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.

• Wound Infection

  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]

  Two patients developed mild postoperative wound infection, which was treated with antibiotic and wound dressing. In the follow-up period, 2 patients complained of slight bend of the penis to the affected side but with no sexual problem. [indianjurol.com]

  Complications: No immediate post-operative complication occurred except wound infection in one which healed by secondary intention resulting in mild fibrosis and curvature. [pjms.com.pk]

  No significant early postoperative morbidity was encountered except for five (2.3%) cases, of whom three had mild wound infection and the remaining two were complicated by bleeding and hematoma required fixation of rubber drain. [nature.com]

• Turkish

  Psychological and sexual measurements Premature ejaculation diagnostic tool The validated five-item Turkish version of PEDT is a short psychometrically validated measure to screen premature ejaculation among Turkish patients, in particular because of [dx.doi.org]

  The articles under the Penile Fracture will also be published in the different journals such as Therapeutic Advances in Endocrinology and Metabolism, Turkish Journal of Endocrinology and Metabolism, US Endocrinology. Penile Fracture [omicsonline.org]

  Turkish Journal of Urology. 2003; 29 (3):344–350. [ Google Scholar ] Mallen CD. Time to revisit Dr Finlay’s casebook? The unique potential of the general practice case report. [ncbi.nlm.nih.gov]

  Case presentation A 32-years-old Turkish man presented to primary care complaining of discoloration of penis since the night before. He did not give any significant sexual or trauma history. [casesjournal.biomedcentral.com]

• Localized Pain

  Imaging may be required, particularly in those patients with an atypical clinical presentation or with severe local pain and swelling that interdicts a thorough physical examination of the penis. [3] The main role of imaging in these patients is to exclude [dx.doi.org]

  Other causes included masturbation and manipulation (i.e. manual and forcible deflection of erect penis commonly during sleep). 15 (88.23%) patients recalled a crackling sound while some localized pain was reported by 12 (70.58%) patients. [pjms.com.pk]

• 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]

  During a long-term interval (mean 3.6±1.9 years) after surgical treatment, CDU revealed that 46.7% of patients had normal vascular system and 26.7, 20 and 6.7% of patients had VOD, arterial insufciency or mixed vascular disease. [nature.com]

• 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.com]

• Neglect

  We report a case of penile abscess and necrotizing fasciitis of penile skin in a 37-year-old male, presented 3 weeks after neglected false penile fracture. [ncbi.nlm.nih.gov]

  The neglected hematoma may lead to abscess formation or deformity. [sexualhealthmedicine.com]

  Penile abscess secondary to neglected penile fracture after intracavernosal vasoactive drug injection. World J Mens Health. 2012 Dec. 30(3):189-91. [Medline]. [Full Text]. Gaspar SS, Dias JS, Martins F, Lopes TM. Sexual Urological Emergencies. [emedicine.com]

• 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]

• Premature Ejaculation

  All participants have completed the Hospital Anxiety and Depression Scale (HADS), Glombok-Rust Inventory of Satisfaction Scale (GRISS), and the premature ejaculation diagnostic tool (PEDT). [ncbi.nlm.nih.gov]

  Psychological and sexual measurements Premature ejaculation diagnostic tool The validated five-item Turkish version of PEDT is a short psychometrically validated measure to screen premature ejaculation among Turkish patients, in particular because of [dx.doi.org]

  Alex Shteynshlyuger is a board-certified urologist, who specializes in all aspects of care for sexual problems in men including ED, premature ejaculation and other sexual concerns. [newyorkurologyspecialists.com]

• Urethral Discharge

  The external urethral meatus showed no urethral discharge. No rolling sign or corporal defects could be detected. Both testes and epididymides were palpably normal. Inguinal lymph nodes were not enlarged. Rectal examination was unremarkable. [ncbi.nlm.nih.gov]

  Urethral rupture was suspected in all patients given the presence of bloody urethral discharge. No preoperative radiographic investigations were necessary. All patients underwent immediate surgical exploration. [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. 
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