My clinical approach
Penile fracture is one of the most distinctive emergencies in urology. The history is typical: a patient reporting a pop during intercourse, immediate detumescence, and an "eggplant penis" on examination. Delay equals complications.
In my practice I follow the EAU Urological Trauma 2024 and AUA Urotrauma 2020 (reaffirmed 2023) guidelines:
- Diagnosis is mainly clinical — imaging only when in doubt.
- Exclude urethral injury in every patient (hematuria, dysuria, blood at meatus).
- Immediate surgical repair within 24 hours — no observation, no conservative management.
- Subcoronal degloving incision for full access and assessment.
- Concurrent urethral repair if injured.
- Erectile function follow-up at 3 and 6 months with IIEF-5.
What is penile fracture?
Penile fracture is the rupture of the tunica albuginea, the dense fibrous sheath surrounding the corpora cavernosa. The term "fracture" is misleading — there is no bone in the penis. It is a tear of the fibrous sheath during erection.
Incidence: ~1 per 175,000 emergency presentations annually, but likely under-reported due to embarrassment or delayed presentation.
Mechanism of injury
Almost all penile fractures occur in the erect state. The tunica is thinner (~0.25 mm vs 2 mm in flaccid state). Common causes:
- Sexual intercourse (60–80%) — abrupt bending when the penis hits the perineum or pubic symphysis. "Woman-on-top" position = increased risk.
- Self-manipulation / forceful bending of erect penis.
- Trauma during sleep on a nocturnal erection.
- "Taqaandan" practice (Middle East) — intentional bending to abort an erection.
Symptoms and clinical signs
Immediate symptoms
- Characteristic "pop" sound
- Immediate detumescence
- Sharp, intense pain
- Rapid swelling
Examination signs
- "Eggplant deformity"
- Extensive hematoma
- Penile deviation away from the tear
- Palpable tunical defect
- Blood at urethral meatus (if urethral injury)
Associated urethral injury
In 10–20% of patients, urethral injury coexists. Signs: hematuria, blood at the meatus, inability or pain on voiding. See: urethral injury.
Diagnosis and imaging
Diagnosis is mainly clinical. Typical history + characteristic findings = penile fracture. Imaging only in equivocal cases:
Detailed history
Circumstances of injury, time since event, reported pop sound, detumescence, signs of urethral injury.
Physical examination
Assessment of "eggplant deformity", deviation, palpation of tear, meatal blood examination.
Penile ultrasound
First-line in equivocal cases. Identifies tunical tear and hematoma. Sensitivity 50–86%.
Penile MRI
In difficult cases. Excellent visualization of tunica and tear location. Should not delay surgery.
Retrograde urethrography or cystoscopy
When urethral injury is suspected — hematuria, blood at meatus, voiding inability.
Treatment — immediate surgery
Penile fracture is a surgical emergency. Conservative management is associated with significantly higher rates of ED, curvature, and fibrotic plaque.
Immediate surgical repair
Within 24 hours of the event. General anesthesia. Subcoronal degloving incision (circumferential) or targeted penile incision. Hematoma evacuation, identification of tunical tear, suture with absorbable sutures (PDS 2-0 or 3-0). Intraoperative assessment for associated urethral injury.
Urethral repair (if needed)
For associated urethral injury: immediate primary repair with absorbable sutures, urethral catheter drainage 14–21 days. See: urethral injury.
Conservative management (ice, analgesics, immobilization): NOT recommended as initial approach. Associated with ED ~30–50%, permanent curvature, and fibrotic plaque. Only in exceptional cases (patient refusal, anesthesia contraindications).
Postoperative course
- Hospital stay: 1–2 days.
- Ice, elevation, analgesia for 48–72 hours.
- Antibiotics for 5–7 days.
- Urethral catheter 24–48 hours (or 14–21 days if urethral repair).
- Sexual abstinence for 6 weeks (until full tunica healing).
