Paris – Is the surgical treatment of a penile fracture an emergency or an intervention that can be postponed? There Dre Alexandra Clerget (Paris Saint-Joseph Hospital) responded to it during a plenary session of the 118th congress of the French Urology Association (CFU), organized from November 20 to 23, 2024 [1].
Fracture of the penis corresponds to the rupture of the albuginea which surrounds one or more corpora cavernosa, and can be associated with an injury to the urethra. It usually occurs following direct trauma during an erection, when the albuginea is particularly thin (around 0.25 mm) and, therefore, more vulnerable.
Fracture of the penis mainly occurs in a sexual context. According to a literature review [2]in 46% of cases, it results from a “misstep” during coitus, often linked to an intromission problem, the trauma being caused by the partner’s pelvic floor.
In 21% of cases, it is due to voluntary flexion, called “manual” (the most common cause of penile fracture in the Middle East being manipulation aimed at stopping the erection by compression, called the “Taghaandan maneuver “).
Traumatic masturbation is responsible for approximately 18% of fractures. Finally, in 11% of cases, the fracture results either from external trauma or from involuntary flexion.
The typical clinical picture, although inconsistent, generally consists of an audible cracking sound at the time of trauma, immediate sharp pain, rapid loss of erection and the almost instantaneous appearance of a hematoma. diffuse, giving the penis a characteristic “eggplant” appearance.
The GOLD Standard is surgical management
Current recommendations recommend surgical management for these patients. The objective of the intervention is to explore the penis, to identify the fracture at the level of the albuginea, then to repair the lesion in order to restore the integrity of the corpora cavernosa. [3]. This intervention aims to limit the risks of long-term functional complications, such as erectile dysfunction, secondary curvature of the penis, Peyronie’s disease, as well as pain during erections.
It has been clearly demonstrated that in patients, particularly those who have refused surgical management, the risk of long-term impact on erectile function is high, with rates of complications (erectile dysfunction, curvature of the penis, pain during erections) varying from 50 to 60% in medically treated cases [4]. On the other hand, in patients who have benefited from exploration followed by surgical treatment, healing and sexual impact are almost zero.
In another publication, surgical treatment performed within 5 hours of fracture showed good results, with 49 out of 51 patients (96%) in the “surgery” group having satisfactory erectile function. [5]. On the other hand, only 9 out of 18 patients (50%) in the “medical treatment” group maintained satisfactory erectile function, thus emphasizing the importance of early surgical treatment.
What is the optimal time for surgical intervention?
The data available on the subject is limited. There are no randomized studies, and prospective studies are rare. Some have suggested that delayed management could allow for a reduction in edema, thereby facilitating localization of the fracture area and making elective approach easier. In total on this subject of delay in surgical intervention, a specific meta-analysis included 12 studies (n = 502), while another, global one, grouped 58 studies (n = 3213).
In a study based on 3 clinical cases, to be taken with caution, the treatment time, between 7 and 12 days, shows positive results: the men presented neither erectile dysfunction nor residual curvature at 3 months after the ‘intervention. Additionally, none of these patients experienced erection pain. [6]. However, this view is not supported by more robust studies, such as this one: of 122 patients with penile fracture, 4.1% developed erectile dysfunction after immediate treatment. On the other hand, this rate rises to 18.2% in the case of deferred treatment, that is to say between 24 hours and 7 days after the fracture. [7].
Another study [8] examined patients treated within 24 hours of their trauma, divided into three groups: one group treated within 6 hours of the fracture, another between 6 and 12 hours, and a final group between 12 and 24 hours.
These groups were comparable in terms of age, fracture severity, and preoperative sexual function, and patients were followed for an average of 44.9 months. There was no significant difference in postoperative sexual function between these groups.
Furthermore, a meta-analysis involving more than 3,213 patients (58 studies) evaluated the long-term repercussions of treatment before (“immediate”) or after 24 hours (“delayed”).[2]. It did not reveal any difference regarding erectile dysfunction (7.8% versus 8.2%, p = 0.59), but highlighted a difference in operative complications (formation of plaques or nodules, curvature of the penis, erectile dysfunction, pain, infections, slight chordaea, need for further intervention, aneurysm, wound edema, urinary disorders) and the rate of secondary curvature.
She noted a higher rate of Peyronie’s disease in patients treated after 24 hours (7.1% versus 37.5%, p = 0.0004).
Still on the question of the optimal time for surgical treatment, a study compared 502 patients treated within 24 hours following the fracture to those treated after 24 hours. No difference was observed in the rate of erectile dysfunction (6.6% versus 4.5%, not significant), but a significant difference was noted, with a higher rate of penile curvature in treated patients. beyond 24 hours (1.8% versus 4.5%) [9].
Penile fracture surgery: better late than never!
“Although the literature is heterogeneous and the available data are mainly retrospective, with a low level of proof, the functional results seem to be preserved as long as surgical treatment is carried out within 24 hours following the fracture,” summarizes Dr. Alexandra Clerget. But it’s better to intervene late than never. Although the rate of curvature and erectile dysfunction is sometimes higher in the event of delayed treatment, these rates remain lower than those observed in series treating patients exclusively with medical treatment. Thus, a patient who presents 7 days after the fracture, with an MRI showing a fracture of the penis, must benefit from surgical treatment to best preserve his erectile function and limit complications linked to his sexual function. »
And the imagery?
Currently, no recommendation specifies the preoperative assessment in terms of imaging for penile fractures. In practice, the exploration and localization of the fracture is mainly done in the operating room, intraoperatively, on the basis of a clinical evaluation. There is no evidence to suggest that it is advantageous to delay intervention to perform imaging studies, unless the suspicion of fracture is low, such as in the case of isolated hematomas, cracking or cracking. evocative clinic.
A national multicenter retrospective study, Fract’AFUFincluded 522 patients from 19 participating centers. This study analyzes several themes, including the impact of the time between the fracture and surgical treatment, sexuality after a fracture of the penis, the impact of the approach (degloving versus elective approach), the place of preoperative imaging and predictive scores, as well as urethral injuries associated with penile fractures, among others.
Links of interest of experts: None
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