Penile Torsion

Penile torsion is rotation of the penile shaft along its long axis, so the median raphe spirals and the meatus is deviated from the midline. In about 80% the rotation is counterclockwise (to the left).

It affects about 1 to 2% of newborn boys, and is often discovered at circumcision. It is classified by the angle of rotation: mild under 60 degrees, moderate 60 to 90 degrees, and severe over 90 degrees.

Pathophysiology. The cause is asymmetric attachment of penile skin and dartos to the shaft, and in some cases corporal asymmetry. The rotation can also occur with hypospadias, chordee and webbed or buried penis.

Torsion can be iatrogenic, from asymmetric skin removal at circumcision.

Rotation of the shaft and glans, usually to the left, with the raphe spiralling. The urinary stream may deviate, and in severe torsion the penis may rotate on erection, causing cosmetic concern and rarely difficulty with intercourse. Most boys are asymptomatic.

• Examination with the penis relaxed and gently straightened, noting the direction and degree of rotation of the raphe and meatus relative to the midline. Measure with the penis at rest, and again on traction.
• Examination for hypospadias, chordee, webbing, buried penis and testes.
• Artificial erection at surgery to check rotation and curvature.
• Imaging is not needed.

Differential diagnosis.

• Chordee
• Hypospadias with associated torsion
• Webbed penis
• Buried penis
• Congenital penile curvature
• Post-circumcision rotation

• Mild torsion (under 60 degrees): observation and reassurance, with no surgery needed. Some improve with growth.
• Moderate to severe torsion, or functional or cosmetic concern: surgery from 6 to 12 months of age, or at circumcision.
  • Degloving of the penile skin and release of dartos attachments, which corrects most moderate torsion.
  • Residual rotation: dartos fixation sutures (5/0 absorbable) to rotate the shaft to the midline, or dorsal dartos plication.
  • Rare severe cases: fixation of the Buck fascia or tunica albuginea.
• 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 daily), with ibuprofen 5 to 10 mg/kg every 6 to 8 hours (maximum 30 mg/kg daily) from 3 months of age.
• Counsel parents before circumcision about the torsion, since circumcision alone does not correct it, and an asymmetric skin cuff can worsen it.
• Complications: bleeding, infection, recurrent rotation (about 5 to 10%), wound breakdown and altered sensation.

Monitoring. Wound review at 2 weeks, then at 3 months and at 12 months, with reassessment at puberty.

Referral and escalation. Refer to paediatric urology for moderate or severe torsion, associated curvature or hypospadias. Urgent referral is rarely needed.