Penile Curvature

A congenital penile curvature is caused by an uneven development of the two chambers that form the penis. This ultimately causes the erect penis to bend towards the aspect that has developed less. From this point of view, congenital penile curvature is quite similar to acquired penile curvature or Peyronie’s Disease, as in both cases there is a convex, longer and a concave, shorter aspect of the shaft penis. However, in case of congenital penile curvature, the asymmetry is due to an uneven development of the chambers of the penis while in Peyronie’s Disease the scarring associated with the plaque causes shortening of one aspect of the penile shaft. Congenital penile curvature usually becomes apparent during adolescence, when the chambers of the penis develop at the highest pace. Fortunately, most of the congenital penile curvatures are minor and do not interfere with penetrative sexual intercourse. Only a minority of congenital curvatures are so severe to require surgical correction.

Although congenital penile curvature may point virtually in any direction, in most cases the penis bends downward; in this case the curvature is called ventral. Ventral curvatures may present in isolation or together with anomalies of the penile urethra (the waterpipe). In congenital penile curvature the deformity can render penetrative sexual intercourse difficult or impossible and therefore can be cause of embarrassment and distress.

Both Peyronie’s Disease and congenital penile curvature can be found in adolescents and young adults and therefore the age of onset is not a good criterion to distinguish between the two conditions. However, in patients with congenital penile curvature there is no palpable lump, which is instead indicative of Peyronie’s Disease.  Also, while most congenital curvatures are ventral, in most patients with Peyronie’s Disease the penis bends upward. Waist deformities are also absent in patients with congenital curvature, which tend to be more gentle and harmonic than the one of patients with Peyronie’s Disease.

While erectile dysfunction is a common finding in patients with Peyronie’s Disease, most patients with congenital penile curvature have adequate erections, as there is no association between cardiovascular risk factors and congenital penile curvature. To render the situation more confusing, some of the patients with congenital penile curvature may eventually develop Peyronie’s Disease later in life and therefore both conditions may coexist.

The diagnosis of congenital penile curvature is based on history taking and on the examination of the patient. Most patients notice the curvature during adolescence. Examination of the penis will demonstrate a soft, elastic tunica albuginea and the absence of the indurated lumps typical of Peyronie’s Disease.

Deformity can be assessed only during erections, when the tunica albuginea of the penis is stretched to its maximum capacity. Self-photography of the erect penis can be a useful tool to identify the nature of the deformity. However, this can underestimate the exact tridimensional extent of the curvature, as the picture is by definition bi-planar. Also, an incomplete erection will make the deformity appear less pronounced. Alternatively, an artificial erection can be induced in the office with the administration of a vasoactive medication. This allows the surgeon to assess more precisely the tridimensional extent of the curvature and better plan the treatment options. Doppler ultrasound scan can be extremely useful to rule out the presence of plaques in the equivocal cases.

In patients with congenital ventral penile curvature it is very important to examine the urethral meatus and the distal urethra as congenital ventral penile curvature may be associated with anomalies of the penile urethra.

There is no effective medical treatment for congenital penile curvature as there is no scarred tissue to target. Therefore the only solution is surgery.

Surgical correction consists in the shortening of the longer, convex aspect of the shaft to make it even with the shorter, concave aspect. This is called tunica albuginea plication (TAP) or Nesbit procedure. Incision of the shorter side and grafting should not be offered as it gives poor results in patients with congenital penile curvature. This is because the curvature is more harmonic and not localized as in patients with Peyronie’s Disease. Fortunately, most patients with congenital penile curvature have an adequate penile size and therefore plication surgery will not cause excessive shortening. Straightening procedures are performed under general anaesthetic as a day case, are very reliable and safe in the hands of experienced, large volume surgeons like Mr Garaffa and patients can usually resume sexual activity four to six weeks afterwards.