madman
Super Moderator
Abstract
Purpose of Review To review the current literature on the acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie’s disease.
Recent Findings The immediate repair of traumatic penile fracture injury is associated with a significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury.
Summary Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.
Introduction
A penile fracture is a rare form of genitourinary trauma, characterized by an acute disruption of the tunica albuginea of the corpus cavernosum. This most commonly occurs in the erect state, when the tunica is both thinner and under increased tension. The etiology of fracture varies based on geographical location; however, blunt trauma during sexual activity continues to represent the majority of cases. One study evaluating sexual position during injury noted that “doggy style” and “man on top” positions comprise 43 and 40% of injuries, respectively, followed by the “woman on top” position at 12% [1]. In the Middle East and Northern Africa, the “Taghaandan maneuver,” an attempt to detumesce oneself through forceful bending is also common [2]. Several concomitant injuries may be present and must be considered at the time of initial diagnosis, including injury to the corpus spongiosum, urethra, or dorsal neurovascular bundle. Prompt evaluation and therapeutic interventions are essential, as long-term sequelae of untreated penile fracture can include persistent erectile dysfunction, penile curvature, male dyspareunia, and voiding dysfunction [3]. While, historically, this form of penile trauma was managed conservatively, the first documentation of surgical repair came from Dr. Fernstrom in 1957 [4]. Over the last 60 years, an increasing body of research has affirmed the benefits of prompt surgical intervention. Since the introduction and increased application of collagenase clostridium histolyticum (CCH; Xiaflex®, Endo, Malvern, PA) for the minimally invasive management of Peyronie’s disease (PD), a new and distinct form of penile fracture has emerged. Few studies have sought to determine if immediate surgical repair is the most appropriate management in this setting. We review and discuss the recent literature regarding penile fracture management and share our institution’s experience in managing penile fracture in the post-CCH setting.
Presentation
The diagnosis of penile fracture is most often made on history and physical examination alone. The presenting complaints often include a popping or cracking sound resulting from blunt injury to the erect penis followed by rapid detumescence, edema, and ecchymosis (often referred to as the “eggplant sign,” Fig. 1a). If there is a concomitant injury to Buck’s fascia, the edema and ecchymosis may extend into the perineum (“butterfly sign,” Fig. 1b), suprapubic, or inguinal region. A recent systematic analysis of penile fracture by Falcone et al. reported a series of 438 patients, with the following symptoms at presentation: penile hematoma (97.5%), rapid detumescence (79%), penile swelling (86%), cracking sound (69%), and penile pain (79%) [3]. One retrospective study of 68 patients with suspected penile fracture identified the “snapping sound” as the most significant predictive factor for surgical diagnosis of penile fracture [5]. Penile deviations are less common but often present and typically demonstrate deviation away from the injured corporal body.
*Imaging
*Urethral Injury
*Surgical Management Current
-Consensus on Surgical vs Conservative Treatment of Traumatic Penile Fracture
-Timing of Surgical Intervention
-Surgical Technique and Operative Materials
*Urethroplasty
*Intralesional CCH
-Risk of Corporeal Rupture
-Identification of Penile Fracture After CCH Treatment
-Current Treatment and Outcomes of Penile Fracture After CCH Treatment
Conclusion
A traumatic penile fracture requires prompt evaluation and surgical intervention. MRI, when available, continues to be the best diagnostic imaging tool when further investigation is needed beyond clinical evaluation. Concomitant urethral injury is often asymptomatic and must always be considered. When managed properly, outcomes of surgical correction are excellent. CCH-related corporal disruption represents a distinct entity from classical traumatic penile fracture. While prompt surgical intervention is appropriate, particularly in the setting of an expanding hematoma or urethral injury, our experience is that patients have done equally well or better with conservative management. If patients have worsening erectile dysfunction or curvature, patients may be offered delayed surgical repair or a penile implant device.
Purpose of Review To review the current literature on the acute management of traumatic penile fracture, with a specific discussion of those injuries following collagenase clostridium histolyticum (CCH) injections for the treatment of Peyronie’s disease.
