Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 1 REVIEW erection of the penis. Sexual intercourse is the most com- mon aetiology for penile fracture, besides forceful bend- ing of the penile shaft, masturbation, and blunt or sharp injury to the penis (2). Trauma to the penis, whether it is blunt or sharp trauma, will cause an abrupt raising of intracavernosal pressure, resulting in the tear of tunica albuginea (2). Average arterial pressure of an erect penis is roughly 100 mmHg in the erect state (3). Penile fracture can easily be diagnosed from the history and physical examination of the patient. In most cases, penile fracture will present with a cracking, snapping sound, rapid detumescence of the penis, acute pain, abrupt swelling, and the presentation of “eggplant deformity” or ecchymosis of the penis. The fracture is more often in the proximal shaft of the penis. The corporal cavernosal tear may occur unilaterally or bilaterally. The most applicable modalities in diagnosing penile fracture are ultrasound (US) and MRI (4). US is widely used in the population because of its availability, non-invasiveness, low cost and safety, but the results are operator dependent. Whereas penile MRI can show more accurate and detailed soft tissue disruption, but it’s expensive and not available in most hospitals (5, 6). Penile fracture is a rare case in the urological field, the incidence reported for penile fracture was 1 case for every 175,000 cases of emergency hospital admissions (1). Immediate surgical exploration and closure of the tunica albuginea is now the most preferred treatment approach for penile fracture. Some complications may occur after surgical treatment of penile fracture, including erectile dysfunction, infections, painful erection, penile curvature, and plaque formation (7, 8). Erectile dysfunction (ED) is known as a major con- cern following the surgery for penile fracture, as it can potentially result in a poor physical and psychological condition for the patient (9). This study is the first meta-analysis discussing some vari- ables of risk factors (age, mechanism of injury, fracture location, surgical approach, side of fracture, urethral injury, and timing of presentation) and their relationship to the occurrence of erectile dysfunction, especially in post- surgery penile fracture patients. Therefore, this knowledge will be hugely beneficial in preventing erectile dysfunction Background: Penile fracture is one of the rare urological emergencies resulting in rupture of the tunica albuginea in the penile corpora cavernosa. Sexual intercourse is known to be the most common aetiology of penile fracture, which usually happens during erection. Immediate sur- gical intervention is crucial to avoid any complications. Erectile dysfunction is the most feared complication after surgery. This meta-analysis aimed to analyse and determine risk factors of erectile dysfunction among patients who underwent penile fracture surgery. Methods: Literature searching was conducted in several data- bases, e.g., Pubmed, Cochrane, ScienceDirect, Google Scholar and DOAJ by applying the Boolean term method. Statistical analyses and risk of bias assessment were calculated through RevMan 5.4.1 and the Newcastle Ottawa Scale (NOS), respec- tively. Outcomes were presented as odds ratio (OR). Results: A total of 6 studies were included, encompassing 527 patients who were diagnosed with penile fracture and underwent surgery for repairment. Risk factors for post-surgery erectile dysfunction were calculated. Age (OR = 0.19, 95% CI [0.07, 0.52], p = 0.001), location of fracture (OR = 0.43, 95% CI [0.22, 0.84], p = 0.01), and side of fracture (OR = 0.06, 95% CI [0.02, 0.21], p = < 0.0001) have significant relations with erec- tile dysfunction. Whereas aetiology, urethral injury, and timing of presentation have statistically non significant effect on the incidence of erectile dysfunction. Conclusions: This systematic review and meta-analysis showed that patients over 50 years of age, those with midshaft fracture, and those with bilateral fractures are significantly more likely to have erectile dysfunction following penile fracture surgery. KEY WORDS: Penile fracture; Erectile dysfunction; Impotence; Risk factor; Urethral injury. Submitted 28 July 2025; Accepted 28 August 2025 INTRODUCTION Penile fracture is one