Penile trauma or fracture is an uncommon but severe injury. Most penile trauma is caused during sexual intercourse. Penile trauma can have a profound impact on a man’s sexual health if it is left untreated. Direct trauma to the erect penis results in increased pressure. This increased pressure can result in the rupture of specific penile tissues.
Penis fracture occurs most commonly in middle-aged men. The evidence suggests that penile injury tends to occur between 30 and 50 years of age. In one 2019 case report, a 40-year-old male presented to an emergency department with penile swelling, bruising, and pain. The man reported that while he was having vaginal sexual intercourse with his wife in the missionary position, he felt his penis buckle. This was followed by a loss of the erection and penile discomfort. Subsequently, he noticed bruising and swelling along the shaft of the penis.
Even though he was able to achieve an erection the next day, he was severely limited by pain and could not engage in sexual intercourse. This is an example of a classic case of penile trauma. Some men also report hearing a ‘snapping’ or ‘popping’ sound during sexual intercourse. This is followed by pain and a rapid loss of the erection.
Not all penile fractures arise from sexual intercourse. A minority of men report penile trauma during masturbation and from rolling over in bed.
How does the penis Work?
Understanding the anatomy and physiology of the penis is essential. In this section of the article, we systematically go through the inner workings of the penis. The penis is the male sex organ that has two main functions. These functions are sexual intercourse and urination. For sexual intercourse to occur, the penis must be erect.
The penis has three parts; the glans, body, and root. The outward part of the penis consists of corpora cavernosa. The corpora cavernosa are erectile tissues that form the bulk of the penis. The inward-facing part of the penis contains the corpus spongiosum. The corpus spongiosum itself contains the urethra. The cavernous body of the penis is wrapped around by a specialized sheet. This sheet is known as the tunica albuginea.
Parasympathetic nerves supply the penile tissues. The activation of these nerves during sexual arousal causes the penile corporeal bodies to become engorged. The penis contains two specialized muscles – the bulbospongiosus and the ischiocavernosus. These muscles compress the veins in the penis to prevent the drainage of blood from the corpora cavernosa.
During an erection, the corpora cavernosa becomes enlarged and firm. The parasympathetic nervous system facilitates erection. The sympathetic nervous system facilitates ejaculation. During ejaculation, semen is ejected from the urethra. This sympathetic stimulation during an orgasm counteracts the parasympathetic nervous system. This causes the penis to become flaccid again.
What Can Cause Injury to the Penis?
More than half of all men with a confirmed penile fracture report direct trauma to the erect penis during sexual intercourse.
The erect penis slips out of the vagina during intercourse and is thrust directly into the perineum or the hard pelvic bone. Sexual positions associated with penile trauma are ‘female superior’ and ‘rear entry’ positions. A minority of men also report penile trauma arising from masturbation injuries. Some even report blunt trauma from falls landing on an erect penis.
During penile trauma, there is increased pressure in the blood-filled corpus cavernosa. This leads to a tear of the surrounding tunica albuginea. 80% of penile ruptures occur on the inner side of the penis. This is because the tunica albuginea is extremely thin at 2mm when the penis is flaccid. The tunica albuginea becomes even thinner at 0.25 mm during an erection.
The diagnosis of a penile fracture is made on a clinical basis. In some instances, physicians may decide to image the penis. These include ultrasound or magnetic resonance imaging (MRI). On physical examination, there can be an ‘eggplant’ deformity. This deformity is characterized by bruising and redness of the penile shaft. The penis may also appear to be angulated, and erections will be asymmetrical in nature. Palpation of the penile shaft will elicit severe pain.
Treatment Options
The evidence suggests that if a penile fracture is suspected, surgical exploration should occur as soon as possible. Delaying surgery should only be considered if the diagnosis of penile trauma is unclear and imaging can be arranged rapidly. The British Association of Urologic Surgeons recommends surgical repair of penile trauma within 24 hours . One study found that early surgical repair within 24 hours was associated with a low complication rate of just 7.6%. Conversely, late surgery that occurred after 24 hours was associated with a staggeringly high complication rate of 68.7%.
