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Penile curvature may be congenital or acquired, due to several etiologies, such as Peyronie’s Disease, penile trauma, or congenital chordee. Peyronie’s Disease is, in the majority of cases, a chronic condition that can have a devastating effect on men’s self-confidence.
This pathology can present as simple pain during erection, to severe penile deformities that totally undermine sexual intercourse, like appreciative penile curvature, indentation of the corpora cavernosa, or severe narrowing of the penile belt. In the initial phase of the disease, the corporal incision and plaque excision, followed by grafting of the incision line or plication of the most extended
incision, reducing the length of the penis, are the first choices of treatment.
After this initial inflammatory phase, plaque excision of the tunica albuginea and incisional fracture of the corpora, followed by prosthesis implantation within the confinement of the corporal fibrotic envelope, is the standard of care.
Penile curvature may be congenital or acquired, due to several etiologies, such as Peyronie’s Disease, penile trauma, or congenital chordee. Peyronie’s Disease is, in the majority of cases, a chronic condition that can have a devastating effect on men’s self-confidence. This pathology can present as simple pain during erection, to severe penile deformities that totally undermine sexual intercourse, like appreciative penile curvature, indentation of the corpora cavernosa, or severe narrowing of the penile belt. In the initial phase of the disease, the corporal incision and plaque excision, followed by grafting of the incision line or plication of the most extended incision, reducing the length of the penis, are the first choices of treatment.
After this initial inflammatory phase, plaque excision of the tunica albuginea and incisional fracture of the corpora, followed by prosthesis implantation within the confinement of the corporal fibrotic envelope, is the standard of care. Peyronie’s Disease interferes with the understanding of sex as a sexually transmitted energy activation had by the couple, becoming, for many patients, an absolute impediment to sexual functioning.
Men with Peyronie’s Disease and erectile dysfunction evaluated at Per Trafford District General Hospital (Altrincham, Cheshire, UK) reported higher levels of anxiety and/or depression than those suffering from diabetes. Penile curvature (PD) is a disease of unknown etiology, characterized by the fibrous proliferation of the tunica albuginea and an increase in penile rigidity during erection. As a result, men often develop penile deformity, accompanied by penile pain during erection if the plaque develops at the level of neurovascular bundles and advanced erectile dysfunction, limiting patient sexual intimacy and satisfaction.
The surgical treatment of ED is a recent trend, taking advantage of newly available pediatric laparoscopic techniques, and can be performed with the disease in the stable phase.
Penile curvature is the occurrence of an abnormal bend in the penis that may render intercourse
difficult or painful. Some 9-10% of men experience such symptoms. Most men have a slight natural bend in the bones of their penis. Erectile dysfunction may cause increased discomfort of the condition. The curvature is innate and can occur during puberty while the penis is soft despite this. Hypotheses include injuries to the penis or strong erections and sudden movement as the possible cause. Inflammation or plaque build-up along the penis’ corpus cavernosum shafts can also lead to curvature.
The penile rupture (fracture or broken shaft) and the penile erosion (bent penis or Peyronie’s disease) affect the penis’ corpora cavernosa. Suddenly fractured tunica albuginea leads to penile rupture, usually in developing countries. Fibrous deposits form on the conversely chronic plaque and result in penile erosion, which occurs in conjunction with erectile dysfunction and the unnatural angulation of the penis. As a result, penile curvature can occur during erection.
Combination of plication or graft with penile prosthesis insertion are mandatory due to high comorbidity of penile prosthesis insertion with these diseases
Several factors can influence the choice between surgical plication and grafting for the treatment of penile curvature. First, the surgeon performing either procedure should be competent in each type of surgery. Both specialist and nonspecialist urologists commonly perform penile plication, with good success in treating erect curvature.
