A penile fracture (PF) is a sudden, traumatic rupture of the tunica albuginea of the corpora cavernosa occurring in an erect penis [1]. It most often occurs during sexual intercourse, but it can also occur during masturbation or when manipulating the penis to conceal an erection [2]. When it occurs, the patient experiences a cracking sound, pain, and detumescence of the penis. This is followed by significant swelling and hematoma, resulting in an eggplant-like deformity [3]. Its etiopathogenesis is related to the resistance of the tunica albuginea surrounding the corpora cavernosa. It occurs when the penis is subjected to sudden axial or transverse stress. This causes an increase in intracavernous pressure that exceeds the tensile strength of the tunica albuginea [4]. The occurrence of a penile fracture is thought to involve several factors. The aim of our work is to study the factors that promote the occurrence of PF in the urology department of the Cocody University Hospital.

This is a descriptive, retrospective, cross-sectional study conducted at the Urology Department of the Cocody University Hospital over a four-year period, from July 2021 to June 2024. During this period, 21 of the 23 identified cases of patients admitted for penile fracture (PF) were included in the study; only complete medical records of patients treated in the department were selected. The variables analyzed included socio-demographic data, factors contributing to the occurrence of PF, and the treatment provided.

We identified 21 patients over 4 years, or 5.25 cases per year. The average age of patients was 35.35 years [28 - 50 years].

In 18 of the 21 cases, penile fracture occurred following a coital mishap, and in 3 out of 21 cases, it occurred during manipulation of the penis to conceal an erection. PF occurred in the doggy-style position in 11 out of 18 cases, in the missionary position in 5 out of 18 cases, and in andromache position in 2 out of 18 cases. Questioning revealed that, prior to sexual intercourse, 13 of the 18 patients had consumed large amounts of alcohol, and 4 of the 18 had taken sildenafil at doses ranging from 100 to 200 mg.

The triad of crepitus, pain, and detumescence was observed in all patients, and they also all presented with an eggplant-like deformity (Figure 1). Scrotal edema (Figure 2) was observed in 6/21 patients, and urethrorrhagia in 4/21 patients. The diagnosis was purely clinical in all patients.

The mean consultation time was 13.81 h [1 - 72 h]. The surgical approach was a circular incision 1 cm from the balanopreputial groove with degloving of the penis in all patients (Figure 3). During surgery, the right side was involved in 14/21 cases. A urethral rupture was observed in 4/21 patients. The lesion was located distally in the corpus cavernosum in 13/21 patients, in the middle third in 2/21 patients, and proximally in 6/21 patients. All patients with a urethral rupture underwent urethroplasty with 3-0 absorbable suture. Tunica albuginea was repaired with 2-0 absorbable suture in 8/21 patients and 3-0 in 5/21 patients. Non-absorbable suture size 2/0 was used in 3/21 patients and 3/0 in 5/21 patients. At the 6-month follow-up, the 10 patients seen in consultation showed the following outcomes: 2 out of 10 developed slight penile curvature which caused neither pain nor erectile issues during sexual intercourse while another 2 out of 10 experienced erectile dysfunction, classified as mild according to the IIEF-5 score.

PF remains a rare but serious urological emergency, requiring prompt management to avoid major functional complications such as erectile dysfunction, permanent penile deformity, or urethral stricture [5]. Our study, conducted in the urology department of the Cocody University Hospital, allowed us to identify several factors contributing to the occurrence of PF, particularly traumatic circumstances related to sexual intercourse, with a predominance of certain risky sexual positions. We observed a penile fracture rate of 5.25 cases per year. The rate of penile fracture varies according to geographical area. The rates in different series in sub-Saharan Africa fall within the same range. Ofori in Ghana found 6.8 cases per year [6]; while Owon’Abessolo in Cameroon found 3.83 cases per year [7] and Molla in Ethiopia 3 cases per year [8]. The frequency is much lower in the Western countries, where Reichenbach observed 6.3 cases/year in a multicenter study (3 centers), as did Bozzini, who found 7.6 cases/year in a multicenter study involving 7 centers [9] [10]. In India, Mir observed a frequency of 12 cases/year [11]. The highest frequencies are observed in Morocco, where Alafifi and Dibingue observed 35.66 and 34.2 cases/year, respectively [12] [13].

