|Year : 2014 | Volume
| Issue : 1 | Page : 23-26
False fracture of the penis: Different pathology but similar clinical presentation and management
Adel Kurkar, Ahmad A Elderwy, Elderwy Orabi
Department of Urology, Assiut University, Asyut 71516, Egypt
|Date of Submission||19-Dec-2013|
|Date of Acceptance||12-Dec-2013|
|Date of Web Publication||13-Feb-2014|
Ahmad A Elderwy
Department of Urology, Assiut University, Asyut 71516
| Abstract|| |
Introduction: Penile fracture is the most common presentation of acute penis. Rupture of the superficial dorsal penile vein (s) may mimic penile fractures with similar clinical presentation but with intact corporeal bodies. Our aim of the study is to highlight superficial dorsal penile vein (s) injury as true emergency with better prognosis.
Subjects and Methods: Sixty-eight patients with suspected penile fractures presented to our hospital between June 2007 and January 2013. Out of these, 11 patients showed intact tunica albuginea on exploration with injured dorsal penile vein (s) identified. Records of such 11 cases were reviewed regarding age, etiology, symptoms, physical signs, findings of surgical exploration and post-operative erectile function.
Results: All 11 patients were injured during sexual intercourse and presented with penile swelling and ecchymosis and gradual detumescence. Mild penile pain was encountered in 5 cases and the "snap" sound was noted in 2 cases. Examination revealed no localized tenderness, or tunical defect. All the patients regained penile potency without deformity after surgical ligation of the severed vessels. One patient developed penile hypoesthesia.
Conclusion: Although the classic "snap" sound and immediate detumescence are usually lacking in the symptomology of dorsal penile vein rupture, its clinical presentation can be indistinguishable from true penile fracture. Surgical exploration is still required to avoid missing tunical tear with possible future complications. The long-term outcome and prognosis are excellent.
Keywords: Dorsal penile vein, false penile fracture, penile fracture, tunica albuginea
|How to cite this article:|
Kurkar A, Elderwy AA, Orabi E. False fracture of the penis: Different pathology but similar clinical presentation and management. Urol Ann 2014;6:23-6
|How to cite this URL:|
Kurkar A, Elderwy AA, Orabi E. False fracture of the penis: Different pathology but similar clinical presentation and management. Urol Ann [serial online] 2014 [cited 2019 Feb 23];6:23-6. Available from: http://www.urologyannals.com/text.asp?2014/6/1/23/127015
| Introduction|| |
Traumatic penile injuries are diverse with penile fracture being the most common one. Vascular penile injuries are another cause of penile trauma which may resemble true penile fracture but without the tunical tear. They include rupture of the penile superficial dorsal vein,  deep dorsal vein,  dorsal artery  and non-specific dartos bleeding. 
These acute penile emergencies necessitate urgent medical attention and in most cases prompt interference. Dorsal vein injury is the most frequent entity which presents with sudden onset of hematoma and swelling mimicking penile fracture. In this study, 11 patients presented with sudden swelling and hematoma of the penis and proved to have superficial dorsal penile vein injury on surgical exploration. We aimed to highlight the superficial dorsal penile vein rupture as the commonest penile vascular injury regarding the clinical presentation, value of imaging and role of surgery.
| Subjects and Methods|| |
The study was reviewed and approved by our institutional ethical review board. The medical records of 11 patients; presented between June 2007 and January 2013 with final diagnosis of superficial dorsal vein rupture, were reviewed retrospectively. The collected data included age, marital status, etiology, use of PDE-5 inhibitors, clinical presentation, physical findings, results of surgical exploration and post-operative follow-up. The patients were not subjected to any imaging procedure. Surgical exploration was done for all patients under spinal anesthesia. Initially, a urethral catheter was inserted. Subcoronal incision was done to explore the penis. Penile degloving was followed by examination of corporal bodies and tunica albunginea. When the tunica was found intact, artificial erection was induced to guarantee the integrity of tunical layer. Subsequently, the hematoma was evacuated and the injured vessels were identified and ligated. Hemostasis was achieved and the incision was closed. The catheter was removed after 1 day. Patients were instructed to avoid sexual intercourse for 4 weeks post-operatively. The patients were followed at an outpatient clinic for erectile dysfunction (ED), medical treatment for ED, penile deformity, curvature, fibrotic nodules and penile sensation.