Coloplast has detailed training events to assist surgeons in placing the plication constrictor wraps, but this widely available product has not been analyzed in detail for safety or success. When using a graft technique such as the Lue or Nesbit procedures, specialists perform the majority of corrective surgeries. Success rates for graft procedures generally exceed 80%. More surgical training is required to succeed with grafting, but the procedures have long-term effectiveness and can correct a wide variety of deformities.
Performing either procedure correctly returns sexual function in 95% of cases where men were initially able to experience full sexual intercourse. In contrast, with plication using the Patient Reported Erection Satisfaction Questionnaire (PREQUE) as a guide, after plication surgery sexual function decreased in 42% (p < 0.0001). A second factor is the degree of penile curvature.
Penis plication can correct significant curvature but may struggle to straighten a severely bent organ. Conversely, tunical grafting can produce excellent erect results, maintaining rigidity and straightness easily during intercourse, but harder residual penile plaques can predispose a penile fracture. Grafting relies on a strong aesthetic outcome, while it must not decrease penile sensation significantly.
Surgical correction of penile curvature is typically recommended when the curvature results in difficulty during sexual activity that adversely affects sexual, psychological, and/or emotional health to the point that alternative medical therapy or devices have not provided effective relief from the condition.
Curvature can be attributed to three types of etiologies, which may correlate with the severity of the curvature and the type of surgical technique that would be best suited for penile straightening. Deviation occurring in the plane that is considered the easiest to correct includes disease pathologies such as congenital penile curvature (ventral) and Peyronie’s disease.
The existence of penile curvature across the regions of the penis is less common but poses a challenge when it occurs. A plaque, or localized area of scar tissue, develops along the lining of the erectile space within the tunica albuginea which can occur across the entire circumference of the penile shaft. It is the most common etiology associated with penile curvature and should be distinguished by an abnormal side curve associated with an hourglass deformation occurring during the erect phase.
Several treatment options to address this precluding condition include a variety of nonsurgical and surgical interventions, which can include vacuum erection devices, oral therapy, localized injections, or more invasive surgery, including penile plication.
Surgical correction of penile curvature is the most popular and most effective treatment for PD. The penile plication with different surgical techniques and corporal shortening procedures are utilized to correct the penile curvature depending on the severity of PD. Peyronie’s disease and congenital penile curvature are mostly treated with the penile plication surgery. Ventral penile plaque is excised partially, and the penile shortening effect of the sutures is applied on the alone or both sides of administrated neurovascular bundles for penile shortening effect during the penile plication.
Candidate patients for the plication surgery have no deformities more than 60 degrees and do not have severe hourglass deformities. This surgery can also be performed with penile prosthesis surgery for patients who have erectile dysfunction and acceptable length and girth of the gland penis. Leriche recommended more than 20 degrees of curvature for performing this surgery.
Invaginating or inverting the convex side ends of the plaques is the technical purpose of the penile plication technique. Mostly 2, 4, 6, or 10 plication sutures are inserted side by side in the alignment of crura adjacent to the suspensory ligament. Frequent insertion of the plication sutures can cause the tension of the sutures and also can degenerate the blood supply of corpora cavernosa.
Grafting procedures, which attempt to equalize the differences in penile length and to avoid loss of girth, have generally been used more frequently in cases with more severe penile curvatures. The main disadvantage of these procedures is that penile shortening that may occur due to the underlying mechanism responsible for curvature is diminished if not completely abolished.
Another disadvantage is that the grafts may be absorbed during the postoperative period or a penile angulation in the opposite direction may ensue just after operation, which have been reported as occurring in approximately 10-30% of patients. Due to these disadvantages, the results of graft procedures have been reported as inferior to those obtained following plication surgery.
There are many modifications of the penile graft procedures: dorsal, dorsolateral, and 16 or 4 dot technique. There is also no consensus regarding the ideal graft material. The choice of graft material could influence the success of the procedures. Prosthetic material, either synthetic or of the patient’s own tissue, is preferred for graft surgery. Prosthetic materials include Furlow’s, dermal, Temm, absorbable suture rods, and silicone. In a study by Schneider et al, they reported that they achieved a success rate of 78% with the autologous saphenous vein grafting technique. In another study by Said et al, silicone rod grafting was performed in 94 patients, and the success rate was found to be 70.2%.
