Abstract

Penile fracture (PF) is considered an emergency in urology. In the literature, there are some case series reporting considerable incidence of PF in some parts of Iran. There are no accurate data about the incidence of PF all around Iran. Although it may be uncommon in other parts of the country and in other countries, it can also be underreported. There are some challenges in the diagnosis, management, and also reporting of these cases. In this review of Iranian medical literature, we searched for penile fracture and penile injury keywords in Medline, Scopus, SID, Google, and Persian medical journals. We reviewed the status of epidemiology, etiology, diagnosis, management, and complications of PF in different parts of Iran in the published literature. To collect more accurate data, we also performed a questionnaire-based study by sending questionnaires by email to 700 urologists throughout the country with a 14% response rate. The incidence of PF varies significantly in different parts of Iran. The western province of Kermanshah has a significantly higher rate of PF. Adding data from different regions of Iran, we calculated that the incidence of PF in Iran can be estimated between 1.14 to 10.48 per 100,000 male populations, most probably closer to the lower end. Although the incidence of PF varies significantly in different geographical areas, urologists practicing in Iran on average may encounter a PF patient every 3.5 months. To diagnose PF, the majority of reviewed studies relied on history and clinical examination and did not recommend imaging except in patients with possible urethral injuries. Immediate surgical intervention can make good functional results with low morbidity and short hospital stay. Delayed surgical intervention and observational management approaches need large population studies with long-term follow-up.

Presentation

Break of the penis is a urological crisis coming about because of a tear in the tunica albuginea of the penis regularly because of strong control, energetic vaginal or butt-centric intercourse or masturbation, shot injuries, or whatever other mechanical injury that causes coercive bowing of an erect penis. More uncommon etiologies incorporate turning over in bed, a hard impact, constrained twisting, or quickly taking off or applying apparel when the penis is erect (1). Most generally, it includes one of the corpora cavernosa. It might likewise influence the two corpora huge, corpus spongiosum or urethra (2). During an erection, the thickness of the tunica albuginea diminishes from 2 mm in the limp state to 0.25–0.5 mm. Accordingly, the penis is more powerless against horrible injury (3). The most well-known instrument of injury is the point at which the penis sneaks out of the vagina and strikes against the symphysis pubis or perineum. In certain reports, 60% of cases happen during consensual intercourse (4) and are more probable when the accomplice is on top (5).

PF is normally underreported in the distributed writing. In the US, the detailed rate is 1 out of 175,000 male populaces. The occurrence of PF shifts in various locales with dissimilar societies. In some Eastern nations the rate is higher and up to one case in seven days may present to a bustling crisis office (6). A few patients may not look for treatment in view of humiliation (2).

Here we audit the study of disease transmission, conclusion, and the board of PF in Iranian distributions and furthermore present our information from a new poll-based overview study.

Definition

PF is characterized as the horrible crack of the tunica albuginea of the corpora cavernosum (Figure 1) (7). The horrible crack of the penis is generally unprecedented and is viewed as a urologic crisis (8). The tunica albuginea is a bilaminar structure (inward roundabout, external longitudinal) made out of collagen and elastin. The external layer decides the strength and thickness of the tunica, which shifts in various areas along the shaft and is most slender ventrolaterally. The elasticity of the tunica albuginea is noteworthy, opposing burst until intracavernous pressure increments to in excess of 1,500 mm Hg. At the point when the erect penis twists anomalous, the unexpected expansion in intracavernosal pressure surpasses the rigidity of the tunica albuginea, and a cross-over cut of the proximal shaft normally results. The penile break may happen all the more as often as possible in “upsetting circumstances, for example, extramarital sex (1).

