1 INTRODUCTION
A penile fracture is an unpleasant event that is mostly encountered during intercourse. Tunica albuginea tear is the main etiology for the symptoms and consequences. Patients might not notice it or might be discouraged to seek medical advice, especially with preserved erections present[
1].
Penile fractures are rare but serious urologic emergencies that require prompt diagnosis and surgical management. Neglecting penile fractures can lead to serious long-term complications such as loss of erection, curvature of the penis, hematoma, or mass formation. This may take months before symptoms appear and become bothersome. Reported incidence varies widely depending on geographic regions, however, the true incidence is much higher than reported because many patients do not seek medical attention due to embarrassment or fear[
2].
The most common cause of penile fracture is sexual intercourse in America and Western European countries[
3], while in the Middle East, Gulf region, and North Africa it is the manual bending of the penis for detumescence, named “Taghaandan”[
4]. The peak rate of penile injury is seen in men with mean age of 30–39 years old[
5]. The injury typically occurs during erection when the tunica albuginea is tense and thinner than in the flaccid state. The pathological lesion is a tear of the outer longitudinal layer of the tunica albuginea, resulting in hematoma, swelling, and skin discoloration[
1]. Our objective is to report our surgical management to excise the penile mass and repair penile curvature.
2 CASE PRESENTATION
In this case report, we present the case of a 55-year-old man who presented with a penile mass and 30° left dorsal curvature 2 months after a neglected penile fracture during intercourse. He recalled a popping sound with no hematoma, bruising, urinary symptoms, pain, or loss of erection. Two weeks after the incident, due to the presence of a penile bump with slightly painful erections, he sought medical advice and was managed conservatively with ice, nonsteroidal anti-inflammatory medications and abstain from intercourse. He presented to our clinic 2 months later with a complaint of penile mass and curvature that had been affecting his erections and penetration.
The patient underwent a penile Doppler ultrasound which showed a fibrotic hematoma with a complex cystic lesion on the right lateral mid-penile shaft measuring 23.1mm × 18.1mm × 28.3mm. The patient underwent a complex penile mass excision with tunica albuginea plication and pericardium graft reinforcement. During the surgery, the scar tissue was excised, and the underlying fibrotic hematoma was removed (Figure 1). A complex cystic lesion was found on the right lateral mid-penile shaft and was also excised (Figure 2). A tunica albuginea plication was performed to correct the 30° left dorsal curvature. A pericardium graft (Tutoplast®, IOP Ophthalmics, Costa Mesa, CA, USA) was applied to reinforce the weakened tunica albuginea and cover the defect (Figure 3). Histopathology of the mass reported grossly “a penile fibrotic mass, measuring 2 cm × 1.8 cm × 2.6 cm with irregular dark brown firm cystic structure filled with yellow-tan necrotic tissue”. Microscopic description showed “a fibrous capsule with central hemorrhage and fibrin”.
The patient tolerated the procedure well and had an uneventful recovery. He was satisfied with the results upon his 6 and 9 months follow-up. No complications nor long-term side effects were reported. He had preserved erectile function and resolved penile curvature.
3 DISCUSSION
The typical presentation of penile fracture is hearing an abrupt “popping” or “snapping” or “crack” during intercourse. This is mainly associated when an erect penis comes out of the vagina and does not reenter in the proper position. This is usually followed by rapid detumescence, penile swelling, and pain. The patient may often notice ecchymosis on the penile shaft, that could spread to his scrotum and lower abdomen, specially if Buck's fascia was injured[
6]. Urethral evaluation is imperative in the presence of hematuria, blood per meatus, or retention of urine[
7].
The involvement of both corpora, corpus spongiosum, and urethra have been reported in some cases of penile fracture[
8]. Urinary extravasation can cause fibrous tissue formation within the corpora cavernosa and subsequent penile deformity[
9]. Penile fractures were associated with urethral injury in 10%–15% of reported cases[
6]. Studies have shown that residual defects occur as a result of delayed treatment or conservative management. One study by Lispky et al., which was the largest report of penile fracture incidences and managements to date, found that only 58% of clinicians managed penile fractures surgically, according to American Urological Association (AUA) Urotrauma guidelines[
8]. While many clinicians still practice conservative management, studies have shown that surgical treatment of penile fractures provides satisfactory results with adequate recovery of sexual function, even on long-term follow-up. However, psychological sequelae are quite common, including fear of recurrence and psychogenic erectile dysfunction[
10].
There are different types of graft materials that could be used to reinforce such defects. Each might have certain advantages or drawbacks in comparison with other types[
11]. Tutoplast®, a processed allograft tissue from cadaveric pericardium, has been used extensively in various clinical applications with great results including Peyronie's curvature repair[
12]. Bovine pericardium is another example of possible graft material that could be utilized giving its high success rates and cheaper cost. Yet on a recent metanalysis by Hosseini et al., there were no reports to compare the efficacy of both pericardium graft types in urologic surgeries[
13].
We utilized Tutoplast®, since its readily accessible in our institution, and we had a vast experience in Peyronie's repair especially with concomitant penile prosthesis implantation surgeries.
There is no literature to date that mentions fibrotic hematoma formation as sequelae of a delayed resentation of penile fracture. The authors decided to report such findings in this unusual presentation and to describe the surgical management to excise the penile mass and curvature repair.
4 CONCLUSION
In this case, we successfully excised the penile mass, corrected the 30° left dorsal curvature with tunica albuginea plication, and reinforced the weakened tunica albuginea with a pericardium graft. The use of pericardium grafts in penile surgeries is relatively common and considered safe and effective. This case highlights the importance of seeking prompt medical attention for suspected penile fractures to avoid potential long-term complications. Early surgical management can prevent loss of erection, curvature of the penis, hematoma, or mass formation, and improve the quality of life for patients with penile fractures.
2023 The Authors. UroPrecision published by John Wiley & Sons Australia, Ltd on behalf of Higher Education Press.
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