Congenital Penile Curvature

Congenital penile curvature is curvature of the erect penis, ventral, lateral or dorsal, without hypospadias or a urethral abnormality. It is also called chordee without hypospadias.

The incidence is under 1% of males, and lateral curvature to the left is the most frequent form.

It usually comes to attention in adolescence or young adulthood, when erections are noticed. It must be separated from Peyronie disease, which is acquired.

Pathophysiology. The cause is asymmetric development of the corpora cavernosa and tunica albuginea, so one side of the shaft is shorter and the erect penis bends toward it. The urethra and spongiosum are normal.

The condition is stable. There is no scar plaque, and the curvature does not progress.

Curvature present from the first erections, with no pain, trauma or palpable plaque. The degree stays unchanged. Complaints: difficulty or inability to have intercourse, partner discomfort, appearance and distress. Erectile function is normally intact. Mild curvature under 30 degrees seldom interferes with intercourse.

• History: onset with puberty, stability, absence of pain, trauma, injury or a plaque.
• Examination of the flaccid penis for plaques, nodules and urethral position, and measurement of stretched length.
• Patient photographs of the erect penis, or a clinic intracavernosal injection test with alprostadil 10 micrograms, repeated to 20 micrograms if the erection is incomplete, and measurement of the angle with a goniometer. Counsel about priapism, and any erection lasting over 4 hours needs emergency care.
• Penile duplex ultrasound for plaques and vascular function when erectile dysfunction is also present.
• Grade curvature as mild (under 30 degrees), moderate (30 to 60 degrees) or severe (over 60 degrees).
• Psychosexual assessment.

Differential diagnosis.

• Peyronie disease
• Chordee with hypospadias
• Penile torsion
• Post-traumatic curvature or penile fracture sequela
• Erectile dysfunction with a partial erection
• Buried or webbed penis

• Mild curvature (under 30 degrees) that does not interfere with intercourse: reassurance and no treatment.
• Surgery is the only effective treatment, offered when curvature prevents or severely limits intercourse, after stable curvature in an adult or older adolescent.
  • Tunical plication on the convex (longer) side: 16-dot or Yachia plication, with non-absorbable or slowly absorbable sutures, or the Nesbit procedure with excision of an ellipse of tunica albuginea. Success is about 85 to 95%.
  • Severe curvature, or a short penis: plaque free tunical lengthening with a graft, which is rarely needed.
• Perioperative cefazolin 2 g intravenously (3 g if over 120 kg) as a single dose.
• Patients are counselled that there is some penile shortening, risk of numbness of the glans, persistent or recurrent curvature, palpable suture knots, and a small risk of erectile dysfunction. Intercourse is avoided for 4 to 6 weeks.
• Penile traction devices, injection treatments such as collagenase, and oral drugs are not effective for congenital curvature.

Monitoring. Review at 2 weeks and 6 weeks, then at 3 months, assessing curvature, sensation, penile length and erectile function.

Referral and escalation. Refer to urology, with psychosexual support when distress is marked. Urgent referral is rarely needed, except for priapism after a diagnostic injection.