Approach to management of penile fracture- Our Three-year experience at a Teaching Hospital

Dr. Sunil Basukala, Department of Surgery, Nepal Army Institute of Health Science (NAIHS), Sanobharyang, Kathmandu, Nepal. Email : anyurysm@gmail.com ORCID ID: https://orcid.org/0000-0001-9853-3160 Introduction Penile fracture is a rare surgical emergency. It usually occurs as a single rupture of the tunica albuginea in one of the two corpora cavernosa; a to determine the etiology, clinical presentation and to review the causes and management of penile fracture. Methods the department of Urosurgery from January 2017 to December 2020 with penile fracture in a tertiary care teaching hospital in Kathmandu. from injury to presentation, investigation done, treatment given and


Introduction
Penile fracture is a rare surgical emergency. It usually occurs as a single rupture of the tunica albuginea in one of the two corpora cavernosa; a to determine the etiology, clinical presentation and to review the causes and management of penile fracture.

Methods
the department of Urosurgery from January 2017 to December 2020 with penile fracture in a tertiary care teaching hospital in Kathmandu.
from injury to presentation, investigation done, treatment given and Results followed by manual manipulation (17.65%). Crackling sound (100%) followed by penile hematoma and pain were the most common presenting symptoms among the patients. Surgical exploration and repair of injury was done in all patients.

Introduction
Penile fracture is a rare presentation in Urosurgery with an incidence of 1 in 175,000. 1 the traumatic rupture of the tunica albuginea of the corpora cavernous. 2 sexual intercourse when the penis strikes the perineum or masturbation. Other causes include rolling over in bed on and external blunt trauma. 3 noise during sexual activity when the tunica ruptures, rapidly followed by pain, detumescence, and a substantial subcutaneous hematoma leading to an 'eggplant deformity' (Figure 1). 4,5 Synchronous urethral injury could be present in 1% to 38% of cases which should be suspected in the presence of voiding symptoms, bleeding per urethra and haematuria. 6 Historically, penile fracture was managed conservatively, but owing to its relatively high morbidity resulting in erectile dysfunction (ED), plaques, painful erections, curvature and infected hematomas ranging upto 30%, surgical exploration with repair of corpus cavernosa is considered a standard mode of management in recent days. [7][8][9] Immediate surgical intervention has also been associated with adequate functional and cosmetic results, with minimal complications. [10][11][12][13] Methods Hospital, which is a tertiary level teaching hospital in Kathmandu, Nepal. Seventeen patients who presented with penile fracture over the period of three years, between January 2017 and December 2020 were included in this study. Patient details which included age, marital status, etiology, clinical presentation, time interval from injury to presentation, investigation done, treatment given, function were collected from case sheet from the hospital (IIEF 5) was used for grading of Erectile Dysfunction (8)(9)(10)(11), mild to moderate (12)(13)(14)(15)(16), mild (17)(18)(19)(20)(21), and no ED (22-25). Statistical analysis was performed by using the Ethics Committee of Nepal Army Institute of Health Sciences (NAIHS).

Surgical procedure:
All seventeen patients who presented with penile fracture of a distal sub-coronal incision, with penile degloving and exposure of the corpora cavernosum, Corpus spongiosus and urethra. Urethral catheterization (14F-16F Foley catheter) was routinely performed, except for the cases where a urethral injury was suspected. Four cases with suspected urethral injury underwent cystoscopy prior to surgery within the same setting; however, no urethral injury three corporeal bodies was performed after degloving the penile shaft (Figure 2). A rent beneath the Buck's fascia Figure 3). Corpora cavernosa lesions interrupted polyglactin 3-0 sutures (Figure 4). Bladder catheter was maintained for 48 postoperative hours ( Figure  5). Patients also received oral ketoconazole 400mg thrice a day and oral diazepam 5mg for two weeks to avoid painful erections. Patients were discharged on oral antibiotics for seven days and were advised to abstain from sexual intercourse for six to eight weeks.  Intraoperatively, penile fracture was found in all the cases. However, no urethral injury was found in this study. Among the injury the mean size of rent in corpora cavernosa was 1.75 ± 1.0 cm. Circumcision was done in all cases in which circumcoronal incision was used. Minor postoperative complications such as discoloration of skin and serous discharge were noted in two patients in immediate postoperative period which were managed conservatively. between 4.15 ± 2.5 days (3-6 days). Erectile function test among these patients was done during the follow up period of three months, however, none of the patient showed Erectile Dysfunction (IIEF-5 >22).

Discussion
Penile fracture remains a rare surgical emergency worldwide, [10][11][12][13] with an incidence of 1 in 175,000. 1 It occurs when the penis is erect because the tissue of the tunica albuginea is thinner during erection and is vulnerable [14][15][16] Emergency department physicians need to be aware of the urgency in the diagnosis of this condition and in the initiation of treatment as any delay increases the risk of complications. Due to the embarrassment associated with such injuries the patients may hesitate to disclose their complaint and delay seeking medical treatment. 6 fracture in our study was 34.35 years with 12(70.5%) of study conducted by Nason et al among 21 cases of penile fracture. 7 Among the cases reported for penile fracture, the most common cause is intercourse, 6-10 but traumas to a tumescent shaft such as masturbation, habit of forcibly bending the erect penis to pass urine or rolling onto an erect penis have also been reported. 12 Sexual intercourse was the leading cause of penile fracture, accounting for 83.33% in our study followed by manipulation during masturbation and trauma. It remains the most common etiology in penile fracture ranging upto 95.23% as shown by few other studies. 7,8 Majority of the cases in our study presented with hematoma of the penile shaft (100%) and followed by pain conducted by Swanson et al which showed that penile hematoma and history of crackling sound during penile cases presented with penile fracture. 8 and physical examination. 17 with a sharp cracking sound in the erect penis followed by rapid detumescence. 6,7 include swelling of the penis, ecchymosis and deviation of the penis to the opposite side. 12 Penile Ultrasound has been an easily available, non-invasive modality which quickly determines the site and length of injury in most of the cases.
tunica albuginea with associated hematoma suggestive of penile fracture. 11,12 Absence of loss of the continuity of tunica albuginea in ultrasound however does not always rule out penile fracture. 6  In our study, none of the patients had urethral injury intraoperatively. Since, we did not routinely perform urethrography in our patients, minor injuries resulting in hematuria could have been healed with short-term urethral by Özorak A et al who conducted a retrospective study among 31 patients with penile fracture that showed no urethral injury though 33 % of patients presented with hematuria on initial presentation. 17 issue. Conservative management such as bed rest, pressure dressings, catheterization, and ice packs for 24-48 hours diazepam were used earlier. However, ten to thirty percent of patients receiving such conservative management developed impaired erections, permanent deformity, or suboptimal coitus. 8-10 Immediate surgical intervention was done among all the patients regardless of the timing of presentation to the hospital in our study which showed lower incidence of erectile dysfunction and less chances of long-term penile curvature with greater patient satisfaction.
Early surgical treatment has been strongly recommended by the studies because of the excellent results, shorter hospitalization, less morbidity, and early return to full sexual activity. [18][19][20]

Conclusion
Penile fracture though rare, is an Urosurgical emergency.
for making a diagnosis for most of the times. Our study showed that immediate surgical repair regardless of the timing of presentation is associated with faster recovery; avoids deformity, impaired erections and increases patient satisfaction.