The discussion of expectations with the patient is an important aspect of the care of an individual risking surgery. The patient should understand all the consequences of performing surgery and the logistics of the procedure. All questions that might arise during the discussion with the patient should be addressed. A full description should be given to the patient, including information about the scars that might develop and the possible decrease in penis size after the procedure.
The fact that the patient will have sutures in the penis and that after the intervention he won’t be able to have erections until the wound is completely healed should be mentioned. Every patient should be told that pain is always present for the first 5-7 days after the operation and that sometimes the application of ice on the penis may be necessary to decrease the pain. Preparatory measures for the postoperative care of the penis and the type of antibiotics and analgesic may also be needed.
To assess for any penile curvature, the patient is often referred for color Doppler ultrasound studies. It is important for the urologist who will perform the surgical correction to evaluate the penis firsthand. During the first visit, the surgeon will examine the patient and ask the patient to show him any photos that he might have with the penis during an erection so as to visualize the entity of the curvature. An evaluation of penile erection is necessary to see which position is the one most comfortable for the patient. The examination should be indicated to evaluate the entity of any spongiofibrosis.
The penis of the patient is inspected to evaluate his ability to have erections and ejaculate and to assess his partner relationship. Information about which position is chosen when sexual intercourses are undertaken should be evaluated so as to establish therotation angle that represents the least curvature. Classic photographs show the extent of the penis and dorsal tension of the angulation. An erect penis is needed in order to take a proper examination of the curve of the penis. The erectile specimen is inspected to analyze the extent of any spongiofibrosis.
Subjective or objective alteration in sexual functioning can be the main reason for referring to subjects with penile curvature. The patient may refer to bending, “narrowing,” or shortening of the penis, discomfort or pain with erection, and sometimes significant erectile dysfunction. However, a small degree of permissible penile curvature may subjectively be seen as significant and become a reason for referring.
Clinic history and physical examination almost always lead to the correct diagnosis of Peyronie’s disease. The most common physical complaints and physical examination of patients with Peyronie’s disease are summarized in Table 1. Physical examination is usually adequate for the diagnosis, while blood investigations, penile radiographs, or penile Doppler ultrasonography are rarely needed for this purpose.
The probability of the patients’ complaints being associated with true Peyronie’s disease increases when the patient is over 40 years old, and plication surgery or grafting seems to be clear according to their length and degree of curvature. Radiological examinations must be asked when there is a strong suspicion of penile trauma in patients who are below 40 years of age. Ageless subjects who admit to penile deviation and had congenital penile curvature never have such complaints before when asked. The presence of a relatively soft mobile flaccid penis which shows deviation both when flaccid and erect does not cause severe bother to such patients.
This penile curvature during erection can control activities that require the presence of other people and can lead to communication disorders between the patient and his environment. This can negatively affect the relationships of patients and the level of self-confidence. The patient does not interact from fear of recurrence. Anxiety and stress control the life of the patient and lead to psychological problems, which in extreme cases can adversely affect the general state of health.
To avoid all these negative consequences, some simple rules should be followed to ensure the absence of negative postoperative outcomes. In the event that the doctor has prescribed the wearing of a pressure bandage, it should be with the belt part under pressure to extend the area of the penile application. Limit the activity in the postoperative period corresponds to the desire.
It is advisable not to play sports for a month. Until time compresses help to achieve the effect of the operation, a normal diet is recommended to provide the necessary amount of necessary vitamins and beneficial trace elements.
Penile reconstructive surgery aims to correct penile deformities caused by the accumulation of fibrotic plaques on the penis called Peyronie’s disease, which causes congenital curvature by filling the potential space between the tunica albuginea, the thick tissue surrounding the corpora and the penile corpus cavernosum. This is derived from the inner layer of the corpora and is responsible for penile erection and erection quality. The abnormalities in the penile plants can cause painful erections, inability to achieve adequate penetration, or both.
