Paediatric Urology

10. CONGENITAL PENILE CURVATURE

10.1. Epidemiology, aetiology and pathophysiology

Congenital penile curvature is penile bending of a normally formed penis with an orthotopic meatus. For penile curvature associated with hypospadias, refer to Chapter 9 on hypospadias. Ventral deviation is the most common type of congenital penile curvature (48%), followed by lateral (24%), dorsal (5%) and a combination of ventral and lateral (23%) [372,442].

While the overall incidence of congenital penile curvature at birth is 0.6-5% [372], the incidence of clinically significant curvature is much lower. The extent of the curvature varies widely, as does the impact on the individual patient [368]. Congenital penile curvature can decrease sexual QoL in adults, and successful repair can restore patients’ psychosocial and sexual wellbeing [443]. Curvature > 30° is generally considered clinically significant, yet many patients with greater curvature may not experience problems [368].

Minor congenital penile curvature may simply be the result of ventral penile skin deficiency. This should be distinguished from more severe curvature due to asymmetry of the corpora cavernosa. Rarely, short urethra is the cause of congenital penile curvature.

10.2. Diagnostic evaluation

Congenital penile curvature is often not documented until later in childhood, because the penis only appears abnormal when erect. Patients are usually concerned with the aesthetic and/or functional aspects of their penis [444]. Detailed history, including sexual function, is important and photo documentation of the erect penis clearly showing the curvature from various angles is essential for optimal preoperative evaluation [445].

10.3. Management

Conservative management is the mainstay of treatment during childhood. Functional complaints are the main indication for surgery rather than the actual degree of penile curvature. Surgery can also be considered if the patient has cosmetic concerns. In general, it is reasonable to postpone surgery until an age at which the patient can decide. Age does not appear to affect the outcome [446].

Surgical correction of curvature aims to achieve corpora of similar size with the ultimate goal of patient satisfaction. The exact degree of curvature is determined at the time of surgery using an artificial erection test. The use of measurement tools aids in the accuracy of curvature assessment, particularly in moderate degrees of curvature [367].

Following assessment of curvature degree, the first step of surgery is degloving of the penile skin, followed by excision of any abnormal subcutaneous connective tissue, if present.

Correcting residual curvature may be achieved by shortening the dorsal, convex side of the curvature. Various techniques are in use for adapting the dorsal tunica albuginea, including wedge excision and closure (Nesbit procedure), plication without excision, and longitudinal incision with transverse closure (Heineke-Mikulicz principle).

All these methods incur the risk of postoperative shortening of the penis, the severity of which depends on the preoperative degree of curvature and the type of repair used [372]. A recent study showed loss up to 1cm in only 6% of patients with curvature > 30 degrees [447]. The proportion of patients bothered by length reduction appears low [446,448]. Altered sensation is also a concern with dorsal manipulation, particularly with mobilisation of the dorsal neurovascular bundle and may be transient [372,448-450].

In rare cases in which dorsal shortening is not sufficient, ventral lengthening may be performed by urethral transection, corporotomies or corporoplasty with grafting. Refer to Chapter 9 for more details on hypospadias.

The overall success rate for correction of penile curvature is 90-100% in most series, although some studies accepted small degrees of residual curvature as straight [372,448,450]. Patient satisfaction rates are equally high [447].

10.4. Summary of evidence and recommendations for the management of congenital penile curvature