06 January 2010

There's no bone in there, but it can still break

Yeah, you know what I mean. 

Yeah, you can go ahead and cringe.  If you're squeamish, you may just want to go ahead and visit LOLcats now, 'cause this is downright uncomfortable to talk about.

The fracture of the penis. 

How does it happen?  As you might expect: the erect penis does not actually have a whole heck of a lot of weight-bearing capacity.  Despite what Tenacious D might have had you think, it is not possible to perform "cock push-ups."  So, when a man or his partner should happen to drop their weight onto the penis on its longitudinal axis, it cannot support the weight and it begins to flex.  The problem there is that when the penis is erect, it's sort of an inflated tube under pressure, with a tough, fibrous capsule to contain the pressure and give it shape.  This is called the tunica albuginea.  It's not very flexible, or the penis would just keep getting bigger and would never get hard.  When the penis is fully erect, the fibers are stretched more or less to their limit.  And when the erect penis is forcibly bent, the fibers on the outside portion of the bend may tear.

So we call it a "fracture" because that's what it looks like, but it's actually more precisely described as a tear in the fibrous envelope that is the tunica albuginea.

But boy does it ever look like a fracture.  It happens with an audible "snap" or pop.  Typically (I've seen this maybe four times in ten years) the penis is bent off at an angle away from the site of the tear; I've seen it bent a full ninety degrees.  There is also usually a large hematoma right beneath the skin at the site of injury.  It hurts like crazy, and if you were really unlucky, the urethra can be disrupted sometimes.  It's not a difficult diagnosis, as it's so unmistakable.  It's also a surgical emergency: it needs to be repaired right away for function to be preserved and to prevent permanent deformity.

The surgery is not for the faint of heart, either.  It involves (take a deep breath before reading the next phrase) degloving the skin of the penis in order to evacuate the hematoma and to access the site of injury to repair it.

So recently I saw an unhappy young man with such an injury.  It was sustained in the usual manner, but it was in fact the mildest one I have ever seen.  The hematoma was not large and the angulation of the injured member was slight.  I thought it was clearly a fracture, but the urologist who examined the patient was uncertain, and the patient, understandably, was quite unwilling to undergo surgery if the diagnosis was unclear.  We discussed diagnostic options.  Ultrasound apparently has a low sensitivity, but, the urologist had read, MRI was supposedly a useful tool.  I did not know that.  So I proceeded to order the first and only MRI of the penis of my entire career.  After an incredulous phone call from the radiologist to confirm the order, we obtained the following images.

tunica
The is a coronal image of the genitals near the level of the penile root.  The red circle indicates a hematoma.  The penis itself is shown in its transverse aspect, like the above anatomic diagram.  The corpora cavernosa are clearly visible, though somewhat distorted by the mass effect of the hematoma.

tunica transverse

This is the "money shot," if you'll excuse the phrase.  A transverse image, catching the penis in two sections as it curves down.  The resolution of this is lovely, and the anatomy is vivid.  The twin corpora are sharply delineated, and the fascia of the tunica is obvious, as is the small tear indicated by the arrow.  You can even see the communication of the blood between the corpus and the hematoma!  What a wonder technology is.

This is not something I expect is commonly seen.  After all, this is almost always a clinical diagnosis, and the only diagnostic study needed may be a retrograde urethrogram to ensure that the urethra is intact. But it's useful to know that there is an option if it is needed.

This case also has a happy ending.  The surgery went well -- with such a small injury it was an easy repair -- and as of this time the patient seems to have made a full recovery.

8 comments:

Anonymous said...

Was the recovery long and hard for the patient?

rlbates said...

I had a comment ready, but "lost" it after reading the one from anonymous. Now I'm lq2m

Johnny Urologist said...

This just made my morning! I agree it's usually pretty obvious. Diagnosed upon history: "she went up, she came down, it went pop, it hurt like hell, now it's black and blue and swollen." At least your guy made it to the ER. The last penile fracture I saw came in about 4 weeks after the injury wondering what had happened and what I could do. And of course the one before that had broken his with someone other than his wife. And the one before that...

WhiteCoat said...

So Shadowfax ...
Rectal FBs. Crash course on sex toys. Fractured penii. "Money shot".
[poke]
Wife and kids on vacation or what?
;-)

rob said...

great article. how could it be that the urologist couldn't diagnose this. they we're doing it, there was sometime of pop or snap, rest is history. Also can't you just draw the fluid from the hematoma as you do with for example cauliflower ear?
thanks, <a href='http://medfuse.com>Robert</a>

Chukwuma Onyeije said...

Wow. Thank you for the educational experience. Clearly when I tell folks that nothing surprises me after my OBGYN residency and Maternal-Fetal medicine fellowship; I'm mistaken.

I've also got a case of "Weird case envy" after reading Johnny Urologists comments.

Sheesh.

litbrit said...

Yikes! I just crossed my legs, and I don't even own one of those. Well, not one that's attached to my person, but anyway...

Tiger Woods should read this post and give thanks to his deity of choice for upwardly-swung (as opposed to downwardly-aimed) golf clubs.

(By the way, Wanda Sykes, in her recent HBO special, did a wonderfully funny bit about "Broke Dick" issues.)

marcb said...

Here's one for you:

http://www.mirror.co.uk/news/top-stories/2010/01/07/firefighters-cut-free-man-s-penis-from-steel-pipe-115875-21949391/