- PDE5i (sildenafil 25mg/night) for first 4–6 weeks — supports return to normal erectile function.
- Re-evaluation at 6 and 12 months with IIEF-5 and curvature assessment.
- Prognosis: erectile function expected normal in >90% of patients with timely surgery.
Complications without treatment
- Erectile dysfunction (~50% without surgery vs <10% with timely repair).
- Permanent penile curvature from "first-intention" healing.
- Peyronie-like fibrotic plaque at site of old tear.
- Arteriovenous fistula (high-flow priapism).
- Urethral stricture if associated unrepaired urethral injury.
- Chronic pain, psychological burden.
Prevention
- Avoid abrupt movements during intercourse.
- Caution in high-risk positions (woman-on-top).
- Adequate use of lubrication.
- Avoid forceful bending of the erect penis.
- Inform sexual partner.
Frequently asked questions (FAQ)
What is penile fracture?
Penile fracture is the rupture of the tunica albuginea (the fibrous sheath surrounding the corpora cavernosa) of the erect penis. It typically occurs during sexual intercourse with abrupt bending of the erect penis. It is a urological emergency.
How urgent is treatment?
Immediately urgent. Surgical repair within 24 hours has significantly better functional outcomes (erectile function, alignment) compared to delayed management. Visit emergency urological care without delay.
What are the symptoms?
Characteristic "pop" or "crack" sound, immediate detumescence, sharp pain, rapid swelling and hematoma ("eggplant deformity"), penile deviation away from the side of injury. In 10–20%, urethral injury coexists: hematuria, voiding difficulty.
How is it diagnosed?
Mainly clinical (typical history + pop sound + hematoma). In equivocal cases: penile ultrasound or MRI. If urethral injury suspected: retrograde urethrography or cystoscopy.
What is the treatment?
Immediate surgical repair: identification and suture of the tunica tear, hematoma evacuation. Delayed or conservative management is associated with ED, curvature, and fibrotic plaque.
What complications occur without surgery?
Erectile dysfunction (up to 50% without surgery vs <10% with timely repair), permanent penile curvature, Peyronie-like fibrotic plaque, urethrocutaneous fistula or urethral stricture if associated urethral injury is missed.
What is the recovery like?
Hospital stay 1–2 days. Sexual abstinence for 6 weeks. Re-evaluation at 6 and 12 months. Erectile function expected normal in >90% with timely surgery.
How can it be prevented?
Avoid abrupt movements during intercourse, particularly in high-risk positions (woman-on-top). Use adequate lubrication, avoid forceful bending of the erect penis.
Related topics
Emergency? Call immediately
For suspected penile fracture (pop sound, detumescence, "eggplant deformity"), contact us immediately. Surgery within 24 hours ensures the best outcomes.
Scientific literature
- EAU Guidelines on Urological Trauma (2024) — Penile Fracture — uroweb.org
- Morey AF, Broghammer JA, Hollowell CMP, et al. Urotrauma Guideline 2020: AUA Guideline. J Urol 2021;205(1):30-35 (reaffirmed 2023) — auanet.org
- Amer T, Wilson R, Chlosta P, et al. Penile Fracture: A Meta-Analysis. Urol Int 2016;96(3):315-29 — pubmed.ncbi.nlm.nih.gov
- Mirzazadeh M, Fallahkarkan M, Hosseini J. Penile fracture epidemiology, diagnosis and management in Iran: a narrative review. Transl Androl Urol 2017;6(2):158-166 — pubmed.ncbi.nlm.nih.gov
- Eke N. Fracture of the penis. Br J Surg 2002;89(5):555-65 — pubmed.ncbi.nlm.nih.gov
Meet the doctor
Dr. Marinos Vasilas, Urologist – Andrologist
Dr. Marinos Vasilas offers specialized management of urological emergencies, including penile fracture with immediate surgical repair and intraoperative assessment for associated urethral injury.
View full profile
