S.-S. Lee, E. Meng, F. -P. Chuang, C.-Y. Yen, S. -Y. Chang, D.-S. Yu, G.-H. Sun

Congenital penile curvature is caused by asymmetry in compliance of tunica albuginea of the corpora cavernosa due to developmental arrest during embryogenesis [1]. Mostly, ventral and/or lateral deviation of erected penis occurs in congenital penile curvature. The prevalence of this condition is probably higher than the 0.4 to 6 per 1000 men previously reported [2, 3]. Penile angulation not only causes sexual dysfunction, difficulty and pain on intercourse or total coital incapacity, but also causes severe psychological problems. Surgical intervention to cure penile curvature is required when coital function is impaired [4, 5]. Nesbit in 1965 performed the first operative correction of penile curvature by excising ellipses from the outer curvature of the penis [6]. Thereafter, different surgical techniques have been described including plicating the elongated corporeal fascia of the penis [7-9]. In this study, we evaluated the long-term outcome, effectiveness and patient satisfaction of tunica albuginea plication as a correction measure of congenital penile curvature.

From January 1992 to January 2002, 106 patients underwent surgical correction of congenital penile curvature by corporeal plication. The criteria for operation included a penile angle of more than 30 degrees, difficulty or inability in vaginal penetration during sexual intercourse, painful vaginal penetration or psychological causes. Patients with Peyronie's disease or chordee associated with hypospadias were excluded from the study. The angle or degree of penile curvature was determined by photographs taken by the patients during erection and by artificially inducing erection by intracavernous injection of papaverine (30 mg) or prostaglandin E1 (PGE1) (10 g). The different directions of curvature, including ventral, lateral and combined ventral and lateral, were recorded. All patients had a rigid erection without erectile dysfunction.

Figure 1A and 1B: Plication of the tunica for A, ventral curvature and B, lateral curvature.

Sixty-eight of the 106 patients completed the post-operative questionnaires and chart reviews. Of these, 42 patients had presented with complaints of difficulty in intercourse preoperatively; the rest of them had no prior experience of sexual intercourse but complained of poor self-image and psychological stress. The primary complaint in all patients was life long penile curvature during erection. All patients had rigid erections but the angulation of the curvature ranged form 30 to 90 degrees. Thirty-three patients had ventral deviation, 23 had left lateral deviation, 3 had right lateral deviation, and 9 had combined lateral and ventral deviation.

Post-operation follow-up ranged 11-132 (mean 69.3) months. Penile straightening was excellent in 62 patients (91 %) and good with less than 15 degrees of residual curvature in 6 patients (9 %). Sixty-seven patients reported no change in erectile rigidity or maintenance and 1, early detumescence. In the 26 patients who had no sexual experience preoperatively, 18 had sexual intercourse without difficulty and 8 presumed good rigidity and straight penis sufficient for intromission. Shortening of the penis without functional problems was noted by 26 out of the 68 patients (38 %) who completed the postoperative evaluation. Thirty-five patients reported feeling palpable induration (suture knots) on the penis. One patient considered this to be bothersome although not interfering with sexual intercourse. Temporary numbness of the glans penis was reported by 3 patients. One patient underwent re-operation because of greater residual curvature of the penis. Subsequently, this patient had excellent straightened rigid penis. With regards to overall patient satisfaction, 60 patients were very satisfied, 6 satisfied, and 2 unsatisfied (Table 1). Of the latter 2 patients, 1 had palpable indurations and the other was dissatisfied because of the shortening of the penis.

Congenital penile curvature is usually the result of disproportion of the corpora cavernosa and corpora spongiosum. It usually presents early in life without any associated erectile dysfunction, as opposed to Peyronie's disease, which is usually accompanied by erectile dysfunction. The direction of penile curvature of our patients was varied. The most common curvature was ventral deviation (33/68). Interestingly, in the group of patients with lateral deviation, right deviation was rare (3/23). None had dorsal curvature (0/68). Chien [10], Poulsen [11] and Catuogno [1] had reported similar penile curvatures in their studies.

Although satisfactory results have been achieved for operative correction of penile curvature by the Nesbit procedure, the reported incidence of complications was high. Over-correction, penile shortening, suture granuloma, penile bulging, hypoesthesia of glans and penile shaft and erectile dysfunction were some of the commonly reported complications by the Nesbit procedure. To minimize these surgical complications, modifications of the original Nesbit procedure have been proposed. These included incision instead of excision of tunica albuginea, intratunical suturing using absorbable suture materials and tunical shaving [8, 9, 12-16]. While these modifications are less morbid than the original Nesbit procedure, most of them are time-consuming and require considerable surgical experience as well as surgical intervention involving tunical incision, vein graft and/or plication. Corporeal plication is an alternative procedure for treating penile curvature, which was popularized by Essed and Schroeder [17] as well as Ebbekoj and Metz [8] as a valid treatment for Peyronie's disease. Although they did not require excision or incision of healthy tunica albuginea to shorten the longer side of the curved penis, they still required mobilization of the neurovascular bundles for ventral curvature. In 1998, Baskin and Lue described a method, which offers many advantages over the other procedures [7]. Their method avoided the dissection of neurovascular bundles and the urethra. The operative method we used in this study is similar to that of Baskin and Lue. To prevent suture breakage or cut through, we also placed multiple nonabsorbable multifilament inverted sutures in one or two pairs to distribute the total force required to straighten the penis.

The rate of excellent penile straightening (91 %) and preservation of erectile function (98.5 %) in our patients are in accordance with those of other published studies. For instance, Chien et al treated 22 patients with congenital penile curvature and 21 patients (95 %) had successful outcomes [10]. In a study by Thiounn et al, all patients (100 %) with congenital penile curvature treated using simple corporeal plication reported both satisfactory cosmetic and functional outcomes at a mean follow-up period of 18 months [18]. In our study, after a long-term follow-up period (mean 69.3 months), no recurrences of penile curvature were reported. However, there was 1 postoperative failure. This patient underwent the same surgical procedure again and had excellent results. The absence of recurrences of penile curvature demonstrates the durability of the procedure employed in our study.

Penile shortening was the major drawback of the plication procedure and occurred in 38 % of our patients.

However, none of them was concerned by this shortening and it did not affect their sexual activity, as has been reported previously [19]. Nonetheless, one patient in the study was unhappy with the shortened penis. Patients should, therefore, be advised of this drawback prior to surgery.

Diminished postoperative penile sensitivity due to irritation and/or damage of the dorsal neurovascular bundles can be avoided by careful attention not to damage the dorsal nerves. Temporary sensory disturbance of the penis was noticed in 3 patients and may be the result of tissue edema. Palpable suture induration has been noted by patients at the plication site in previous studies [7, 20]. Thirty-five patients in this study noticed palpable induration on the penis, but only one considered it to be bothersome, although it did not interfere with sexual intercourse.

Penile plication has not only a high surgical success rate both cosmetically and functionally, but also a high patient satisfaction rate (88 % very satisfied, 8 % satisfied). We propose that in carefully selected patients with congenital penile curvature, operative treatment by plication instead of other more invasive corrective surgery should be implemented.