Congenital Curvature
ERIK GROSSGOLD
JEREMY TONKIN
Patients with straight erections have normal and symmetrical expansion of all tissue layers of the penis. This requires normal tissue elasticity and compliance. During tumescence, the penis fills with blood and the tissues reach their limits of compliance. The limits of compliance of the tunica albuginea are especially important in rigidity; however, those with curvature may have an asymmetrical expansion of any one aspect of their penis. Thus, curvature can be due to decreased compliance of one aspect of the penis or foreshortening of one erectile body.
Penile curvature is described as either congenital or acquired. With regard to congenital curvature, there exists congenital curvature and chordee without hypospadias. Some use these terms interchangeably; however, they should not be thought of as synonymous.
Devine and Horton (1) proposed a classification system for congenital penile curvature consisting of five separate types of curvature. Types I to III can be collectively termed chordee without hypospadias (Fig. 74.1). This term in general refers to an abnormal development of ventral penile tissue in the presence of a normally placed meatus. For patients with type I, none of the surrounding layers are normal and there is malfusion of the corpus spongiosum. Patients with type II curvature have a dysgenic band of fibrous tissue lateral and dorsal to the urethra. This is believed to have formed from the mesenchyme that would have normally become the Buck and dartos fasciae. Type III congenital curvature exists in patients with a normally developed urethra, corpus spongiosum, and Buck fascia. The abnormality in these patients is in the dartos fascia, which has an elastic band that causes the penis to curve acutely. Not infrequently, these patients have a large and prominent mons pubis.
The authors refer to type IV curvature as congenital curvature of the penis. In type IV penile curvature, development of the urethra, fascial layers, and corpus spongiosum is normal. The defect is a relative shortness or inelastic area of the tunica albuginea. It is our experience that these patients have a penis of small or normal length when flaccid, but when erect, the penis may be larger than expected. This is thought to be due to hypercompliance of the tunica albuginea that allows hyperexpansion of the penis. Many of these patients will remember curvature prior to puberty, but this becomes more accentuated after pubescence and the penile growth spurt that occurs during adolescence.
Type V curvature is the rarest, and some have questioned whether it exists. This type is described as the congenitally short urethra. The short urethra is not elastic enough or of adequate length, leading to ventral curvature during erections.
 FIGURE 74.1 Cross section of the penis displaying the forms of congenital curvature of the penis. The normal penis is in the center. Class I: Epithelial urethra beneath the skin. Dysgenic tissue beneath it represents undeveloped corpus spongiosum, Buck fascia, and dartos fascia. Class II: Normal urethra and spongiosum but abnormal Buck and dartos fasciae. Class III: Abnormal dartos fascia only. Class IV: Normal urethra and fascial layers with abnormal corporocavernosal development. Class V: Congenital short urethra (rare). (Reprinted with permission from Devine CJ Jr, Horton CE. Bent penis. Semin Urol 1987;5:252. Copyright © 1987 Elsevier Inc.) |
DIAGNOSIS
Patients usually present in their late teens to early 30s. Most men cannot remember their penis ever being straight but may have assumed their curvature was normal. After puberty and the onset of sexual activity, they realize that their curvature impedes sexual relations. Some patients also attest that their curvature has worsened since puberty. Occasionally, a patient will present after the age of 30 years. This is due to either having been sexually active but found sex functionally or psychologically difficult or, less commonly, sexually inactive due to curvature and embarrassment issues.
All patients should undergo a complete history, including an extensive sexual history and physical examination. This should include time since onset and any prior traumatic events. Penile examination should focus on evidence of subclinical fracture or Peyronie disease, the latter being rare in this younger patient population. Patients at our institution are required to supply photographs of their erect penis for documentation of the curvature (Fig. 74.2). The photographs are also beneficial in distinguishing between congenital curvature and chordee without hypospadias. Psychological aspects of the disease also need to be addressed. On occasion, patients with significant psychological issues are evaluated preoperatively by a certified sex therapist and treated as needed.
Patients with chordee without hypospadias usually present with a ventral or ventrolateral curvature (2) and usually have a penis that is normal or shorter than normal in length. As mentioned, these patients also recall penile curvature throughout their life but may note some progression of the curvature during or after puberty. Many of these patients have abnormalities of the ventral penile skin. This may be noted as a hooded prepuce or a high insertion of the penoscrotal skin (penoscrotal tethering). The deep ventral tissues of the penis may seem to be inelastic to examination and stretch. The inelastic tissue that is palpable is the dysgenic tissue that has replaced the Buck and dartos fasciae.
 FIGURE 74.2 Preoperative photograph of an erect penis from a congenital curvature patient demonstrating a typical ventral curvature. |
Some of these patients, because of their curvature and smaller-than-average length, have significant self-image issues. When identified, these are the patients who benefit from psychological counseling preoperatively.
INDICATIONS FOR SURGERY
Patients with congenital curvature usually have ventral or ventrolateral curvature. This can be poorly tolerated by the patient and/or their sexual partners. Patients who have significant enough curvature to impair their sexual function are candidates for surgery. Surgery for chordee without hypospadias is successful in this patient population, with most curvatures repaired in a single procedure. Many times, the curvature is corrected by excising the dysgenic tissue on the ventrum of the penis and mobilization of the corpus spongiosum. For patients with congenital curvature, many procedures have been described.
ALTERNATIVE THERAPY
There are no alternative therapies to surgery for this condition.
SURGICAL TECHNIQUE—CONGENITAL CURVATURE
There exists a wide variety of surgical procedures to repair congenital curvature, including incision and plication, incision with grafting, and penile disassembly. Most congenital curvatures are straightened completely with incision and plication alone.
Incision and Plication
In patients who have been previously circumcised, an incision is made through the circumcision scar. Due to the previous circumcision, the new patterns of lymphatic and venous drainage could lead to marked penile edema if an incision is made proximal or distal to the old scar. The incision is made down to the superficial layer of the Buck fascia. The penis is degloved in this plane. Once completely degloved, an artificial erection is created by introducing intravenous approved normal saline into the corporal space. Perineal pressure is needed initially to aid in storage, but prolonged pressure is not required because these patients have normal erectile function and will store the saline once initial tumescence is achieved. A tourniquet placed at the base of the penis is not recommended because this can mask or distort the proximal extent of curvature.
The artificial erection demonstrates the degree and location of maximal curvature. A layer of dysgenic tissue may be noted that includes the Buck and dartos fasciae. If so, this tissue is completely mobilized and excised. Care is taken not to
injure the corpus spongiosum. In some cases, this will need to be detached from the glans to the penoscrotal junction. If injured, the urethra is closed primarily using a fine, absorbable suture. Patients who suffer from a differential elasticity between dorsal and ventral aspects of the corporal bodies may receive some benefit from the excision of the inelastic dysgenic tissue but are rarely straight and often require further maneuvers to straighten the penis. An artificial erection is repeated after this, and if straight, the skin is closed and the procedure is terminated (Fig. 74.3).
injure the corpus spongiosum. In some cases, this will need to be detached from the glans to the penoscrotal junction. If injured, the urethra is closed primarily using a fine, absorbable suture. Patients who suffer from a differential elasticity between dorsal and ventral aspects of the corporal bodies may receive some benefit from the excision of the inelastic dysgenic tissue but are rarely straight and often require further maneuvers to straighten the penis. An artificial erection is repeated after this, and if straight, the skin is closed and the procedure is terminated (Fig. 74.3).
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