| Results|| |
A total of 11 patients with aged range from 23 to 45 years (a mean of 33) presented within a median of 4 h after trauma (range 2-32). Nine patients were married and 2 were single. All the injuries were reported during erection; 9 after vaginal intercourse and 2 after masturbation. Four patients used 100 mg Sildenafil before sexual intercourse; two of them used Tramadol in addition. All the patients presented with penile swelling and bluish discoloration of skin [Figure 1]. Snapping or cracking sound was absent in all patients except two. Mild penile pain was reported in 5 patients. There was no bleeding per urethra or urinary troubles. All patients experienced gradual detumescence. Physical findings included penile shaft ecchymosis and edema in all patients. There was no penile deformity, deviation, or glans abnormality. Tunical defect could not be palpated. All the patients were managed with immediate surgical exploration. Examination of tunica albunginea did not detect any tear even after induction of artificial erection. However, the source of bleeding was found to be lacerated or avulsed superficial dorsal vein which was ligated and secured [Figure 2]. There were no urethra or suspensory ligament injuries. Closure of subcoronal incision was done at the end of the surgical exploration [Figure 3]. No intra-operative or immediate post-operative complications were noted. The mean follow-up period was 15 months (ranged from 8 to 23 months). All patients restored penile potency without any penile deformity, curvature or nodules. One patient developed penile hypoesthesia.
|Figure 1: A case of dorsal penile vein rupture presenting with penile swelling, edema and ecchymosis|
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|Figure 2: After the exclusion of tunica injury, the superficial dorsal penile vein was found to be injured and was ligated|
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|Figure 3: Closure of subcoronal incision at the end of the surgical exploration|
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| Discussion|| |
Penile injuries are uncommon because of the well-protected location on the body and a high degree of genital mobility.  Penile fracture is the most common traumatic injury to penis. It is defined as the disruption of the tunica albuginea with the disruption of corpus cavernosum.  Penile fracture is readily diagnosed by thorough history and physical examination. A history of vigorous sexual intercourse or penile bending during masturbation together with a snapping sound, rapid detumescence and penile discoloration is characteristic in such cases. Examination usually reveals swollen, ecchymotic, tender and deviated penis. Sometimes, the tunical defect can be palpable. Conservative treatment may result in complications in up to 29% of cases. These include ED, penile curvature, abscess or debilitating plaques and significantly longer period of hospitalization and recovery. ,,
Vascular penile injuries are less common causes of acute penis which may mimic penile fracture. They occur predominantly during intercourse, less commonly when turning or falling on the bed with the penis erected, or during masturbation. The patients present with hematoma, swelling and gradual detumescence. Although false penile injuries are clinically similar to true penile fracture, they usually could be differentiated by the lack of the snap penile sound, absence of tunical defect, gradual detumescence and post-traumatic new erection. , These false penile injuries include superficial dorsal vein, deep dorsal vein and dorsal artery injuries as well as non-specific dartos bleeding. ,,,
Anatomically, the major penile vasculature consists of the superficial and deep dorsal veins and the dorsal artery of the penis, lying out of the tunica albuginea. The deep artery of the penis is in the middle of the corpora cavernosa and is covered by the tunica albuginea. The deep dorsal penile vein and deep dorsal artey are present underneath the Buck's fascia while superficial dorsal vein rests outside the fascia.  The ecchymosis due to superficial dorsal vein rupture can spread through the subcutaneous tissue of the scrotum and perineum. On the contrary, the hematoma due to deep dorsal vein rupture and penile fracture is confined to the space beneath Buck's fascia and thus remains within the penile shaft as long as Buck's fascia remains intact.  If ecchymosis involves scrotum, perineum or pubic area, a diagnosis of either true penile fracture with tearing of Buck's fascia or of false penile fracture with superficial dorsal vein rupture can be considered.  Rupture of the deep dorsal vein is almost difficult to differentiate from that of cavernous bodies, except for the absence of an initial snap and sometimes of pain. 
