Penile Fracture Management (AUA Urotrauma 2020)

Algorithm Steps

1. ▶

   Start

   Suspected Penile Fracture

   Acute penile injury with classic presentation

   1. ●

      Action

      Classic History & Exam

      Diagnosis is primarily clinical

      • Popping/cracking sound during erection
      • Immediate detumescence
      • Rapid swelling and ecchymosis
      • 'Eggplant deformity' - swollen, purple penis
      • Penile deviation away from injury
      • Usually during intercourse or masturbation
      1. ◆

         Decision

         Signs of Urethral Injury?

         Blood at meatus, gross hematuria, inability to void

         1. ●

            Action

            Urethral Evaluation

            10-22% have concomitant urethral injury

            • Retrograde urethrogram (RUG) OR
            • Flexible cystoscopy
            • Document injury location and extent
            • Plan repair at time of tunical repair
            • Place suprapubic catheter if complete disruption
            1. ●

               Action

               Prepare for Surgery

               Prompt surgical exploration and repair

               • NPO, IV access
               • Consent for exploration and repair
               • Discuss potential outcomes
               • Urology consult if not already
               • Target: Surgery within 24 hours
               1. ⚠

                  Warning

                  ⚠️ Early Repair Critical

                  Delay increases complication risk

                  • Surgery <24h: 7.6% complication rate
                  • Surgery >24h: 68.7% complication rate
                  • 96% good outcomes with surgical repair
                  • 50% good outcomes with conservative treatment
                  • ED risk increases with delayed repair
                  1. ●

                     Action

                     Surgical Exploration & Repair

                     Definitive management

                     • Degloving incision (circumcision or ventral)
                     • Evacuate hematoma
                     • Identify tunical defect(s)
                     • Primary repair with absorbable suture (3-0 or 4-0)
                     • Interrupted or running closure
                     • Repair urethral injury if present
                     • Close in layers
                     1. ●

                        Action

                        Post-Operative Care

                        Recovery and monitoring

                        • Foley catheter for 24-48 hours
                        • Compression dressing
                        • Ice to reduce swelling
                        • NSAIDs for pain (avoid if urethral repair)
                        • Abstain from sexual activity 4-6 weeks
                        • Urology follow-up in 2-4 weeks
                        1. ●

                           Action

                           Patient Counseling

                           Discuss expected outcomes

                           • Most patients resume normal erectile function
                           • Risk of erectile dysfunction 1-10%
                           • Risk of penile curvature (Peyronie's) 1-10%
                           • Risk of painful erection
                           • May need long-term follow-up if issues arise
                           1. ✓

                              Outcome

                              Good Outcome Expected

                              With prompt repair, 96% satisfactory results

                           2. ✓

                              Outcome

                              Monitor for Complications

                              ED, curvature, chronic pain possible

         2. ◆

            Decision

            Diagnosis Clear?

            Classic history and physical examination

            1. ●

               Action

               Consider Imaging (If Equivocal)

               Not routinely needed if diagnosis clear

               • Ultrasound: Most common, readily available
               • MRI: Higher sensitivity if US equivocal
               • Look for tunical defect
               • Do NOT delay surgery for imaging
               • If imaging equivocal but clinical suspicion high → explore