Epidemiology

Injury during sexual relations is liable for around 33%, all things considered; the female-predominant position is most ordinarily announced. The system of activity may prompt shame, making patients abstain from looking for treatment and furthermore adding to the late introduction and underreporting of the cases. Starting in 2001, 1,331 cases were accounted for in the writing. The occurrence of associative urethral injury in detailed cases is 10–58% (9). The occurrence of PF in territories with particular societies is extraordinary (1). In investigating Iranian writing we discovered information from four diverse topographical districts of Iran. Shafi et al. (6) announced 84 patients in a long time from Northern Iran. 66 of these patients (79%) were singles and 46 (55%) were living in provincial zones. The mean period of patients was 28.11 years old (going from 26 to 45). Asgari et al. revealed 68 PF patients in a long time from Tehran, Central Iran (10). Ahmadnia et al. referenced in their investigation that during a 10-year time frame, they treated 116 patients with a mean period of 32.78 (going from 16 to 62) (11). An investigation in Kermanshah, Western Iran, revealed 18 years’ experience, with 373 patients (12). Moslemi explored the PF in a 9-year time span in Qom Province, Central Iran. He discovered 86 patients with a mean period of 36.74, (going from 17 to 62), 56 (65%) wedded, and 30 (35%) singles. He additionally revealed the occasional variety of this issue and demonstrated that 22 cases (25.5%) happened in spring, 25 (29%) in summer, 17 (20%) in harvest time, and 22 cases (25.5%) in winter with the most reduced rate in pre-winter that was measurably critical (13). Overall in four areas of Iran, the mean number of PF cases treated by urologists was accounted for as high as 15 cases for each year (1). To gather more complete information and furthermore to search for any new change in frequency of PF we played out a survey-based examination. Of 891 urologists in Iran, we had the option to send a survey (Figure S1) to 700 urologists in various pieces of Iran. 97 urologists finished the poll. The reaction rate was 14% which contrasting with accessible writing appears to be adequate. Table 1 shows the outcomes from our examination. In Western Iran, the mean recurrence of PF patients treated by urologists was 1 every 2.31 months, Eastern Iran: 1 for every 3 months, Southern Iran: 1 for every 4.8, Northern Iran: 1 for every 5.18, Capital of Iran (Tehran): 1 for every 7.2 and Central of Iran (aside from Tehran): 1 for every 10.5 months.

Table 1

Calculated incidence of PF cases in different areas in Iran

In this review, the number of detailed cases inside recent years in various regions of Iran was: North Iran: 96, Tehran: 307, South Iran: 118, East Iran: 27, Center: 25, West: 55. We ought to recognize that this information is restricted to the focuses that reacted to the poll. In light of this examination, the 97 urologists who reacted to the poll (counting urologists with no case to report), in general, had 987 cases in 3 years which implies 3.39 cases every year. We can compute that our reacting urologists from all various pieces of Iran, on normal have seen one PF patient each 3.5-month over the most recent 3 years.

The Worst and Best Analysis of our information was done to figure the frequency of PF. In the best examination of information, we accepted that all PF cases detailed by respondent urologists are the entire cases established in the home region of correspondents and the non-respondents had no PF cases to report; so the denominator of the yearly rate is equivalent to add up to in danger populace (male populace) during a report year and the nominator of rate is equivalent to the revealed number of PF cases. In the most noticeably awful investigation, we expected that the information of no respondent urologists was missed and furthermore we accepted an equivalent number of populaces of catchment territory of every urologist in every region and split the number of inhabitants in every area between urologists rehearsing in that region similarly. Hence, subsequent to ascertaining the pace of PF for respondents we summed it up to different urologists of every area by direct change technique and decided the assessed occurrence rates. At long last, the occurrence rate in 100,000 and 175,000 in danger populace was determined by the increase of determined rate to 100,000 and 175,000 separately. Computing the occurrence in each 175,000 populace was done to make it simpler to contrast and rate in the US which is one for every 175,000 guys.

With the absence of a better and more dependable wellspring of information, it is sensible to accept that the genuine number of cases is a number among the most noticeably terrible and best gauges. Likewise, we can gauge that the genuine number is nearer to bring down the end since the urologists with a higher number of cases presumably had a higher opportunity to react to this poll. This implies frequency of PF in Iran can be assessed between 1.14 to 10.48 per 100,000 male populaces (truly conceivable nearer to bring down end). Additionally, the frequency is by no means uniform, and the Province of Kermanshah has the most elevated rate, with low rates in numerous different parts.

Etiology

Regular reasons for PF are intercourse, masturbation, turning over in bed, constrained flexion to accomplish detumescence, and some other irregular causes (14). The ‘Lady on top” position represents the most serious danger to PF, albeit no precise survey has substantiated this (15). Patients of the time report that they were having sexual relations in a work area (with the patient on top) and the penis sneaked out, hitting the edge of the work area. It appears to be that there is topographical variety in its etiology dispersion (16). Patients ‘massaging and snapping’ the erect penis to accomplish quick detumescence in inadmissible circumstances, is another reason in Middle East nations (7,17). This is classified as “Taqaandan”. a typical practice in the Province of Kermanshah in Western Iran. A report from Zargooshi et al. shown that in 269 of 352 (76%) patients, “Taqnaadan” was the reason for PF (12). The basic reason for PF in Iranian distributions are sex (17.9–89%), masturbation (11–73.8%), and injury (8.3–28.5%) (6,11,13,18). In our review, the most well-known etiologies among each of the 620 announced cases with known etiologies over the most recent 3 years were: intercourse in 350 cases (56%), non-intercourse injury in 146 (24%), masturbation in 108 (17%), and different causes in 16 (3%) cases.