Although sudden detumescence is an important marker of penile fracture in contrast to gradual detumescence which suggests an intact corpora cavernosa, there are a few reports of continued intercourse after fracture. , Even though there are some clinical differences between false and true penile fracture, the two conditions may still overlap with possible long-term complications of missed tunical tears being a major concern. 
Diverse radiological methods such as cavernosography, , ultrasonography , and magnetic resonance imaging (MRI) , have been utilized to diagnose and assess penile fracture. However, an ideal radiographic imaging is lacking until now. The sensitivity and specificity of these techniques are significantly different and none has proven to be the reliable diagnostic investigation and definitely differentiate false from true penile fracture. Penile ultrasound is operator dependent investigation and may give false negative results due to small albuginea disruptions or the presence of clots at the fracture' site.  Caversonography carries the risk of infection, priapism and contrast hypersensitivity in addition to its false negative results.  MRI has the advantages of mutiplanar capacity and high soft tissue resolution, making it the most precise imaging tool in cases of penile fracture.  However, MRI cannot be used as a routine diagnostic mean in cases of suspected penile fracture as it is costly, time exhausting and not always available. In our practice, even in cases when false penile fracture is suspected, we recommend to perform immediate surgical exploration to avoid an opportunity to repair a missed tunical tear that may lead to ED.
The high frequency of dorsal vein injuries noted in our patients may be attributed to childhood circumcision. Circumcision causes the penile skin to be more tightly stretched. During intercourse, elongation of the compressed taut penile skin during intercourse may result in laceration of the veins.  In addition, four of our patients have received PDE-5 inhibitors which may contribute to this high rate due to vigorous intercourse.
All our patients underwent immediate surgical exploration. Surgical management aimed at evacuation of the hematoma, identification or exclusion of the tunica injury and ligation of any injured vessels. A degloving circumferential subcoronal incision was performed, which provides good cosmetic results and exploratory advantage with exposure of the entire tunica bilaterally and the urethra.  The evacuation of the hematoma in false penile fractures might prevent possible future complications. 
Among surgically treated patients with penile fracture, those undergoing repair within 8 h of injury had significantly better long-term results than did those having surgery delayed 36 h after the occurrence of insult.  Unlike true penile fracture, time is not a prognostic factor for patients with pseudo-penile fracture.
Limitations to our study include its small sample size and retrospective nature of the study.
| Conclusions|| |
Superficial dorsal penile vein injuries are uncommon penile injuries that simulate true penile fracture. Although, few clinical differences exist between these two conditions, however, due to lack of reliable, fast and practical imaging modality, surgical exploration is advised to avoid the long-term complications of missed tunical tears. Surgery offers additional advantages as evacuation of hematoma and repair of possible dorsal penile vessel (s) injury.
| References|| |
|1.||Koifman L, Barros R, Júnior RA, Cavalcanti AG, Favorito LA. Penile fracture: Diagnosis, treatment and outcomes of 150 patients. Urology 2010;76:1488-92. |
|2.||Polo HE, Garrigós MJ, Ruiz PM, Tendero TP, Marcos SM. Penile hematoma caused by deep dorsal vein rupture during intercourse. Arch Esp Urol 2000;53:473-5. |