The average age of our patients was 35.35 years. PF most often occurs in young men who engage in vigorous sexual activity and frequently seek to perform feats of strength. This young age has been observed by most authors [6] [8] [9] [12].

The average consultation delay observed in our study was 13.81 h [1 - 72 h]. Consultation delays vary from one study to another; Ofori [6] in Ghana observed a consultation delay of 29 h [3 h - 10 d], Owon’Abessolo [7] in Cameroon observed a delay of 5 h [1 - 72 h] and Alafifi [12] in Morocco observed that 80% of patients consulted within 24 h.

The majority of fractures observed in our series (18/21) occurred during a misstep during intercourse, which confirms that sexual intercourse remains the main cause of penile fractures, as observed by several authors [2] [14]-[16]. Some studies in the West report that up to 94% of cases of PF occur during sexual activity, while in the Middle East, 76% of cases are associated with self-manipulation (e.g., taqaandan, a popular Middle Eastern practice that involves bending the longitudinal axis of the penis during erection to achieve detumescence) or masturbation [17].

The so-called “doggy style” position appears to be the riskiest, found in 61% of cases in our series, which is consistent with other studies [3] [6] [15]. This position exposes the penis to greater mechanical stress, increasing the risk of rupture of the tunica albuginea; the penis then strikes the buttocks or coccyx. Some authors have identified other sexual positions that also promote PF, such as the “missionary” position [11] [18] and the “Andromache” position [17] [19] [20]. Syarif et al. concluded after a literature review that PF most often occurs in sexual positions where the man is dominant (doggy style and missionary) [2].

Furthermore, we observed alcohol consumption in 72% of patients before sexual intercourse, as well as sildenafil use in 22%. These factors could contribute to decreased motor control or increased penile rigidity, thus increasing the risk of injury [21]. Alcohol, due to its effects on alertness and coordination, is often cited as a risk factor in other studies [22] [23].

Clinically, the classic triad of PF (cracking sound, pain, detumescence) was consistently observed, confirming its importance in clinical diagnosis [14] [15] [24]. The eggplant-like deformity remains a pathognomonic sign, facilitating immediate recognition of the condition. Scrotal edema and urethrorrhagia, present in 28% and 19% of patients respectively, reflect the variable severity of associated lesions. We did not need to perform any paraclinical examinations to establish the diagnosis because the clinical presentation was suggestive. In cases of doubt, an ultrasound or MRI of the penis can be performed, which is the best way to establish the diagnosis [25] [26]. These examinations allow for precise localization of the lesion and guide surgical treatment through an elective approach. All our patients underwent surgical intervention, a treatment that currently constitutes the gold standard [27] [28]. The procedure involved making a circular incision below the balanopreputial groove with degloving of the penis. This allowed for complete exploration and adequate repair of the lesions. In our study, the lesion was predominantly located in the right corpora cavernosa and distally. Several authors have reported predominantly involvement of the right corpora cavernosa without any explanation [6] [11] [12] [29]. Urethral rupture, present in 19% of patients, was systematically repaired, which is essential for preserving urination [5]. According to Faridi et al. [30], urethral injury, which is rare, is most often associated with bilateral rupture of the corpora cavernosa; this was not observed in our study. We did not perform an elective approach, which has the advantage of allowing for an earlier resumption of sexual intercourse compared to degloving [9].

The 6-month follow-up was marked by the occurrence of mild problems in 4 out of 10 patients seen in consultation. Our results are difficult to interpret given the high number of patients lost to follow-up. Some authors claim that complications such as erectile dysfunction, penile curvature, and pain during intercourse occur when treatment is delayed (>24 hours) [6] [8] [10] [13]. Alafifi [12], on the other hand, places more emphasis on the treatment technique itself, which he believes is responsible for these complications. However, this assertion is not shared by other authors who have observed that the delay in treatment does not influence the occurrence of short- and medium-term complications [9] [27] [31].

At the Cocody University Hospital, PF are primarily linked to sexual trauma, with contributing factors, such as the doggy-style position, alcohol consumption, and the use of vasoactive medications. Prompt surgical intervention improves the functional prognosis. These findings highlight the importance of educating patients about the risks associated with certain sexual practices and the consumption of alcohol or medication before sexual intercourse.