Combining penile prostheses with correction of penile deformities is prescribed over time for certain surgical indications of poor response to drugs. In this case, Peyronie’s disease is associated with erectile dysfunction, and the same surgical procedure can be treated simultaneously. The search for a surgical treatment that is effective and safe with fewer complications has generated several options, and a comparison of the main surgical techniques currently offered to treat penile curvature is published as an expert panel SID classification committee.
The appearance of penile curvature can be bothersome and have a significant impact on the patient’s sexual life; it can also be related to pain or difficulty in engaging in sexual activities. In these cases, requiring medical or surgical treatments, in Peyronie’s disease, a clear division is established by the chronic phase, which occurs after at least 3-6 months since the outbreak or by the acute phase, when conservative treatments are prescribed as the main option for changes. The acute phase begins with underlying the acute or subacute onset of symptoms and lasts up to six months.
At our institution, before surgery, the hair is removed from the lower abdomen cranially to the level of the pubis. In the preoperative period, all patients receive 1000 units of dalteparin sodium (heparin) subcutaneously daily, the night before and the morning of surgery. Ciprofloxacin 500 mg is given before surgery and for the first week afterward. Intravenous antibiotic prophylaxis with 1 g of cefazolin is administered at the time of anesthesia induction. Before starting the penile devascularization procedure, we demineralize the patient’s arm, so we make sure that the final ischemia time will be minimized.
In the operating room, an 18-French Foley catheter is inserted, and the distal balloon is filled with 10 cc of saline, ensuring that the urethra is not deviated to the right side of the penis. We place a Fenestrated Subcutaneous Unishop (FSU) drain over the pubis to remove the urine that drains from the bladder where the penis will occlude it. We also cover the penis with Steri-Drape surgical aperture film and a sterile gauze mesh. Finally, we elevate the patient’s penis with an electric lift placed at the patient’s feet and fix it to both sides of the tibia with safety adhesive tape. As for the surgical team, we use bagged sterile Bianco gloves and maximum sterile barrier precautions.
For a patient with penile curvature, here is a step-by-step guide to what he can expect from surgical correction: The patient should normally be prep-shaved and given an enema the day before surgery and on arrival in the hospital. Pre-operative labs are drawn, intravenous fluids are infusing, and antibiotics are part of his intravenous protocol. With anesthesia, the patient will fall asleep and be in the ‘exposure’ position.
The exposure is a supine 30-degree angle. The perineum is sterilely prepped and a sterile drape is gently placed in position. The urologist should already be scrubbed in and wearing gloves and a sterile gown. The desired position of the ventrally-exposed penis is in a helpful manner-produded at a 45-degree angle is a grease pencil mark on the scrotum (peno-scrotal junction). The antiseptic solution will sterilize the skin surface for the proposed incision.
If hair is present, then it will be clipped from the work area. The first incision is a vertical ‘Y’ which is about 1-1.5 cm above the mark on the scrotum. This first move usually takes care of the majority of the wooden exposure. The length of blade used on the #15 should be no more than 5 cm in length; anesthetic time will keep the temples trim and keep the cabin view open. Some foam gauze is stuck on the legs of the bed; this keeps the sterile surface in place for later usage.
The long metzenbaum scissors are used to cut beneath the skin, all in a sterile manner. The curved forceps are used to open up and hold this skin area, which has a ‘light’, fancy appearance. Straight DeBakey forceps can handle skin with a heavy appearance. Five large mosquito clamps can handle a heavy skin tent. After this skin exposure is done, the alloplastic graft can be seen and touched. The curved metzenbaum scissors are used to free up the graft from the corpus cavernosa. The graft is only stuck in a few areas and is easily liberated, with bleeding promptly controlled and managed.
