PD is considered an acquired inflammatory condition, and this opinion is supported by histopathological examination that shows the existence of perivascular inflammatory processes in the loose connective tissue located between the tunica albuginea and penile erection tissue causing the formation of plaque [4, 7]. One hypothesis is that bleeding within the multilayered tunica albuginea of the corpus cavernosum leads to the infiltration of chronic inflammatory cells by increasing the rate of TGF-β1 (transformation of beta-growth factor-1), and the formation of fibrin tissue. Over time, with chronic inflammation, the fiber elasticity of the tunica albuginea disappears focally at the site of plaque formation, which causes penile curvature when erect [7].
Although penile fracture is rarely associated with PD, erect penis angulation can cause greater trauma with vaginal penetration and an increased risk of penile fracture [7]. In our patients at the time of surgery, we did not obtain fibrosis plaque on the left shaft penis. This could be because the penis fracture area was precisely the same place as the plaque from PD. It is estimated that PD is present in around 0.3–13.1% men around the world [5]. In German, Minor et al. [7] reported that the prevalence of the disease among men with a mean age of 57.4 years was 3.2%. A linear trend was observed for the prevalence of the disorder ranging from 1.5% for 30- to 39-year-old men to 6.5% for men > 70 years old [4].
Penile fracture is the tearing of the tunica albuginea from the corpus cavernosa [8]. The tunica albuginea is among the toughest of body fascias. (It is able to withstand rupture at pressures above 1500 mmHg.) The tunica albuginea measures 2 mm in a flaccid penis and becomes thinner (0.25–0.5 mm) during erection [9]. Rupture of the tunica albuginea is more likely when the penis erect because the tissue of the tunica albuginea is thinner and vulnerable to a sudden increase in the intracorporeal pressure. The corpus spongiosum and urethrae might also be affected. The tear is mostly unilateral and transverse [10]. However, it is well known that most patients have some unilateral damage to the corpus cavernosum [11, 12]. Only a small percentage have a urethral injury. In fact, in the most extensive series published on this subject, only 5 of 300 patients had evidence of urethral injury [13].
The etiology of penile fracture varies with the geographical area. In the Western hemisphere, sex is the majority cause of penile fracture cases [9, 14]. In Japan, it was reported that only 19% of penile fracture cases resulted from sexual intercourse, with a larger proportion caused by masturbation and rolling in bed when the penis was erect [15]. Meanwhile, in the Middle East and North African countries, the most frequently reported cause is forced manipulation [1].
Kramer [16] reported a retrospective study of 16 patients with penile fractures undergoing surgery, and that there was an association between this clinical condition and sexual relations under stressful situations. Meanwhile, in another study in Saudi Arabia in 2014, it was found that heterosexual relationships were the most common cause (67%), with fewer cases resulting from penis manipulation (14%) and homosexual intercourse (10%). Woman on top was the most common heterosexual position resulting in penile fracture (50% cases), followed by “doggy style” (29% cases), and in four patients (10% cases), the cause was unclear [17]. El-Taher et al. [18] reported that 67% of cases were in the proximal shaft, and McAninch et al. reported that the distal third of the penile shaft is most often involved.
Penile fracture diagnoses are made based on history and clinical examination, as well as the classic triad of audible “cracking,” followed by rapid detumescence and intense pain. Although imaging might be necessary for better evaluation, it is often unnecessary [19]. A urethral injury should always be ruled out by asking about any voiding difficulty, history of blood per meatus or hematuria, and a retrograde urethrogram should promptly be requested to optimize treatment planning with simultaneous urethral repair during surgery [17, 20].
Ultrasonography (US) is often used for evaluation of suspected penile fractures [2] and PD [7], because it can identify the specific location of a tear in almost all patients. US can confirm the diagnosis of penile fracture and determines the location of the plaque, thus guiding the specific location of the incision.
PD surgery management (penile plication) is typically done if the curvature is > 60° [7]. In our patient, penis angulation was less than 15° upon induction of an artificial erection, so we did not perform penile plication.
Some previous studies have favored conservative treatment for traumatic rupture to the penis. However, because 10–30% of these patients experience coitus difficulties, penile deformities, and suboptimal erections, conservative management is now unpopular [16]. Cummings et al. (1998) reported that a delay of 24–48 h does not adversely impact the postoperative functioning of the penis [21]. Bozzini et al. show that delaying surgical intervention results in significant erectile dysfunction. Surgical treatment must be planned as soon as possible to avoid postoperative erectile dysfunction [1]. A multicenter study with a large sample in Europe in 2018 reported that delaying surgical intervention results in significant erectile dysfunction [1]. On the other hand, there is literature reporting that definitive therapy with excellent results is still possible after a sufficiently golden period of trauma, without increasing long-term complications [18, 22].
The most frequent postoperative complaints of penile fracture are erection dysfunction, penile curvature, pain with erection, and penile scarring [2, 9]. Meanwhile, for patient PD who underwent plication are penile shortening, discomfort at suturing location due to palpable suture knots, and pain with erection [4, 7]. For our patient, no complication occurred in surgical management, and there was no disturbance of sexual intercourse.