The surgical approach for penile trauma involves making an incision over the area of injury. Depending on the surgeon’s preference and training, he or she may make a circumferential or longitudinal incision. After making the incision, collections of blood known as hematomas are evacuated by the surgeon. This enables the surgeon to relieve the tense pressure within the corpus cavernosal. The surgeon can also visualize the underlying defect in the tunica albuginea. Absorbable surgical sutures are used for the repair of the ruptured tunica albuginea.
The most concerning complication of penile trauma is sexual dysfunction. All men who suffer from penile trauma will experience some extent of sexual dysfunction. Some men experience sexual dysfunction only during the immediate post-operative period. However, some men do go on to have long-lasting sexual dysfunction even after the penile trauma has been surgically addressed. There is also a psychological component of this long-term sexual dysfunction. This is because men who have sustained penile trauma during sexual intercourse may develop anxiety and fear of repeat injury. Hence, they may change their sexual practices and even avoid sexual intercourse.
Surgery for penile trauma is not without its own complications. As an invasive procedure, surgery carries risks of bleeding and infection. Furthermore, general anesthesia in surgery has risks as well. They include stroke, heart attack, and respiratory depression. Specific procedural risks of penile trauma repair include (Amer et al., 2016):
- Plaque or nodule development
- Penile curvature
- Erectile dysfunction
- Pain
- Penile infections
- Aneurysm
- Urinary disorders
Importantly, the rate of erectile dysfunction after surgical repair is low and ranges from 1-5%. Another potential long-term complication of a penile fracture is Peyronie disease. Peyronie’s disease is a progressive disease that is characterized by a curvature of the penis and painful erections. Essentially, it is a disorder of wound healing of the tunica albuginea, which causes scarring. The association between penile trauma and Peyronie’s disease has yet to be proven. Still, researchers believe that poor wound healing after penile trauma could progress to this disease.
In some cases, penile injuries can be associated with urethral injury. The urethra is the passage through which urine flows in the penis. The American Urological Association (AUA) recommends that at the time of surgical repair, the urethra must also be evaluated if there is blood in the urine or urinary retention. According to the evidence, about 15% of men with penile trauma have a concomitant urethral injury. A urologist can evaluate the urethral injury. Urologists routinely use urethrography to visualize the urethra. Alternatively, a flexible fiber-optic scope can be inserted through the urethra to provide direct vision.
Since penile trauma is a physical injury, there are no medications that can address this issue. Physicians may prescribe patients with non-steroidal anti-inflammatory drugs (NSAIDs) such as Ibuprofen. Alternatives include Paracetamol or Morphine for pain relief. However, these drugs do not address penile trauma directly and do not influence short-term or long-term outcomes. Hence, surgery remains the definitive treatment option for penile fractures.
When to See a Doctor
Men who experience any penile pain after sexual intercourse or masturbation are strongly advised to see a physician. Contrary to popular belief, there may not be a classical ‘popping’ or ‘snapping’ sound during penile trauma. The absence of these sounds is not a reliable way to exclude penile trauma. The main factor which determines the quality of life and penile function after trauma is how the soon surgical repair is undertaken. Hence, men should not take the risk and delay potential surgical treatment when in doubt.
Most cases of penile trauma occur during sexual intercourse. However, penile trauma can also occur during aggressive masturbation, rolling over in bed, or even falling on an erect penis. Penile pain is not normal under any circumstance and should be promptly evaluated by a healthcare professional. Men are advised to attend an emergency department instead of visiting their primary care practitioner.
After the surgical repair is undertaken for penile trauma, men are advised to avoid sexual intercourse or masturbation for at least 6 weeks. Sexual activity can be resumed when the pain, bruising, and swelling of the penis have resolved.
Conclusion
Penile trauma is an uncommon but serious emergency. Penile trauma necessitates rapid surgical exploration and repair within 24 hours. This traumatic problem is diagnosed clinically by trained healthcare professionals. However, ultrasound and MRI imaging may be useful when in doubt. Surgical repair is associated with a low complication rate. Most men achieve full satisfactory sexual outcomes in the long-term. Men who have penile pain, swelling, or bruising during or after sex or masturbation are strongly advised to seek medical attention at an emergency department.