Table 2 show complementary data on the etiology of PF in Iran.

Table 2

Etiology of PF in Iran

Clinical manifestations

The clinical introduction of PF is regularly genuinely direct. The conclusion is made dependent on history and actual assessment discoveries (19). PF is described by unexpected breaking or popping sounds, torment, and prompt detumescence. Neighborhood growing and staining of the penile shaft happens and may reach out to the lower stomach divider. The burst tunica might be unmistakable. Patients may report insignificant to extreme sharp torment, contingent upon the seriousness of the injury. Upon actual assessment, penile injury is plainly obvious (15). In a regular PF, the typical outer penile appearance is totally decimated due to huge penile disfigurement, growing, and ecchymosis (the alleged “eggplant” distortion, Figure 2) (9).

Shafi et al. detailed that the most well-known indications of PF are penile agony (35.7%), hematoma (29.8%), and edema (11.9%) (6). They likewise announced that the normal delay among break and showing up to the medical clinic was 5.9 hours. Break of corpus cavernous in their arrangement of 76 patients was correct-sided in 59.5%, left-sided in 29%, and the two sides in 11.5% (6). In an examination in Western Iran, the creator announced the site of injury was in the correct corpus cavernosum in 65 (71.4%) and in the left corpus cavernosum in 26 (28.5%) cases (20). Ahmadnia et al. demonstrated that the most widely recognized site of injury found with the explorative medical procedure was the correct side (55%) and horizontal perspective (74%) of the corpus cavernosum (11). Moslemi revealed that the time from injury to introduction to the medical clinic was variable from 3 to 72 hours and all patients gave the average clinical image of a trademark “pop” solid at the hour of injury, agony, detumescence, and moderate to serious hematoma. The actual assessment uncovered penile growing, ecchymosis, and critical delicacy on palpation of the penile shaft. The penile deviation was clear in 82 cases (95.4%). The site of injury was on the right side in 48 cases (59%) and the left side in 32 cases (39%), and in 2 cases (2%) break was reciprocal (13).

In our investigation, 531 patients were introduced for treatment inside the initial 24 hours and 190 patients following 24 hours. In this examination, patients’ clinical appearances were tormented, growing and staining in 354 cases, agony and expanding in 183 cases, disconnected torment in 184 cases, hematuria in 18 cases, and impotency in 7 cases. The detailed entanglements of PF were: chordee in 72 patients (10%), Peyronie’s plaque in 2 (0.2%), and barrenness in 44 patients (6%).

Diagnosis

Amer et al. in a meta-investigation study referenced that 31 creators utilized no imaging to analyze PF, accentuating that a precise finding is a conceivable dependent on clinical evaluation alone. Then, 22 creators utilized different imaging modalities to affirm the conclusion including ultrasonography study (USS) (21), cavernosography (22), retrograde urethrography (23), and Magnetic Resonance Imaging (MRI) (22). European Association of Urology (EAU) rules propose that imaging (USS or MRI) might be valuable in diagnosing PF (3). Moreno Sierra et al. (24) accentuated that integral tests were useful, yet they were not conclusive. In clinical assessment, ecchymosis and growing of penis and troublesome voiding inpatient recommend urethral crack because of PF and in dubious cases, urethra ought to be assessed by urethrography (25). The swollen, ecchymotic phallus regularly goes amiss to the side inverse the tunica tear due to hematoma and mass impact. The broken line in the tunica albuginea might be unmistakable (1). Given that urethral injury happens habitually, preoperative urethrography ought to be viewed when the urethral injury is suspected. Notwithstanding, in light of the fact that urethrography can be tedious and off base, intraoperative adaptable cystoscopy is presently regularly performed regularly not long before catheter position at the hour of penile investigation at whatever point urethral injury is suspected (1). The common history and clinical introduction of PF typically make adjunctive imaging examines superfluous. Notwithstanding, when the set of experiences and actual assessment are obscure for PF, ultrasonography can set up the determination (26). Ultrasonography has become the favored imaging study to assess PF in light of the fact that it is fast, promptly accessible, noninvasive, reasonable, and precise. Penile ultrasound is generally valuable for precluding crack in patients with low clinical doubt (27).