For surgical techniques, the intraoperative blood loss is similar. Hematomas are usually seen post-surgery and may necessitate surgical evacuation. Skin and the underlying tissue necrosis, infection, dehiscence, and prolonged hospitalization may also occur. As for patient complaints, whether they had a plication or graft was made, complaints did not differ.
There was no incontinence, nor severe slogan erections in the early or late period of the patients. Graft thrombosis was not seen. But the problems persisted for a while. There was a significant improvement in painful erection and difficulty in sexual intercourse. A longer duration of patient follow-up is needed to conclude any real difference in post-procedure complications. Dipstick evaluations are used for blood and urine parameters required after plication and graft. In cases where adequate mobilization and tension were not made and dissection was curtailed, there were more frequent complaints of increased hardness in the corpus below the site of surgery.
Complete erection performance maintained in about 80% of the patients with plication for 10.3 months. According to a study, penile length after penile plication and the appearance of patients are significantly improved in the early and late period. As can be expected the patients were satisfied with the appearance of their penis in a state of erection and the restoration of the appearance of their penis at rest. The lower suture of the skin was removed 30 days later.
After pleating all procedures continue through a Y-shaped incision to hide the severe curvature that may occur by day 6 (n=2), erections were painful. On postoperative day 22, necrosis was observed in the upper part of the urethral mucosa line. A small section of the glans necrosis was debrided, and stent placement in the urethra was planned to help with healing. After removing the stent on day 28, the 2 finger breadth dehiscence was detected, revealed with skin and underlying sutures. In the early period, the patients were called daily and regularly followed up.
The wound edges were brought together with a purse string suture. It was detected that the underlying tissue was not healing as expected. Afterwards, the tissues did not close despite scalpel use and flaps pulled with tension to the outer edge of the surgical site. The patients were called daily, and a nurse researcher dressed the wound in the early period. The wound was debrided and vacuum dressings were applied. Short periods of antibiotics and medium-length periods of pain were administered, and the wound was healed with serous discharge.
In any blood vessel or nerve-related surgical procedure, including the operations for penis curvature correction, undesired complications may occur. These complications are extremely rare in experienced and skilled hands but may include the following:
Bleeding and infection, if severe, can lead to an unsightly scar. Although rare, a surgeon can establish poor approximation technique, especially if manually-inserted plication sutures are used. If recurrent, easier removal of the excessively sutured tissue is often compromised by the quality of the remaining tissue.
If a reconstruction procedure is contemplated, grafting will probably be needed if an artificial graft is used. It can be seriously weakened or (more commonly) partly released from underlying corporal bodies, with subsequent graft malrotation or prolapse into the proximal meatus. This shift might present as an unexpected sudden-onset curvature recurrence, occurring months to years after narrowing. Individual graft suture plications can also cut the graft along predetermined suture tracks.
Even in the absence of tension, any autologous diseased or damaged tissues that are sutured together will almost inevitably elevate its respective area as the body completes the ensuing repairing response.
Such a delayed-lengthened buttonhole might leave the patient with residual or new curvature and relatively easy graft prolapse and erosion. In this case, any underlying disease that extends into the proximal meatus can laterally limit the tunical shortening effect. In some rare instances, the relatively simpler and previously less blood-vessel-heavy procedure, plication, will be preferable.
Cases where the graft is prone to corporeal erosion because infectious or inflamed is not uncommon. However, lost from the proximal curvature for increased length may prove long-term healthier than short-changed tissues.
The integrity of the penis structure is due to the equilibrium of the forces that keep it straight. This function is susceptible to a huge diversity of metamorphoses. The most textual foundation includes those conditions with extension and associated reversible penile erectile dysfunction and corpora cavernosa is not calcified. Likewise, it is expected that any bump placed in the tunica albuginea disrupts this commission and as a result, it will manifest as a penile curvature.