of the urological emergencies char- acterized by rupture of the tunica albuginea in the corpo- ra cavernosa of the penis, which requires an immediate surgical intervention (1). It commonly occurs during What are the risk factors for erectile dysfunction following penile fracture surgery? A systematic review and meta-analysis Harith Naufal Subrata 1, Syah Mirsya Warli 2, 3 1 General Practitioner, Rantauprapat Regional General Hospital, Labuhanbatu, Indonesia; 2 Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Sumatera Utara - Haji Adam Malik General Hospital, Medan, Indonesia; 3 Department of Urology, Universitas Sumatera Utara Hospital, Universitas Sumatera Utara, Medan, Indonesia. DOI: 10.4081/aiua.2025.14195 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 H. Naufal Subrata, S. Mirsya Warli 2 among penile fracture patients. Early detection of these risk factors can assist physicians in making clinical decisions. This meta-analysis aims to determine the contributing risk factors regarding erectile dysfunction following penile frac- ture surgery in order to provide eligible evidence for advances in knowledge and patient services. MATERIALS AND METHODS Literature search We performed literature searches in several databases, e.g. Pubmed, Cochrane, ScienceDirect, Google Scholar, and DOAJ, by applying the Boolean term method. We did the litera- ture searching by applying keywords: “Penile fracture” AND (“Erectile dysfunction” OR “Impotence”) AND “Risk factor”. Data extraction The Population, Intervention, Comparison, and Outcome (PICO) principle was used in this study, with penile frac- ture patients who underwent surgery repairment as the population, surgery as the intervention, the occurrence of erectile dysfunction as the comparison, and potential risk factors (age, mechanism of injury, fracture location, sur- gical approach, side of fracture, urethral injury, and tim- ing of presentation) as the outcome. Cohort and case- control studies were included in this meta-analysis. Information collected from each study included age, smoking history, mechanism of injury for penile fracture, location of fracture, side of fracture, urethral injury, and timing at presentation. The data also included the author’s name, year of publication, sample size, age, and follow-up period. Risk of bias (RoB) analysis Risk of bias assessment was done by using Newcastle Ottawa Scale (NOS) for cohort and case-control studies consisting of 3 variables, i.e., selection of the participants to the study (4 points maximum), comparability of the groups (2 points maximum), and assessment of the out- come to the exposure (3 points maximum), with the cumulative value of 9 points. Data synthesis Data analysis was done by using Review Manager version 5.4. The strength of correlation between variables was measured using Odds Ratio (OR) and 95% confidence inter- val (CI). Statistical significance of OR was measured by using the p-value from the Z-test and the heterogeneity measured with the inconsistency index (I2) test. A p-value < 0.05 was deemed as statistically significant. I2 ≥ 50% is considered high heterogeneity, whereas I2 < 50% is considered low heterogeneity. Furthermore, a Forest plot was generated for each variable to assess the publication bias. RESULTS We applied the PRISMA flowchart guideline in the iden- tifying process of the study. At first 1,672 studies were identified, and only 6 articles were eligible for this meta- analysis at the end of the selection process. PRISMA flow- chart for identification of the studies and characteristics of the studies are shown in Figure 1 and Table 2, respectively (6, 8, 10-13). Following the removal of dupli- cates, 1,586 titles and abstracts were screened, and 18 full texts were retrieved for further appraisal. Evaluation of full-text studies identified 6 articles eli- gible for inclusion in this meta- analysis, as shown in Figure 1. Additional reasons for exclu- sions were studies containing not relevant data, incomplete information, and studies that were not written in English. Figure 1. PRISMA Flowchart of the identification of eligible trials. Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 3 Erectile dysfunction following penile fracture Inclusion criteria for this meta-analysis were: patients who were healthy prior to injury, original research stud- ies, studies that comprehensively discussed the associa- tion between erectile dysfunction and penile fracture sur- gery, and study designs that were in cohort and case report. The studies were excluded if: patients had sexual problems prior to injury, or if the studies did not mention erectile dysfunction after surgical repair or if the studies included patients with other diseases. Studies were also excluded if they didn’t provide OR as the statistic meas- urement, in addition to this, letters and case reports abstracts were also excluded for analysis. Out of the 6 studies that are included, 527 patients were enrolled in this meta-analysis. The six studies that were included were published between 2012 and 2025. The characteristics of the selected studies are summarized in Table 1. All of the studies were considered as good qual- ity, as shown in Table 2. Of these 6 studies, 5 were cohort studies and 1 was a case control study. Age Three cohort studies discussed the relationship between age at injury and the occurrence of erectile dysfunction following surgery, which divided patients < 50 years as group 1 and patients ≥ 50 years as group 2. The statisti- cal analysis for this variable was calculated through Review Manager 5.4. The OR for age and erectile dys- function following surgery were statistically significant. In addition to this, we found a 0% inconsistency index in this calculation. Mechanism of injury Three cohort studies, which were included in this meta- analysis investigated the correlation between mechanism of injury or etiology and postoperative erectile dysfunction. As the mechanisms of injury were varied, we divided them into a sexual intercourse group and a non-sexual inter- course group. From the calculation we found that the OR was 0.70 (CI 95%: 0.39-1.24, p = 0.22) which was con- sidered as not statistically significant. With 0% of I2, there was also no risk of heterogeneity in this calculation. Location of fracture Four studies, consisting of 3 cohort studies and 1 case-con- trol study, discussed the potential relationship between the location of fracture and ED occurrence. The OR reported was 0.43 (CI 95%: 0.22-0.84, p = 0.01). The calculation showed that the location of fracture (proximal or middle shaft) was statistically significant as risk factor of erectile dysfunction following surgical repair for penile fracture. Surgical approach A study from Chaker et al. 2025 investigated the correla- tion between surgical approach and ED occurrence. The OR for this variable was 5.09 (CI 95%: 2.03-12.78, p = 0.0005), which is statistically significant. From this result we can figure out that patients with a coronal approach are 5 times more likely to have ED in the future than the control group. Side of fracture The location of the fracture was divided into unilateral and bilateral groups. Two cohort studies and 1 case-con- trol study were included. The OR was 0.06 (CI 95%: 0.02-0.21, p < 0.0001) which was considered to be sig- nificant. These results showed that if the fracture occurs on both sides, there is a 94% probability of having ED fol- lowing the repairment surgery. Table 2. Summary of patient characteristics included in meta-analysis. Author, year Age range/mean of sample age Sample size (n) Time period Erectile dysfunction (n) Follow-up period Barros 2021 24 to 69 years 18 cases January 2014 to January 2019 3 cases 3 to 18 months Assmy 2012 35 years 166 cases January 1989 to May 2010 11 cases 106 months Chaker 2025 38 ± 12 years 87 cases 2012 to 2023 44 cases ≥ 12 months Din 2023 35.89 ± 4.2 years 25 cases January 2022 to February 2023 9 cases ≥ 1 week Patil 2019 28.8 ± 7.59 years 18 cases July 2014 to January 2017 8 cases NR Sharma 2021 33.64 ± 9.46 years 62 cases September 2014 to August 2019 7 cases ≥ 2 weeks NR: not reported. Table 1. Risk of bias assessment using Newcastle Ottawa Scale (NOS) for case-control study and cohort study. Author, year Selection Comparibility Outcome Representative Selection of Ascertainment Outcome of interest Main factor Additional Assessment Sufficient Adequacy of the exposed cohort external control of exposure not present at the factor of outcome follow-up follow-up start of the study Barros 2021 * 0 0 * * * 0 * * Assmy 2012 * * * * * * * * * Chaker 2025 * * * * * * * * * Din 2023 * * * * 0 * * 0 * Patil 2019 * * * 0 0 0 * * * Sharma 2021 * * * * * * * * * Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 H. Naufal Subrata, S. Mirsya Warli 4 Urethral injury Urethral injury coexisting with penile fracture was also investigated as a risk factor for ED in 2 cohort studies and 1 case-control study. Even though the calculation showed that patients with urethral injury are 60% more likely to have ED in the future, as shown in Figure 2, the result Figure 2. Forest plot for the impact on risk factors on incident erectile dysfunction: age, etiology, location of fracture, surgical approach, side of fracture, urethral injury, and timing of presentation. Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 5 Erectile dysfunction following penile fracture was not statistically significant [OR 0.40 (CI 95%: 0.12- 1.40, p = 0.15)]. Timing at presentation Timing to the operating room was also considered as a risk factor for ED occurrence in some studies. Four stud- ies that were included in this meta-analysis. The results indicate that timing at presentation (< 24 hours vs ≥ 24 hours) was insignificant to the occurrence of ED follow- ing penile fracture surgery. The OR was 0.70 (CI 95%: 0.27-1.71, p = 0.46). DISCUSSION Treatment options for penile fracture include conserva- tive and surgical intervention approaches (14). The surgi- cal exploration was the treatment of choice when a penile fracture is suspected. Surgical approach was preferred because of the good functional and cosmetic outcome with minimal complication (15). Surgical exploration combined with circumcision was recommended to main- tain local hygiene, prevent phimosis, and provide a better aesthetic outcome (16). Some patients may develop post-surgery complications. Complications following the surgery repair are varied, such as ED, deviation of the penis, development of fibrous plaque, and voiding problems. ED is a huge prob- lem that impacts both the physical and the psychological condition of the patient (6, 15, 17-20). Some studies showed that the ratio of ED after surgery varied from 0 to 16.6% of patients (21, 22). According to the study by Zhu et al. 2024, a multivariate analysis was made to investigate the correlation between age and post-surgery ED. The report said that age was not significantly related to the occurrence of postoperative ED (OR 1.004 and p = 0.922) (9). This finding contra- dicted our findings, which depicted a major association between age at injury and the incidence of ED [OR 0.19 (CI 95%: 0.007-0.52, p = 0.001)]. Along with our find- ings, a study by Avci et al. 2023 over 58 penile fracture patients also reported a significant correlation between age and post-surgery ED (p = 0.004) (23). Similarly, the study by Ortac et al. 2020 reported that the patients with ED were older compared to non-ED patients (p-value 0.001) (24). Mechanism of trauma has no significant relation as the risk factor of ED following penile fracture surgery, as reported by Silva et al. 2024 (p = 0.896) (25). These results are presumably in accordance with our study, as we also reported no significant relationship between the mechanism of injury (sexual intercourse and non-sexual intercourse) and ED incidence [OR: 0.70 (0.39, 1.57), p = 0.22]. Original research by Silva et al. 2024 showed a significant connection between lesion location and erectile function (p-value = 0.035) (25). This report is also in line with our study, which investigated the correlation between frac- ture location (proximal vs middle shaft) and ED occur- rence [OR: 0.43 (0.22, 0.84), p = 0.001]. Although we included only one study that discussed the relationship of surgical approach and ED incidence, we concluded that there was a significant relation between different types of surgical approaches (coronal vs elective) and ED incidence [OR: 5.09 (2.03, 12.78), p = 0.0005]. However, a study conducted by Ouanes et al. 2021 in 138 cases with a mean age of 31.2 years reported differently. They investigated the correlation of the incision type that was used by surgeons and the occurrence of ED. The results reported that the incision type (elective vs circum- ferential degloving) was not statistically related to ED occurrence, as they measured a p-value > 0.05 (26). Silva et al. 2024 reported that lesion laterality (right/left/ bilateral) has a correlation to the occurrence of ED after penile fracture