Recent Findings The immediate repair of traumatic penile fracture injury is associated with a significantly better prognosis for long-term sexual health. Corporal disruption following CCH administration has several distinct features, and the trend is to manage these patients conservatively in the absence of urethral injury.
Summary Traumatic penile fracture repair continues to have excellent results when performed immediately following injury. The post-CCH treatment setting portends increased difficulty during surgical management and can be successfully managed in most cases by conservative measures.
Introduction
A penile fracture is a rare form of genitourinary trauma, characterized by an acute disruption of the tunica albuginea of the corpus cavernosum. This most commonly occurs in the erect state, when the tunica is both thinner and under increased tension. The etiology of fracture varies based on geographical location; however, blunt trauma during sexual activity continues to represent the majority of cases. One study evaluating sexual position during injury noted that “doggy style” and “man on top” positions comprise 43 and 40% of injuries, respectively, followed by the “woman on top” position at 12% [1]. In the Middle East and Northern Africa, the “Taghaandan maneuver,” an attempt to detumesce oneself through forceful bending is also common [2]. Several concomitant injuries may be present and must be considered at the time of initial diagnosis, including injury to the corpus spongiosum, urethra, or dorsal neurovascular bundle. Prompt evaluation and therapeutic interventions are essential, as long-term sequelae of untreated penile fracture can include persistent erectile dysfunction, penile curvature, male dyspareunia, and voiding dysfunction [3]. While, historically, this form of penile trauma was managed conservatively, the first documentation of surgical repair came from Dr. Fernstrom in 1957 [4]. Over the last 60 years, an increasing body of research has affirmed the benefits of prompt surgical intervention. Since the introduction and increased application of collagenase clostridium histolyticum (CCH; Xiaflex®, Endo, Malvern, PA) for the minimally invasive management of Peyronie’s disease (PD), a new and distinct form of penile fracture has emerged. Few studies have sought to determine if immediate surgical repair is the most appropriate management in this setting. We review and discuss the recent literature regarding penile fracture management and share our institution’s experience in managing penile fracture in the post-CCH setting.
Presentation
The diagnosis of penile fracture is most often made on history and physical examination alone. The presenting complaints often include a popping or cracking sound resulting from blunt injury to the erect penis followed by rapid detumescence, edema, and ecchymosis (often referred to as the “eggplant sign,” Fig. 1a). If there is a concomitant injury to Buck’s fascia, the edema and ecchymosis may extend into the perineum (“butterfly sign,” Fig. 1b), suprapubic, or inguinal region. A recent systematic analysis of penile fracture by Falcone et al. reported a series of 438 patients, with the following symptoms at presentation: penile hematoma (97.5%), rapid detumescence (79%), penile swelling (86%), cracking sound (69%), and penile pain (79%) [3]. One retrospective study of 68 patients with suspected penile fracture identified the “snapping sound” as the most significant predictive factor for surgical diagnosis of penile fracture [5]. Penile deviations are less common but often present and typically demonstrate deviation away from the injured corporal body.
*Imaging
*Urethral Injury
*Surgical Management Current
-Consensus on Surgical vs Conservative Treatment of Traumatic Penile Fracture
-Timing of Surgical Intervention
-Surgical Technique and Operative Materials
*Urethroplasty
*Intralesional CCH
-Risk of Corporeal Rupture
-Identification of Penile Fracture After CCH Treatment
-Current Treatment and Outcomes of Penile Fracture After CCH Treatment
Conclusion
A traumatic penile fracture requires prompt evaluation and surgical intervention. MRI, when available, continues to be the best diagnostic imaging tool when further investigation is needed beyond clinical evaluation. Concomitant urethral injury is often asymptomatic and must always be considered. When managed properly, outcomes of surgical correction are excellent. CCH-related corporal disruption represents a distinct entity from classical traumatic penile fracture. While prompt surgical intervention is appropriate, particularly in the setting of an expanding hematoma or urethral injury, our experience is that patients have done equally well or better with conservative management. If patients have worsening erectile dysfunction or curvature, patients may be offered delayed surgical repair or a penile implant device.
