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Penile curvature – A frequent tormenting problem

Χωρίς κατηγορία 2943

With the term curvature of the penis we mean the “bending” that may possibly exist on the body of the penis from birth, and in this case it is called congenital curvature, or the one that occurs later in the adulthood, and in this case is called acquired curvature. The curvature can exist in any direction upwards, downwards, to the left or to the right. Usually combinations of the aforementioned curvatures may exist. The curvature can also regard the front half or the rear half of the body of the penis. Finally, the curvature can be small or big, and in this case it can reach or even exceed 90 degrees, making the vaginal penetration difficult or impossible. More rarely, there can be a ring like stenosis somewhere on the body of the penis, and in this case the erect penis has the form of a sandglass.


 

P37aThe congenital curvature can be due to fibrous chords that are located under the skin of the body of the penis. This condition can present alone or usually may accompany a lower position of the urethral meatus on the glance or on the body of the penis. This situation is called hypospadias. More rarely, there can be a disproportion of the length of the corpora cavernosa, which are the basic erectile units of the penis. In this case the penis bends towards the shortest corpus cavernosum. The acquired curvature is due to thickening and hardening of a part of the fibrous sheath, which covers externally the corpora cavernosa, resulting to the formation of a hard fibrous plaque, of a different size in each case, which can easily be palpated. This condition is called Peyronie’s disease, from the name of the French doctor who discovered it and the plaque is called Peyronie’s plaque. This disease has an unknown cause. Sometimes an over bending injury with or without fracture of the erected penis during sex is mentioned, but mostly the medical history is clean. This condition is not  cancer.

 

The hard plaque pulls back during erection and does not allow the proper dilatation and stretching of the corpora cavernosa consequently leading in bending and angulation of the penis. The extent of the curvature depends on the size and the position of the plaque. The Peyronie’s plaque in its initial appearance can be accompanied by  painful erection, which is an indication of inflammation in the acute phase of the disease. Over time the pain goes away and only the curvature remains. The acute phase of the disease, which is characterised by the appearance and augmentation of the plaque, can last up to 6 months. After this period the plaque and consequently the curvature are usually stabilized. In 10% of the cases the plaque may resolve and the penis may become straight again without treatment.

Penile curvatures often causes severe psychological problems, and sometimes in cases of curvatures bigger than 30 degrees functional problems during vaginal penetration may appear. In these cases patients have to straighten their penis by holding it to achieve penetration and they also have to avoid specific positions during sex . Pain during sexual contact can become a serious problem. Finally, this condition may cause erectile dysfunction due to psychological and anatomical reasons, especially if other reasons  such as diabetes, atherosclerosis, use of sedatives and antihypertensives drugs or neurological diseases, preexist.

The diagnosis is easily accomplished by the medical history and the palpation of the plaque, and the penile ultrasound can verify possible calcification of the plaque. In cases of  Peyronie’s disease with erectile dysfunction, a control of the blood supply of the penis  by color Doppler could be performed to exclude dysfunction of the venoocclusive mechanism.

Various medications have been tried for conservative treatment of Peyronie’s disease, such as oral administration of vitamin E, paraminobenzoic acid (Potaba), colchicine and tamoxifen and  injections of collagenase, corticosteroids and interferon in the fibrous plaque. Recently Xiaflex injections in the plaque given promissing results. The oral pharmaceutical treatment is usually not effective. However, since the surgical repair of the curvature is recomended after the resolution of the acute phase and the stabilization of the curvature, which usually takes at least six months after its appearance, the patient may try some medical treatment during this waiting period. Recently a combination of tadalafil 5mg once a day for six months with daily use of a penile strecher device have presented promissing results in penile straightening.


 

The most effective treatment for the repair of the curvature of the penis is surgery. There are three categories of surgical techniques to straight te penis. The selection of the method depends on anatomical parameters, that is the length of the erected penis and the degree of the curvature, the  presence and the severity of a possible preexisting erectile dysfunction, the patient’s desire and the doctor’s experience.

 

Η τοποθέτηση ραμμάτων από την αντίθετη πλευρά της κάμψης προκαλεί μια αντίθετη κάμψη, που αντιρροπίζει την ήδη υπάρχουσα με αποτέλεσμα τον ευθειασμό του πέουςThe first category includes the techniques of shrinking of the corpora cavernosa in the oposite site of the curvature by sutures, with or without removal of “windows” of the fibrous sheath of the corpora (tunica albuguinea). This creates actually an opposite curvature, which counterbalances the existing curvature and thus the penis is straightened. The surgeon controls the repair of the curvature during the operation by causing artificial erections and may put more sutures until the desired result is achieved. These techniques are effective, easy, fast, can be performed with spinal anesthesia and the duration of hospitalization is one day. They do not affect adversely the erections  and also do not present serious complications. The patient can fully return to his activities after two or three days. He can have a sexual contact after a month. Many patients afraid, that with these techniques  may have an additional loss of length of their penis, due to the shrinkage. However, this is not really the case, because the lost length is due to the curvature that was caused by their disease and not by the straightening operation.

 

P39aThe second category include techniques of complete removal or cutting out the Peyronie’s plaque and closing of the created gap of the fibrous sheath (tunica albuguinea) by an implant. Cutting out the plaque usually in the shape of an a H results to loosening of the corpora cavernosa during erection and consequently to straightening of the penis. This tecnique is easier than complete removal of the Peyronie’s plaque, with the same good results and fewer complications. Various implants are used to cover the gap of the tunica. The problems with these implants, whether they become from the patient himself (autologous), like skin or venous implants collected from the legs, or from animals, like the bovine pericardium (heterologus), or are synthetic, are related with the significant prolonging of the operation, significantly higher cost and with the intervention of the surgeon andrologist on tissues he is not familiar with. A pioneering technique, that I have applied, is the coverage of the gap, after cutting out the plaque, by a free graft  from the patient’s prepuce. The preputial graft is cheap, easy and fast to be collected, familiar to the urologist and without the disadvantages of the skin grafts like shrinkage and “ballon” formation on the graft site resulting to dysmorphia of the penis. The main advantage of  these techniques is, that the penis is “unshrinking” during straightening, getting back its initial length. However, these operations are prolonged, expensive, relatively difficult, they require general anesthesia and hospitalization of three to four days. A circumcision is always performed. The sexual contact is allowed after one to two months. Complications, which may sometimes occur, include reduction of sensory of the glans and the appearance or deterioration of a preexisting erectile dysfunction. For these reasons, these operations are proposed only to patients with relative short penis, and/or big curvature more than 90 degrees or with a sandglass deformity of their penis. The use of a stretching device after the full healing can aid the full recovery of the length of the penis.

 

Η τοποθέτηση για 3-6 ώρες την ημέρα για 3-6 μήνες μιας ελκτικής συσκευής μετεγχειρητικά βοηθά στην αποκατάσταση του αρχικού μήκους του πέους σε περιπτώσεις σοβαρής κάμψηςFinally the third category of techniques are used in cases whith coexisting of severe erectile dysfunction and curvature. In these cases the placement of a penile prostheses with or without the application of appropriate mechanical handling of the plaque (modeling) during the implantation of the prostheses, repair both conditions with excellent results. There are no further problems regarding the function of the prostheses, due to the preexisting curvature, although sometimes the intense fibrosis, due to Peyronie’s disease, may makes the implantation difficult. However, in the hands of an experienced surgeon the results are always excellent.