The agents that justify the diverse forms of penile curvature are quite diversified. Epidemiologically, the congenital etiology of the penile curvature is responsible for up to 20% of all cases of penile curvature that deserve treatment with a prosthesis. Here, it is best to isolate the second sphere of penile curvatures because it covers a wide spectrum of diagnosed pathologies.
Generally, the congenital pathogenesis of the penile curvature that cannot reach target erection is endorsed freedom by the considerable size and swelling of the penis that is managed in groups of men who lead their partners to ejaculate with their fingers already inside the vagina until they complete the first year of life. These persons exhibit deformations in the dorsal region of the penis (sharply angulated with a V-shape) and the penis tilts upwards, displaying the form of a hooded bird (“bellclappers” deformity).
Diagnosis of penile curvature is not usually difficult. However, some men may have a penile deformation (due to scarring) which has occurred for so long they may think this is “normal” because they are not able to have an erection any other way. If a man has difficulty bending his penis or erections have a good quality, then he should visit his family physician or urologist.
Physical examination by a doctor experienced in treating such problems can determine if there is an underlying medical condition causing the bending or if the ability to enjoy sex could be improved through treatment that corrects the curve in your penis.
If treatment is desired and attention has been paid to avoiding all the potential risks, then treatment of the penile curvature is always a matter for the patient himself. No one needs to have his penis straightened if he does not wish. If they want to learn about the potential risks versus benefits of treatment, then their primary healthcare provider, general practitioner, family physician, or local urologist are good places to start. If patients desire, they are free to ask to be referred to a urologist with special interest and expertise in the area.
Once Peyronie’s disease is diagnosed, which can be done reliably based on the patient’s history and physical examination, the patient can be assured that the disease is self-limited. In other words, he can count on the fact that he will experience a complete resolution of the acute phase, followed by improvement, and finally stabilization of the disease.
For this to happen, many months of waiting are needed. This is sometimes enough, as some patients are not bothered by the deformity of the penis. Unfortunately, the penis is not only a male organ, but also an important element of Western culture values. The inability to have a straight sexual intercourse is definitely a problem in this part of the world, whereas it may be a smaller problem in other parts, especially in older people. This is why various treatments are proposed for this disease. These treatments can be divided into surgical and conservative ones.
The former include straightening maneuvers and modifications of the penis, the fewest possible destructive interventions, and the destruction or resection of that part of the albuginea causing the curvature. The latter include stretching and/or compressing devices, injections into the plaque, iontophoresis of drugs into the plaque, low-intensity extracorporeal shock wave therapy (LI-ESWT), laser therapies and the administration of oral drugs. Hormones do not work in males.
The disease is a local one, not a hormonal or systemic one. However, the local response is secondary to local androgens, so that an immunohistochemical decrease in androgen receptors in fibroblasts and an increase in α-2-macroglobulins, which bind and sequester testosterone, occur in patients with this disease. Furthermore, micro-RNAs regulating androgen receptors are significantly down-regulated in the tissue of these patients.
Men should seek an opinion from a trained urologist if they feel that their penis is deviating significantly from the normal penis as they understand it or as it has been previously.
Sometimes the deviation occurs over a prolonged period or overnight, and if there is associated pain or difficulty with penetration or maintenance of the erection, medical help is warranted. A trained urologist will be able to differentiate between a functional, psychological problem that may have as its manifestation this curvature and assure the couple that a normal penis does not always have to be arrow straight.
Only a trained doctor will be able to do a proper assessment of the problem with a careful history and a proper examination. The age, time since development, pain associated with it, degree of penile deviation associated with the condition, and previous penile trauma, whether sexually induced or as an innocent bystander in accidental and sports-related injuries, must be recorded. The erection angle, presence of any palpable plaques, and the status of the neurovascular status have to be carefully evaluated.
Photographs in the office can help communicate the abnormality, are part of the medical record, and provide a baseline for future comparison later on in the not so distant future. Most of the tools required for initial evaluation are already in any urologist’s Office.
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