Chordee

Chordee is ventral curvature of the penis, noticed on erection, caused by tethering or disproportion of ventral tissue. It is found with hypospadias in most cases, and rarely as an isolated anomaly with a normally placed meatus.

Hypospadias occurs in about 1 in 200 to 300 male births. Curvature accompanies more proximal forms, and is usually under 30 degrees in distal hypospadias.

Pathophysiology. Mechanisms:

• Skin and dartos tethering, which release on degloving.
• Dysplastic urethral plate, spongiosum and Buck fascia pulling the glans ventrally.
• Corporal disproportion, with the ventral tunica albuginea shorter than the dorsal.

Severity on artificial erection: mild under 30 degrees, moderate 30 to 60 degrees, severe over 60 degrees.

Ventral bowing of the shaft on erection or traction, a ventral or incomplete foreskin (dorsal hood), and a ventral meatus in hypospadias. Small boys are seen at neonatal examination, with later concerns in adolescence about erection, intercourse and appearance. Check testes and the other genital anatomy.

• Clinical examination of the penis at rest and with traction, with photographs when available.
• Artificial erection at surgery: saline injected into the corpora with a tourniquet at the base, to measure the angle before and after each corrective step.
• Examination of meatal position, urethral plate and foreskin. Examine the testes and inguinal region.
• Disorders of sex development testing (karyotype, hormone profile, pelvic ultrasound) for proximal hypospadias with undescended testes or ambiguous genitalia.
• Uroflowmetry and ultrasound in adults, with assessment for Peyronie disease.

Differential diagnosis.

• Penile torsion
• Webbed or buried penis
• Congenital penile curvature (lateral or dorsal)
• Peyronie disease in adults
• Disorders of sex development
• Post-surgical fibrosis

• Curvature under 20 to 30 degrees without symptoms in infants: observation, since mild curvature rarely needs correction.
• Surgery at 6 to 18 months of age, performed under general anaesthesia with a caudal block. Steps are taken in order until the penis is straight on artificial erection:
  • Degloving of the penile skin and release of the dartos, which corrects many cases.
  • Excision of fibrous tissue on the urethral plate or ventral shaft.
  • Dorsal tunical plication (Nesbit procedure) for residual curvature up to about 30 to 45 degrees.
  • Division of the urethral plate with urethral reconstruction, or ventral corporal lengthening with a graft, for severe curvature over 45 to 60 degrees.
• Perioperative cefazolin 25 to 30 mg/kg intravenously (maximum 2 g) as a single dose.
• Analgesia: paracetamol 15 mg/kg orally every 6 hours (maximum 60 mg/kg daily and 4 g), with ibuprofen 5 to 10 mg/kg orally every 6 to 8 hours (maximum 30 mg/kg daily) from 3 months of age.
• Adults with persistent curvature: tunical plication, with counselling about shortening and numbness.
• Complications: bleeding, infection, fistula, meatal stenosis, recurrent curvature (about 5 to 10%), penile shortening, reduced sensation, and erectile disturbance in adults.

Monitoring. Review at 2 weeks, 3 months, 6 months and 12 months, then at puberty for recurrence of curvature and voiding.

Referral and escalation. Refer to paediatric urology. Urgent referral for suspected disorders of sex development or severe proximal hypospadias with ambiguous genitalia.