|3.||Armenakas NA, Hochberg DA, Fracchia JA. Traumatic avulsion of the dorsal penile artery mimicking a penile fracture. J Urol 2001;166:619. |
|4.||Shah DK, Paul EM, Meyersfield SA, Schoor RA. False fracture of the penis. Urology 2003;61:1259. |
|5.||Godec CJ, Reiser R, Logush AZ. The erect penis: Injury prone organ. J Trauma 1988;28:124-6. |
|6.||Morey AF, Rozanski TA, Wein AJ. Genital and lower urinary tract trauma. Wein: Campbell-Walsh Urology. 9 th ed. Ch. 83. Philadelphia, Pa: Saunders Elsevier; 2007. |
|7.||Nicolaisen GS, Melamud A, Williams RD, McAninch JW. Rupture of the corpus cavernosum: Surgical management. J Urol 1983;130:917-9. |
|8.||Penson DF, Seftel AD, Krane RJ, Frohrib D, Goldstein I. The hemodynamic pathophysiology of impotence following blunt trauma to the erect penis. J Urol 1992;148:1171-80. |
|9.||Feki W, Derouiche A, Belhaj K, Ouni A, Ben Mouelhi S, Ben Slama MR, et al. False penile fracture: Report of 16 cases. Int J Impot Res 2007;19:471-3. |
|10.||Pereira PA, Fentes PD, Caamaño TV, Parra BM, Parrado VL, González CM. Rupture of the superficial vein of penis: Therapeutic options. Arch Esp Urol 2010;63:871-3. |
|11.||Chung KW. Gross Anatomy. 5 th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 265-7. |
|12.||Nicely ER, Costabile RA, Moul JW. Rupture of the deep dorsal vein of the penis during sexual intercourse. J Urol 1992;147:150-2. |
|13.||el-Sherif AE, Dauleh M, Allowneh N, Vijayan P. Management of fracture of the penis in Qatar. Br J Urol 1991;68:622-5. |
|14.||Tiong JT, Taylor A, England E, Hirsch R. Fracture of the penis: Review with case report. Aust N Z J Surg 1988;58:428-31. |
|15.||Kalash SS, Young JD Jr. Fracture of penis: Controversy of surgical versus conservative treatment. Urology 1984;24:21-4. |
|16.||Wood HM, Angermeier KW. Editorial comment to (False penile fracture: Value of different diagnostic approaches and long-term outcome of conservative and surgical management). Urology 2010;75:1356-7. |
|17.||Jack GS, Garraway I, Reznichek R, Rajfer J. Current treatment options for penile fractures. Rev Urol 2004;6:114-20. |
|18.||Gedik A, Kayan D, Yamiþ S, Yýlmaz Y, Bircan K. The diagnosis and treatment of penile fracture: Our 19-year experience. Ulus Travma Acil Cerrahi Derg 2011;17:57-60. |
|19.||Koga S, Saito Y, Arakaki Y, Nakamura N, Matsuoka M, Saita H, et al. Sonography in fracture of the penis. Br J Urol 1993;72:228-9. |
|20.||Hoekx L, Wyndaele JJ. Fracture of the penis: Role of ultrasonography in localizing the cavernosal tear. Acta Urol Belg 1998;66:23-5. |
|21.||Abolyosr A, Moneim AE, Abdelatif AM, Abdalla MA, Imam HM. The management of penile fracture based on clinical and magnetic resonance imaging findings. BJU Int 2005;96:373-7. |
|22.||El-Assmy A, El-Tholoth HS, Abou-El-Ghar ME, Mohsen T, Ibrahiem el HI. False penile fracture: Value of different diagnostic approaches and long-term outcome of conservative and surgical management. Urology 2010;75:1353-6. |
|23.||Beysel M, Tekin A, Gürdal M, Yücebaº E, Sengör F. Evaluation and treatment of penile fractures: Accuracy of clinical diagnosis and the value of corpus cavernosography. Urology 2002;60:492-6. |
|24.||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 2009;16:4568-75. |
|25.||Bar-Yosef Y, Greenstein A, Beri A, Lidawi G, Matzkin H, Chen J. Dorsal vein injuries observed during penile exploration for suspected penile fracture. J Sex Med 2007;4:1142-6. |
|26.||El-Taher AM, Aboul-Ella HA, Sayed MA, Gaafar AA. Management of penile fracture. J Trauma 2004;56:1138-40. |
|27.||Al-Reshaid RA, Madbouly K, Al-Jasser A. Penile abscess and necrotizing fasciitis secondary to neglected false penile fracture. Urol Ann 2010;2:86-8. |
|28.||Asgari MA, Hosseini SY, Safarinejad MR, Samadzadeh B, Bardideh AR. Penile fractures: Evaluation, therapeutic approaches and long-term results. J Urol 1996;155:148-9. |
[Figure 1], [Figure 2], [Figure 3]