Penile Torsion
Penile torsion is defined as rotation along the long axis of the penis. It occurs in approximately 1 in 80 patients. The rotation almost always occurs in a counterclockwise direction ( Fig. 121.1 ). It appears to be secondary to dysgenetic dartos bands with rotation of the median raphe. The orientation of the corporal bodies and the corpus spongiosum are normal. It may also occur secondarily after hypospadias repair, repair of chordee, or circumcision. The torsion seen in the uncircumcised penis is due to abnormal skin and dartos fascia investiture of the penile shaft. The location of the median raphe offers the best clue that underlying torsion is present.
Preoperative Preparation
For a boy with penile torsion, it is essential to understand the cause. The surgeon should inform the family that circumcision is usually necessary when repairing penile torsion, and this should be part of the counseling of the family preoperatively. In general, preoperative antibiotics should be administered, and the surgeon should be prepared to perform artificial erection during the case because lateral and ventral bending of the penis is common in severe torsion.
Surgical Repair
Surgical repair is indicated when greater than 60 degrees of counterclockwise rotation of the penis is present and the family desires a circumcision. The patient is positioned in the supine position. In severe cases when access to the penile and bulbar urethra are needed, the legs should be separated to allow space to work. For both penile torsion and chordee, the use of a penile glans traction suture of Ticron or Prolene is helpful with dissection and placement of a penile tourniquet. This suture is placed in a horizontal fashion perpendicular to the urethra and not involving it.
Making a circumferential incision proximal to the coronal margin begins the procedure. The skin is dissected completely off the shaft of the penis to the base of the penis, transecting dysgenetic dartos bands. These bands are often found on the ventrum and extend from the midshaft proximally into the scrotum. It may be necessary to transect the dorsal suspensory ligament. The authors find that occasionally a ventral midline incision is useful to get the penis mobilized proximally and to gain access to the suspensory ligaments. Degloving alone or in combination with resection of abnormal dartos corrects torsion in many patients. After the penis is degloved, if the urethral meatus is not rotated to the left, simply realigning the median raphe back to the midline after removing excess skin is sufficient to correct penile torsion in mild cases.
With moderate cases of torsion, as depicted in the first figure showing a child with approximately 80 degrees of counterclockwise torsion, a broad-based dartos flap can be mobilized from the undersurface of the dorsal penile skin ( Figs. 121.2, A , and 121.3, A ). Liberal use of stay sutures on the penile shaft skin and separate sutures in the dorsal dartos tissue will assist in dissecting the dartos flap from the undersurface of the dorsal penile skin. The dartos flap can then be rotated around the right side of the penile shaft ( Fig. 121.3, B ) and sutured with interrupted 5-0 Vicryl or chromic suture ventrally ( Figs. 121.2, B and 121.3, C ). The sutures should not be placed directly over the urethra. The amount of flap rotation is determined by the degree of penile torsion that needs to be corrected. This maneuver rotates the penis in a clockwise direction, thereby correcting the counterclockwise torsion. In the literature and in our own personal experience, this technique has been able to correct torsion as severe as 80 to 90 degrees, especially when combined with resection of the abnormal ventral dartos.
In more severe cases of penile torsion, dysgenetic dartos bands must be severed at the base of the penis, and the base of the right corporal body is sutured thus affixing it to the pubic symphysis. Often this requires a ventral proximal midline incision to aid in dissection and suture placement. This assists in clockwise rotation, counteracting the counterclockwise rotation of the dysgenetic bands. This is done by dissection dorsally and on the right side to the penoscrotal junction and down to and through the penile suspensory ligament. The suture should be placed in such a manner to avoid the dorsal penile nerves at the 10 o’clock position. Placement lateral to this is sufficient to avoid the nerve and get good rotation. A radical form of urethral mobilization in severe torsion with chordee has been described in the literature, but in the combined experience of the authors, it has never been needed for correction of isolated penile torsion.
Realigning the shaft skin circumferentially around the phallus after excess skin has been removed completes the procedure. This completes the circumcision. In severe torsion, the surgeon should make no effort to align the median raphe in the midline because this can create inadvertent counterclockwise rotation. The skin should be realigned where it comes up to the preputial collar. If the ventral midline incision was needed, then the raphe can be reconstructed as well upon skin closure. In infants, this is usually accomplished with 5-0 or 6-0 chromic suture. The penis is then dressed with a bio-occlusive dressing positioned circumferentially around the shaft of the penis tight enough to prevent oozing but not so tight as to prevent voiding.
Postoperative care usually consists of bacitracin ointment to the glans penis three or four times daily with diaper changes and removal of the dressing on postoperative day 2 or 3. If the dressing starts to bunch at the base of the penis, creating a tourniquet, then it should be removed immediately.
Lateral Penile Curvature and Chordee Without Hypospadias
Lateral penile curvature in infants and young boys is almost always caused by corporal body disproportion. Although urethral anomalies have been described, they are more in the scope of hypospadias repair and are not covered in this chapter. In the corporal disproportion circumstance, the urethral spongiosum and urethral length are normal and not causing bending of the phallus. With erection, the longer corporal body will push toward the shorter corporal body, creating lateral curvature and often rotation. This tends to occur to the left side, and the torsion is usually counterclockwise.
In boys with chordee not caused by urethral abnormality, the defect represents a possible arrest in normal development . This chapter discusses curvature secondary to corporal body disproportion and fibrotic Buck or dartos fascia.
An understanding of the sensory distribution of the dorsal penile nerves is helpful in surgical correction of penile curvature. The most important neuroanatomic finding related to the anatomy of the dorsal nerve is that it has multiple branches running along the surface of the tunica albuginea from the classic dorsal 11 and 1 o’clock positions as it exits under the pubic symphysis and moving distally to the 5 and 7 o’clock positions at the junction of the corporal bodies with the urethral spongiosum. The 12 o’clock midline position does not have any neural structures ( Fig. 121.4 ).