Shariat et al. for a situation arrangement report in Shiraz assessed the job of ultrasound in the demonstrative guide of PF. They reasoned that ultrasound is a solid methodology to identify the presence and site of tear in the tunica albuginea and can likewise assist with the right conclusion in troublesome cases with atypical history or introduction (2). The penis is an ideal design for imaging by ultrasonography. It doesn’t contain bone or air, which blocks sound waves, and it is promptly available. The sharp tissue interfaces between the corpora and tunica albuginea can be indicated obviously with sonography. In ultrasound, the combined corpora cavernosa, the cavernosal conduits, the tunica albuginea, and the corpus spongiosum are effortlessly recognized. The corpora cavernosa are of uniform hypoechoic reflectivity and the tunica can be viewed as an echogenic envelope encompassing the corpora. Corpus spongiosum is of higher echogenicity. Ultrasound can recognize the site of the tear as an interference of the echogenic line of the tunica albuginea (28). In two investigations in Western Iran, ultrasonography was not utilized for finding. Determination was made dependent on clinical introductions, proposing that regular history and actual discoveries seldom warrant further radiographic examinations, for example, sonography, thinking about its bogus negative outcomes, and administrator reliance. Attractive reverberation imaging is another symptomatic apparatus that is precise yet costly (12,20). Ahmadnia et al. made their determination by history and clinical assessment. The urethral injury was identified by retrograde urethrography in 4 patients (3%) who had perceptible hematuria and urethrorrhagia. They recommended that there is no compelling reason to perform retrograde urethrography except if the patients have net hematuria or urethrorrhagia. They reasoned that the key to accomplishment in the treatment of PF is to accomplish a fast conclusion dependent on history and an actual assessment, keep away from superfluous imaging tests, and do prompt a medical procedure to reproduce the injury site (11). Moslemi additionally made findings utilizing history and actual assessment in all patients (13).

Different choices for the conclusion of PF and the degree of accompanying injury are MRI, cavernosography and urethrography which are not utilized in the vast majority of the patients in light of being tedious and trouble in admittance to the administrator for imaging and furthermore due to the expense. In an investigation by Mydlo et al., the cavernosography discoveries were erroneously negative in 28.5% of PF patients (29). In another investigation done in Qatar, ultrasound had a bogus negative outcome in two out of 12 patients with PF (17%) (30). Retrograde urethrography ought to be performed if the urethral injury is associated dependent on the presence of blood at the meatus, hematuria of any structure, dysuria, or urinary maintenance. Ultrasound output ought to have the option to identify conceivable urethral injury, anyway in presence of clinical doubt for urethral injury and an ordinary ultrasound examine, retrograde urethrography should, in any case, be performed (2). Cavernosography is debilitated in the assessment of a speculated PF on the grounds that the time has come devouring and new to most urologists and radiologists (2). In spite of the fact that MRI has been accounted for to be a noninvasive and precise alternative to identify interruption of the tunica albuginea (31) and can recognize corpus cavernosum break portrayed by the brokenness of the low sign tunica albuginea (32), it has not been utilized broadly for the assessment of patients with manifestations and actual discoveries reminiscent of PF. In our unpublished investigation of 357 patients, ultrasonography was acted in 62 cases (17%), MRI in 22 (6%) cases, and urethrography in 12 (3%) of the patients. The rest of the patients (74%) had no indicative examination before the surgery.

Management

Lion’s share of creators recommends critical careful treatment, to diminish the term of hospitalization and careful confusions, for example, penile disfigurement and erectile brokenness (Figure 3) (1). Numerous contemporary distributions suggest that presumed PFs be immediately investigated and precisely fixed (33).