repair, although not statistically significant (p = 0.667) (25). Our review compared only two groups in relation to lat- erality: unilateral vs bilateral. We calculated the relation- ship between unilateral or bilateral fracture and the occurrence of ED among postoperative patients showing a significant correlation between the two groups, with OR 0.06 (0.02-0.21) and p < 0.0001. Urethral injury is suspected whenever hematuria, blood in the meatus, and voiding symptoms are present, although the absence of the findings can’t exclude it (27-29). The tunica albuginea thickness of the penis will decrease from 2 mm in the flaccid state to 0.25 mm in the erect state along with the increase of intracavernous pressure, which makes it very easy to rupture against penile trauma (5, 28-30). A multivariate analysis done by Zhu et al. 2024 reported the OR of postoperative ED in presence of urethral injury was 11.330 (p = 0.002) which was statistically significant, although this report is contradicted by our study [OR 0.40 (CI 95%: 0.12-1.40, p = 0.15)] (9). In our study, the timing of presentation to the operating room was insignificant. Our study reported a OR of 0.70 (0.27, 1.81) with p-value of 0.46 for the correlation between timing of presentation and ED occurrence. A study by Bulbul et al. also found a result similar to ours (p = 0.979) (31), whereas Ouanes et al. showed a different result reporting a p-value of 0.03 in their study (26). A meta-analysis done by Amer et al. 2016 reported that there was no significant association while comparing immediate and delayed surgery to the rates of ED (RR 0.82: 0.41-1.66, p = 0.59) (32). Finally, a study conduct- ed by Ortac et al. also obtained results similar to ours, reporting a p-value of 0.235 for the correlation of the time of presentation to the hospital after injury and the postoperative erectile dysfunction (24). The strength of our study is that this is the first meta- analysis that extensively discusses the risk factors of erec- tile dysfunction after penile fracture surgery. Other meta- analyses (32-36) have previously evaluated the outcomes of penile fracture repair surgery but have not focused their analysis on the risk factors for the occurrence of erectile dysfunction after the procedure. This study showed us which risk factors have a significant relation- ship to the occurrence of erectile dysfunction and which do not. 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Authors' contributions: Syah Mirsya Warli contributed to the resources, supervision, and editing of this review.Harith Naufal Subrata contributed to the data curation and analysis, resources, and writing original draft for this review. Acknowledgments: We thank the Medical Faculty of Universitas Sumatera Utara and Adam Malik General Hospital for their consistent support for the author during this research. Archivio Italiano di Urologia e Andrologia 2025; 97(3):14195 7 Erectile dysfunction following penile fracture 31. Bulbul E, Gultekin MH, Citgez S, et al. Penile fracture: Tertiary care center experience and long-term complications after immediate repair. Andrology. 2022; 10:560-6. 32. Wong NC, Dason S, Bansal RK, et al. Can it wait? A systematic review of immediate vs. delayed surgical repair of penile fractures. Can Urol Assoc J. 2017; 11:53-60 33. Shebl SE. The presentation and outcomes of penile fracture with associated urethral injury: A systematic literature review. Arch Ital Urol Androl 2023; 95:11082. 34. Syarif S, Azis A, Natsir AS, Putra MZDA. What is the most dan- gerous sexual position that caused the penile fracture? A systematic review and meta-analysis. Braz J Urol 2024; .50: 28-36. 35. Falcone M, Garaffa G, Castiglione F, Ralph DJ. Current Management of Penile Fracture: An Up-to-Date Systematic Review. Sex Med Rev 2018; 6 253-60. 36. Kominsky H, Beebe S, Shah N, Jenkins LC. Surgical reconstruc- tion for penile fracture: a systematic review. Int J Impot Res. 2020; 32:75-80. Correspondence Harith Naufal Subrata hharithnaufal@gmail.com General Practitioner, Rantauprapat Regional General Hospital, Labuhanbatu, Indonesia Syah Mirsya Warli, MD, PhD (Corresponding Author) warli@usu.ac.id Division of Urology, Department of Surgery, Faculty of Medicine, Universitas Sumatera Utara-Haji Adam Malik General Hospital, Medan, Indonesia Jl. Bunga Lau No.17, Medan, Indonesia