So Bored, I Broke a Hot Dog – Penis Fracture

In the spirit of “Making America Great Again,” I did what every great American citizen would do over the July 4th weekend – BBQ meats. As I was working the grill, I started daydreaming about those 8-hour shifts, but unfortunately stopped paying attention to the grill, leading to the demise of an unfortunate hot dog.

RIP Frank.

The image of the sad, broken hot dog on the ground brought me back to a recent presentation to the emergency department: A 40-year-old male presented with a chief complaint of “broken penis.” Just prior to arrival, he was getting intimate with a lady friend. In the midst of a quick change of positions, he states that he “missed”, heard an immediate pop, and screamed out in agony. His partner shrieked at the sight of his grossly deformed, swollen penis. She immediately called 911 and left the scene of the crime.

 

What is a penis fracture?

A penis fracture is a traumatic rupture of the tunica albuginea.

Penis fractures commonly occur during sexual intercourse with the patient’s partner on top of patient. The engorged corporal bodies in the patient’s erect penis can rupture with enough force against the pubic symphysis or perineum of his partner.

When this occurs, the patient will hear a pop, followed by detumescence and deformity of the shaft, as well as immediate swelling.

Of note, there is also a practice called “Taqaandan.” This is the most common cause of penile fracture in Middle Eastern countries. Taqaandan, which comes from a Kurdish word meaning “to click,” involves bending the top part of the erect penis while holding the lower part of the shaft in place, until a click is heard and felt. Taqaandan is said to be painless and has been compared to cracking one’s knuckles. Taqaandan may be performed to achieve detumescence and can become habitual. 

 

What are the classic exam findings? (Please be advised that graphic images follow)

A classic “eggplant” appearance (swelling, discoloration, and deviation away from the defect in the tunica) of the penis is often seen.

The “butterfly sign” occurs when Buck’s fascia is disrupted resulting in swelling and ecchymosis throughout the perineum.

 

What is the workup?

History and physical exam are usually enough to diagnose a penis fracture; however, it is important to identify urethral injury for our urology colleagues. On exam, patients with urethral injury will typically have blood at the meatus or gross hematuria.

Aside from surgical exploration, the gold standard to test for urethral injury is a retrograde urethrogram (“RUG”). A RUG involves placing a Foley into the patient’s urethra, injecting contrast dye, and then obtaining an image under fluoroscopy. There will be extravasation of dye at the site of urethral injury.

Ultrasound can also be used to visualize any breaks in the tunica albuginea. The tunica albuginea is a hyperechoic linear structure, which will have hypoechoic breaks in patients with penis fracture. You can also visualize flow across these hypoechoic breaks as well.

 

What is the disposition?

Urological consultation is a priority. Surgical exploration and repair is necessary to prevent long term sequelae of penis fracture. Complications may include penile deviation, painful intercourse, painful erection, erectile dysfunction, priapism, skin necrosis, arteriovenous fistula, urethrocavernous fistula, and urethral stricture. The goals of surgery are to evacuate the hematoma and repair any tunica albuginea/urethral defects.

 

The moral of the story – don’t miss. Happy 4th of July!

 

 

 

Sources:

Jack GS, Garraway I, Reznichek R, Rajfer J. Current Treatment Options for Penile Fractures. Rev Urol 2004;6(3):114-120.

Stapczynski, J. S., & Tintinalli, J. E. (2016). Tintinalli’s emergency medicine: A comprehensive study guide (8th ed.). New York, N.Y.: McGraw-Hill Education LLC..

Radiographic imaging – https://radiopaedia.org/articles/penile-fracture

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Derick

PGY-2 Emergency Medicine Resident at SUNY Downstate Medical Center/King's County Hospital Center
Clinical Monster in Training @DrAlfonsoEM

1 comment for “So Bored, I Broke a Hot Dog – Penis Fracture

  1. Anonymous
    July 4, 2017 at 7:38 pm

    great post

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