Penile fracture in a 32-year old man with sexual dysfunction: A case report of rare outcome of the use of aphrodisiacs

Penile fracture is a very rare urological emergency resulting from the traumatic rupture of the tunica albuginea of one or both corpora cavernosa. Immediate surgical treatment is the current standard of care with lower risks of late complications, including erectile dysfunction, penile curvature, and tunical scar formation. We report a case of a patient with sexual dysfunction who took a combination of Anafranil and Sildenafil to enhance his sexual performance to satisfy his girlfriend, but ended with a penile fracture. Our case exposes the degree of frustration suffered by patients with sexual dysfunction and the extent to which they can go in the quest for a solution to their problem, the outcome may be unfavorable.Patients should be informed about the possible complications of Sildenafil either used singly or coadministered with Anafranil for improved sexual function, and recreational use of these drugs should be discouraged.


Introduction
Penile fracture is an uncommon or, probably, a rarely reported urological emergency [1] commonly associated with extramarital affairs, sexual intercourse in out-of-the-ordinary locations, penile manipulation and unusual sexual positions(woman on top and "doggy style") [2,3]. It is a result of traumatic rupture of the tunica albuginea of one or both corpora cavernosa, due to twisting or bending of the penile shaft during erection] [4]. This may extend to the corpus spongiosum and the urethra [5]. Although the diagnosis is based on clinical findings, radiological investigations such as Doppler ultrasound or MRI may be required for better evaluation, but is usually unnecessary [6].
The use of aphrodisiacs to enhance sexual activity is a common global practice. There is a paucity of literature associating its use with a penile fracture. We present a case of penile fracture during sexual intercourse enhanced by the ingestion of aphrodisiacs.

Case Report
EE was a 32-year-old married man with three children who presented to the outpatient clinic, with pain, swelling, bending in his penis and inability to pass urine about 30 hours before presentation. This occurred during a vigorous sexual intercourse with his girlfriend, when he missed the vaginal target in one of the thrusts, hitting his erect penis on her perineum. He heard a 'pop' sound from his penis, experienced severe pain and lost tumescence. He also rapidly developed swelling of his penis, pain in his penoscrotal region and could not pass urine. Trying to pass urine aggravated the pain and blood was instead coming out of his urethra. He admitted to have taken a tablet each of Anafranil and Vega 100(Sildenafil), obtained from a chemist shop, to enhance his sexual performance because his girlfriend had been complaining of his not satisfying her sexually due to "quick" ejaculation. He was taken to a nearby general hospital where he was told that he had a fracture of the penis and a cold compress was applied to it. Suprapubic aspiration of urine was done to keep him comfortable before he was referred to Niger Delta University Teaching Hospital.
Physical examination revealed a swelling with ecchymosis on the right side of his penis, causing a lateral angulation towards the left, blood at the urethral meatus and the medial aspect of the left thigh and scrotal swelling (figure 1). His bladder was distended to about 16 centimeters above the pubic symphysis. A diagnosis of penile fracture with urethral disruption in a patient with sexual dysfunction was made. Laboratory and radiological investigations were not done due to the lack of resources. He was counseled and referred to the accident and emergency department for the attention of the urologist.

Discussion
Penile fracture is an uncommon or, probably, a rarely reported urological emergency [1]. It is rarely reported because of the associated embarrassment, shame, or lack of guidance [7]. It occurs when an erect penis undergoes a blunt bending or twisting trauma during sexual intercourse or otherwise, and causing a tear/rupture of the tunica albuginea and tracking of blood from cavernosal sinuses into the subcutaneous plane [4,5].
Activities that can result in penile fracture include sexual intercourse, turning over in bed, a direct blow to the erect penis and violent bending of the penis to interrupt erection [8,9]. There may be associated urethral injury manifesting as voiding difficulty and blood at the urethral meatus or haematuria. The diagnosis is usually clinical but occasionally, the presentation may be occult and the patient may present with pain with or without swelling, requiring doppler scan for an accurate diagnosis. Immediate surgical repair is the gold standard of care. Delayed repair or conservative management is fraught with complications [10,11,12].
This patient's problems emanated from sexual dysfunction which presented as premature ejaculation, which his girlfriend complained about. Sexual dysfunction is a common problem globally, affecting men to different degrees [13]. It has a serious effect on sexual life, causing pain and decreased sense of self-worth, concern for reproductive capacity, annoyance, frustration and avoidance of sexual intimacy for the person or partner [14]. These feelings can promote affective disorders with resultant decreased levels of sexual enjoyment and satisfaction [15]. The feelings described above made the index patient succumb to aphrodisiacs -sildenafil combined with Anafranil -which promised to negate the threat on his sexual life.
Common aphrodisiacs in the Nigerian Niger Delta area are locally brewed products from plants such as "coscorene", "AK-47", "burantashi" and "monkey tail" which are made from some roots/herbs or chemicals in an alcohol base. The alcohol component positively elicits an increase in sexual desire in moderate quantities but is associated with difficulties in reaching sexual pleasure in larger quantities [16]. The safety data of other constituents of locally brewed products are unavailable, mechanisms of action are unclear and there is a lack of knowledge to support the extensive use of these substances, hence the uses of these products may be risky to the human being [17]. Some of them are even adulterated with unapproved chemical agents, which can be toxic to vital organs with nightmarish sequelae. The synthetic chemicals include Vega 100 (Sildenafil), Anafranil (Clomipramine hydrochloride) and tramadol. These drugs were originally produced for various medical disorders. Sildenafil was produced to treat pulmonary hypertension; clomipramine hydrochloride is an antidepressant and tramadol a synthetic opiate that is an addictive and controlled drug. Aphrodisiacs have side effects that cannot be ignored. A testament to this is the drug-induced priapism which has been reported by some researchers [18,19]. Although a sexual dysfunction results in serious psychological distress, priapism results in more significant pain because it is an emergent condition requiring urgent medical or surgical intervention and associated complications.
Penile fractures arising from the use of aphrodisiac by this patient was not a direct complication of its use. Still, it emanated from his aspiration to satisfy the sexual desire of his partner, who had complained of sexual dissatisfaction due to premature ejaculation.
Anafranil is known to delay ejaculation while sildenafil sustains an erection [20,21]. The combination of these two drugs created an effect of exhilaration. One of his vigorous thrusts missed the vaginal target and hit the perineum with a resultant penile fracture in this mood.
Therefore, it is imperative to raise the awareness of primary care practitioners of the looming health burden of aphrodisiacs among young people. Patients should be informed about the possible complications of sildenafil either used singly or co-administered with Anafranil for enhanced sexual activity. The recreational use of these drugs should be discouraged.

Conclusion
Penile fracture is a rare urological emergency but its occurrence secondary to the use of aphrodisiacs is a rarer condition. Patients should be informed about the possible complications of Sildenafil either used singly or coadministered with Anafranil for improved sexual function. The recreational use of these drugs should be discouraged.