Urethral Injury with Penile Fracture

Mechanism, anatomy, and presentation: 1) Penile fracture mechanism - rupture of tunica albuginea of corpus cavernosum (rarely cavernosa, occasionally with urethral involvement) during forceful bending of erect penis; commonly during intercourse (rear-entry, woman-on-top positions in Western literature, taqaandan/forced manual bending in Middle Eastern series), masturbation, or rolling onto erect penis; 2) Anatomy - corpus cavernosa surrounded by tunica albuginea (1-2 mm thick); urethra runs in corpus spongiosum on ventral surface; cavernosal injury alone in 80%, combined cavernosal-urethral in 10-20%, isolated urethral rare; bilateral cavernosal injury rare; 3) Risk factors for urethral injury - bilateral cavernosal rupture, large hematoma, distal/midshaft injury, blood at meatus, voiding difficulty, gross hematuria; 4) Classic presentation - sudden cracking/popping sound during intercourse or activity, immediate loss of erection, severe pain, rapid swelling and ecchymosis ('eggplant deformity' - deviation away from injury site), palpable defect; 5) Urethral injury suspicion - blood at meatus (most sensitive), gross hematuria, dysuria, urinary retention, perineal/scrotal hematoma, inability to void, palpable urethral defect during exploration; 6) Differential - rupture of dorsal vein (hematoma without classic cracking sound), Mondor disease, traumatic urethritis without fracture.

Diagnosis and imaging: 1) Clinical diagnosis usually sufficient - characteristic history with classic findings is diagnostic; immediate exploration generally indicated; 2) Retrograde urethrogram (RUG) - perform before surgery if urethral injury suspected (blood at meatus, gross hematuria, voiding difficulty); identifies extravasation, partial vs complete transection, location; should be performed in operating room or controlled setting given fracture itself; 3) Ultrasonography - bedside option to confirm tunica albuginea defect; less sensitive than MRI but rapid; identifies hematoma; 4) MRI - gold standard for accurate localization of tunica defect and identification of urethral injury; reserved for atypical cases or when uncertainty about diagnosis exists; not routinely needed; 5) Cystourethroscopy - alternative or adjunct, performs simultaneous diagnosis and may guide repair; 6) Differential diagnosis - subcutaneous hematoma without tunica defect (false fracture, dorsal vein rupture, ruptured dorsal artery) can mimic; absence of cracking sound with persistence of erection less consistent with fracture.

Surgical management and outcomes: 1) Timing - immediate or early surgical exploration (<24 hours) standard, with better outcomes than delayed (less complications, better erectile function); operative within 24 hours is widely accepted; 2) Surgical approach - circumferential subcoronal degloving incision provides excellent exposure of all cavernosa and urethra; less invasive limited longitudinal incision over palpable defect alternative; 3) Tunica albuginea repair - identification of defect (typically transverse or oblique, 1-3 cm), evacuation of cavernosal hematoma, repair with absorbable sutures (PDS or Vicryl 2-0 or 3-0) in interrupted figure-of-eight; both corpora examined; 4) Urethral injury repair - partial transection: closure with absorbable sutures (5-0) over urethral catheter; complete transection: primary anastomosis after debridement, splayed/spatulated; long defect or complex injury: buccal mucosa onlay graft or staged repair; 5) Catheter management - 14-21 day urethral catheter or suprapubic, depending on injury complexity; remove after voiding trial; 6) Postoperative care - antibiotics, ice for first 24 hours, no sexual activity 6 weeks, gradual resumption, careful follow-up for 6 months; 7) Outcomes - excellent if early repair: erectile function preservation 85-95%, voiding satisfactory 85-95%; complications: ED (5-15%), urethral stricture (5-15%), penile curvature (5-10%), painful erection (uncommon), persistent hematoma; delayed presentation (>24 hours) increases complications 2-3x; 8) Conservative management - reserved for stable patients without urethral injury, small defects, late presentation (>14 days); higher rate of complications and chronic curvature; not recommended unless surgery not possible.