Disruption or tear in the tunica albuginea of the corpora cavernosa.
Most typically due to a buckling type injury with abnormal force placed on an erect penis – usually sexual intercourse, but is described in trivial situations. Taqaandan (forced detumescence) common in Middle East, fractures also described with manipulation after collagenase injections.
Pathology
Tunica albuginea is bilaminar – inner circular and outer longitudinal fibres.
The outer longitudinal layer determines strength and thickness – thinnest area is ventrolaterally. Tunica thickness falls from 2 mm to 0.5 mm with erection.
Most commonly there is a transverse laceration at the proximal shaft, ventrally or laterally.
10 – 20 % associated with urethral injury.
10 % bilateral corporal injury (these are more likely to also have urethral injury).
Presentation & work-up
Typical features:
- Snapping or cracking or popping sound
- Immediate detumescence
- Discolouration and bruising and swelling (eggplant deformity)
May be delayed presentation. Pain is variable – some patients have little pain.
If Buck’s remains intact, bruising contained to penis. If Buck’s is breached, the haematoma can track up under the superficial dartos of penis and up under Scarpa’s and Colles to perineum and suprapubic region.
Classically swollen penis deviates away from the side of the injury.
Most urethral injuries will be associated with visible haematuria, blood at the meatus or difficulty/inability voiding.
DDx – rupture of the dorsal vein or other vessels – not usually associated with rapid detumescence.
Imaging
Imaging is not necessary to confirm the diagnosis with supporting history and examination.
It can help in equivocal cases, and may also have a role in operative planning
Ultrasound:
- Relatively accessible, cheap, and easy to obtain
- May allow identification and marking of site of injury, allowing versatility of incision
- Can be difficult to identify fracture if significant haematoma
MRI:
- Can accurately identify location of injury and urethral involvement
- Expensive, limited availability and time consuming
- Can be useful if equivocal clinically and equivocal ultrasound
Treatment
Surgical exploration and repair provides better outcomes than observation and conservative management.
Surgical exploration should be as soon as practical – there is no evidence that 24 – 48 hour delay compromises outcomes.
Can either be a degloving circumferential incision (+/- completion circumcision) or longitudinal incision either ventrally or over known site of injury.
If concerns regarding urethral injury – flexible cystourethroscopy can be performed prior to incision and catheter placement.
Repair corporal tear with absorbable suture – 3-0 PDS.
Repair urethral injury with fine absorbable interrupted sutures over a catheter – i.e. 4-0 or 5-0 PDS – and leave a catheter for 2 weeks with consideration of pericatheter urethrogram prior to removal.
Complications
Penile curvature – 5 – 10 % for repaired injuries, as high as 50 % with conservative management.
ED – one study showed 8 % ED with surgical repair cf. 41 % with conservative management.
Sensation changes, stricturing and psychosexual complications possible.
Infection of haematoma.