In the emergency department, eggplants aren’t just a suggestive emoji — they’re also a sign of injury from overenthusiastic sex.
When a patient’s penis looks bloated and purple, it’s a sign of penile fracture (there is considerable literature, in fact, about “eggplant deformity”). Another sign? When the patient reports hearing a loud “snap!” during intercourse.
That was just one fun tidbit from a virtual talk at this year’s American College of Emergency Physicians annual meeting, given by Lauren Westafer, DO, MPH, MS, of the University of Massachusetts Medical School and Baystate Medical Center in Springfield.
Genitourinary trauma is no joking matter and such injuries should be treated seriously, Westafer said. “These are actually true emergencies.”
Penile fracture occurs when there’s a tear in the tunica albuginea, the lining of the penis around the erectile tissue. “When anything in the body tears, it also invokes a swelling response,” she said. Inflammation can then impinge on the urethra.
The injury occurs when there’s “some sort of rotational force against the erect penis,” she said, typically during sexual activity like intercourse or masturbation or even rolling over. A Middle Eastern practice known as taqaandan, or “penile cracking,” can also cause the condition.
“This is a clinical diagnosis,” she said. “Typically, you can hear the history, perform the physical exam, and put it together that this patient has a penile fracture.”
It’s critical to treat the condition since penile fracture can cause urethral injury, scarring, and erectile dysfunction, Westafer said. Call urology in all cases, but take time to gather information about details such as whether the patient can urinate and whether blood is at the meatus. To avoid multiple calls, she said, “you want to have all the information lined up and ready to go.” Surgery is the ultimate treatment, but the ER may provide supportive care until surgery is available, she said.
Another not-uncommon complaint in the ER is ischemic priapism – an erection of over four hours that’s caused by blood that stays in the penis – which also qualifies as an emergency, Westafer said. In contrast, she said, non-ischemic priapism is painless and doesn’t need instant treatment — and is much less common.
“Priapism is essentially a compartment syndrome of the penis,” she said. “And compartment syndrome anywhere is a surgical emergency. You’ve got to get that taken care of ASAP and reduce that pressure. Time is erectile tissue. You have irreversible damage in 24 hours.”
There are many possible causes of priapism, she said, such as drug use and sickle cell disease. As for treatment, “the first thing I do is a dorsal nerve block and aspirate. You want to do it really quickly.”
Be prepared for a lot of blood. “We’ve aspirated over 100 ccs, 150 ccs of a patient with priapism previously,” she said. Phenylephrine and an immediate urology consult may be needed if the patient remains erect.
Men are not the only ones to suffer injuries from sex. Women may experience vaginal tears during sexual activity, said Westafer, such as when partners have “disproportionate” anatomy.
Tears can also suggest abuse, however. “Oftentimes when this happens, it’s not a result of consensual behavior between two adults,” she said. “There may be something else going on here.”
If there are red flags, she said, screen for sex trafficking, sexual assault, and intimate partner violence. “It’s something really important to think about.”
These patients can hemorrhage substantially or – rarely – have an intraperitoneal perforation, she said. Treat the bleeding and consider an ob/gyn consult, she advised.
A third category of injury is those involving the rectum, most often objects lodged in it.
Westafer advises against asking a patient, “I see your chief complaint is a rectal foreign body. Tell me more about that. I hear you stuck something up there.”
Patients with objects in the rectum aren’t likely to report a foreign body as their chief complaint, she said, instead typically reporting something else: “It’s abdominal pain, it’s back pain, it’s nausea, it’s constipation. It’s something else. It’s not necessarily, ‘I have a jar of mushrooms stuck up my rectum.'”
A “non-judgmental history” can offer information about the object, she said. The next steps, an exam and X-ray, will provide information about the object and, crucially, its orientation, she said. CT scans may also be helpful. Call surgery if the object is sharp, she said, or consider removal in the ER if the object is blunt.
And remember, she said: “This is not the time to be funny or to make a patient the laughingstock of the department.”
Westafer reported no relevant disclosures.