The distal circumcising cut might be proper when the area of the break is unsure on the grounds that it gives openness to every one of the three penile compartments. Conclusion of the tunic imperfection with intruded on 2-0 or 3-0 absorbable stitches is suggested. Profound bodily vascular ligation and over-the-top debridement of the sensitive hidden erectile tissue ought to be maintained a strategic distance from (1). European Urological Association (EAU) rules recommend that subcutaneous hematoma, without a related crack of the cavernosal tunica albuginea doesn’t need careful mediation. Nonsteroidal analgesics and ice packs are suggested. Intra-employable adaptable cystoscopy is helpful to analyze urethral injury and to additionally confine urethral harm. Traditionalist administration of penile crack isn’t suggested (15). Ahmadnia did a medical procedure for his patients and a burst of tunica albuginea was stitched with non-absorbable (3/0 nylon) stitches and the bunches were set on the interior surface (nonstop technique). A while follow-up of his patients demonstrated no confusion (11). In an investigation in Western Iran, patients went through quick activity or medical procedure was deferred until the following morning. Careful treatment comprised of a degloving circumferential cut of the penile skin, departure of the hematoma, control of drain, and debridement and conclusion of the deformity in the tunica albuginea with a running or intruded, upset bunch 2 or 3-0 nylon stitch. He indicated that there were no huge intraoperative or quick postoperative intricacies, and most patients have been released the home the first day after a medical procedure. He recommended that delay in a medical procedure until the following morning didn’t bring about any trouble in careful dismemberment or postoperative course (20). Additionally, different investigations likewise proposed that, despite the fact that medical procedure is superior to moderate administration, careful postponement of as long as 7 days after the injury doesn’t antagonistically influence the consequences of fix (27,34).

Safarinjad et al. researched the effect of prompt careful fix and traditionalist treatment of PF on penile vascular records in 146 precisely treated (bunch 1), and 56 moderately treated patients (bunch 2). All members went through penile duplex Doppler ultrasonography, and Doppler boundaries were estimated. They presumed that the current technique for careful treatment doesn’t give better results as far as erectile capacity and penile vascular hemodynamics (35). In another investigation in Western Iran, Zargooshi assessed the drawn-out result of PF. His patients worked after utilizing a degloving entry point. Ten patients had a venous injury and 352 had PF. In the subsequent visits, notwithstanding noting the survey, the patients finished the International Index of Erectile Function (IIEF), Erection Hardness Grading Scale (EHGS), and Global Self-Assessment of Potency (GSAP). He indicated that postoperatively, practically all patients built up a lasting, immaterial, fibrotic knob, and his time-tried methodology gave fantastic long-haul sexual capacity (12). Moslemi performed a careful fix in every one of the 86 cases, utilizing 4/0 Prolene non-absorbable or 4/0 Vicryl absorbable persistent stitches, for the conclusion of tunica albuginea longitudinal way and 4/0 chromic stitches, for the conclusion of the skin in running style. He indicated that practically all patients had the option to accomplish a full erection with a straight penis. In two patients (2.3%), gentle shape and torment during erection were accounted for. He didn’t report early complexities in patients for a middle development of a half year (13). Asgari et al. led an examination on 68 patients who went through pressing careful fix somewhere in the range of 3 hours to 4 days after PF. He indicated that of 32 patients who finished a poll after a medical procedure, useful outcomes were amazing in all aside from 3 (9%), who created penile arch and torment during intercourse. In these three patients, a medical procedure was accomplished over 48 hours after injury (10). In our overview from 59 reacting urologists study, 42 (71%) urologists proposed crisis medical procedure for PF, 13 (22%) suggested postponed a medical procedure in the following morning, and four (7%) recommended traditionalist administration. In this arrangement, 468 cases were treated by corporal fix, 22 cases required both corporal and urethral fix, and 26 cases were treated with moderate administration.

Conclusions

We reviewed all the available literature on penile fracture in Iran. We also performed a questionnaire-based study by sending questionnaires by emails to 700 urologists throughout Iran to collect more accurate data about the epidemiology, etiology, diagnosis, complications, management, and consequences of penile fracture in Iran. We found that the incidence of PF varies significantly in different parts of Iran. The western province of Kermanshah has a significantly higher rate of PF (3.1 to 39 cases per 100,000 male populations). The higher rate of PF in the Province of Kermanshah can be related to lack of sexual education and the practice of “Taqnaadan”, to hear a snap sound from the erected penis, which made its incidence higher than other parts of the country. Adding data from different regions of Iran, we calculated that the incidence of PF in Iran can be estimated between 1.1 to 9.9 per100,000 male population (most probably closer to the lower end). Urologists practicing in Iran on average may encounter a PF patient every 3.5 months.

To diagnose PF, the majority of reviewed studies and also our responded urologists relied on history and physical examination did not recommend imaging, except for, in patients with possible urethral injuries. They also concluded that immediate surgical intervention can make good functional results with low morbidity and short hospital stay. Delayed surgical intervention and observational management approaches need large population studies with long-term follow-up.