It is not unusual for the patient to delay (up to several days) presenting to his physician or emergency department. Men commonly complain of a bending force of the erect penis with associated pain and instantaneous loss of erection. Oftentimes men will also admit to hearing an "audible pop". If an instant loss of erection has not occurred, it is unlikely that a penile fracture has occurred.
Profuse subcutaneous bleeding leading to the development of massive penile shaft and scrotal bruising and swelling can be associated with this event. This is commonly referred to as an eggplant deformity of the penis. In extreme cases, a tear in the urethra (urine channel) can also occur. The hallmarks of this are the presence of blood in the urine (gross or microscopic) or the inability to pass urine.
When the patient presents for evaluation it is essential that an urgent urologic consultation be sought. Failure to repair the tunica albuginea rupture is associated with the development of delayed penile curvature and erectile dysfunction (ED). A sensitive but thorough history should be taken from the patient. A directed genital physical exam should be performed with attempt to palpate a tunica albuginea defect. The patient should be asked to void. A urinalysis should be performed on this specimen. If blood is present in the specimen, an X-ray of the urethra (retrograde urethrogram) should be performed to identify the site and degree of the urethral tear. If a urethral injury is found, repair depends on the degree and extent of injury.
The diagnosis of a penile fracture largely depends on the history and a focused physical exam. Occasionally, if an aspect from the history or physical exam is not suggestive of a penile fracture, radiologic imaging may be obtained.
Historically, cavernosography was used to identify the site of the tunica albuginea tear. This investigation has been replaced by MRI or penile ultrasound. These imaging modalities are reserved for those cases where either the history or physical findings are not fully consistent with penile fracture, in an effort to spare the patient a visit to the operating room.
