. Unfortunately, this practice markedly increases the prevalence of PF in the Iranian population when compared to that found in other countries.

It is highly possible that the actual frequency of PF is underreported and underestimated, because of the embarrassment which causes patients not to seek medical attention soon after an accident. Sometime penis amputation might occur, even though this is very rare and mostly associated with particular cultural practices or other circumstances. PF is also particularly frequent as consequence of gunshot wounds or skin diseases like Fournier gangrene, famous for causing marked skin loss on penis and scrotum.

The mechanism of PF can be easily understood by considering the structure of penis. The penis is composed of 3 main bodies of erectile tissue called left corpus cavernosum, right corpus cavernosum, and corpus spongiosum. They are all individually surrounded by the Buck fascia, while the left corpus cavernosum and the right corpus cavernosum are also enveloped by the tunica albuginea, an extensible tissue primarily made up of elastin and collagen. Blood arrives at the urethra and penis from the internal pudendal arteries, which then divide into the dorsal penile artery, the cavernosal artery, and the bulbourethral artery. This latter then directly supplies the corpus cavernosum, which fills with blood becoming stiffened and causing the erection to occur.

In an erect state, the tunica albuginea thins considerably, going from an initial thickness in the flaccid state of 2 mm to a final one in the erect state of just 0.25-0.5 mm. In this situation the tunica albuginea loses elasticity, becoming much more fragile and exposed to possible mechanical traumas. If a trauma occurs, this lacerates the tunica albuginea, leaving behind a mechanical injury which prevents the penis from enlarging again. The tears are usually horizontal and regular, and generally involve just one corpus cavernosa. The damage might result in penile laceration and frequently in urethral injury as well. The classical complications of PF include erectile dysfunction, especially while practicing vaginal penetration, permanent penile curvature, urethral injury and pain during sexual intercourse.

Preventing PF requires avoiding all those sexual activities which might cause a blunt physical trauma to the penis. Particular attention should be used while choosing the positions during sexual intercourse. These include the woman-on-top position, when the female straddles the male unaware of the physical damage being created and with her entire body weight loaded on the penis, and the missionary position, especially when this is performed on hard surfaces like desks or another pieces of furniture. Furthermore, the male should penetrate the partner when the penis is fully erect, to avoid sudden torques and twits, and should never engage in too much aggressive and vigorous sexual activities and acts of masturbation.

Penile fracture (PF) is the result of a mechanical trauma due to an abrupt lateral bending of the penis or a rapid blunt force exerted on it during an erection, and it is usually associated with sexual activities such as vaginal intercourse or vigorous masturbation [1], which frequently involve damages on the urethra [2] [3] and injuries on the nearby nerves and blood vessels [4].

PF is a relatively uncommon traumatic rupture [5] which needs urgent medical treatment. It is usually diagnosed with a physical examination, generally followed by prompt surgical repair. Surgical repair is strongly recommended, because if left untreated PT might cause severe future complications like deformities of the penis or inability to have or maintain an erection (generally referred to as erectile dysfunction).

Penile fracture (PF) is the rupture of the tunica albuginea, the fibrous envelope which surrounds and protects the internal cavernous body of the penis. PF is the result of a mechanical trauma due to an abrupt lateral bending of the penis or a rapid blunt force exerted on it during erection, and it is usually associated with sexual activities such as vaginal intercourse or vigorous . This is a relatively uncommon traumatic rupture which needs urgent medical treatment. It is usually diagnosed with physical examination, generally followed by prompt surgical repair. Surgical repair is strongly recommended, because if left untreated PT might cause severe future complications like deformities of the penis or inability to have or maintain an erection (generally referred to as erectile dysfunction).

As previously aid, PT usually occurs during sexual activities, for example when during a vigorous vaginal intercourse the penis slips out of the vagina and violently hits the surrounding regions such as perineum or pubic symphysis. PF is particularly frequent when the woman is on top on the man, since she may not aware of the harm she is causing to the erected penis with her movements. Other possible causes include vigorous masturbation, or accidental events like turning over in bed, occasional forced bending, and hastily removals or applications of cloths on the penis when this is erected.

Preventing PF requires avoiding all those sexual activities which might cause a blunt physical trauma to the penis. Particular attention should be used while choosing the positions during sexual intercourse. These include the already mentioned woman-on-top position, when the female straddles the male unaware of the physical damage being created and with her entire body weight loaded on the penis, and the missionary position, especially when this is performed on hard surfaces like desks or another pieces of furniture.

1. Greenberg's Text-Atlas of Emergency Medicine. Lippincott Williams & Wilkins. 22 November 2004. p. 318. 
2. Roy M, Matin M, Alam M, Suruzzaman M, Rahman M. Fracture of the penis with urethral rupture. Mymensingh Med J. Jan 2008;17(1):70-3. 
3. Amit A, Arun K, Bharat B, Navin R, Sameer T, Shankar DU. Penile fracture and associated urethral injury: Experience at a tertiary care hospital. Can Urol Assoc J. Mar-Apr 2013;7(3-4):E168-70. 
4. Haas CA, Brown SL, Spirnak JP. Penile fracture and testicular rupture. World J Urol 1999 17 (2): 101–6. 
5. Reis LO, Cartapatti M, Marmiroli R et al. Mechanisms Predisposing Penile Fracture and Long-Term Outcomes on Erectile and Voiding Functions Advances in Urology, Volume 2014 (2014).
6. Zargooshi J. Penile fracture in Kermanshah, Iran: report of 172 cases. J. Urol. 2000 164 (2): 364–6. 
7. Ateyah A, Mostafa T, Nasser TA, Shaeer O, Hadi AA, Al-Gabbar MA. Penile fracture: surgical repair and late effects on erectile function. J Sex Med. Jun 2008;5(6):1496-502. 
8. Peitzman AB, Rhodes M, Schwab CW, Yealy DM, Fabian TC. The trauma manual: trauma and acute care surgery. Lippincott Williams & Wilkins. pp. 305–. 2007
9. Agarwal MM, Singh SK, Sharma DK, Ranjan P, Kumar S, Chandramohan V, et al. Fracture of the penis: a radiological or clinical diagnosis? A case series and literature review. Can J Urol. Apr 2009;16(2):4568-75. 
10. Perovic SV, Djinovic RP, Bumbasirevic MZ, Santucci RA, Djordjevic ML, Kourbatov D. Severe penile injuries: a problem of severity and reconstruction. BJU Int. Jan 20 2009. 
11. Ghilan AM, Al-Asbahi WA, Ghafour MA, Alwan MA, Al-Khanbashi OM. Management of penile fractures. Saudi Med J. Oct 2008;29(10):1443-7. 
12. Maruschke M, Lehr C, Hakenberg OW. Traumatic penile injuries--mechanisms and treatment. Urol Int. 2008;81(3):367-9.