Congenital Penile Curvature (Chordee)

OVERVIEW:

Congenital penile curvature, or chordee, is defined as a congenital process which can be associated with hypospadias and is manifest by a curvature of the erect penis. This can be noted in the infant child, but may not be noted until the man becomes sexually mature and when he recognizes that there is a deformity of the penis in the erect state.

When young men present to the doctor for evaluation they are usually found to have long, elastic penises with ventral or downward curvature but dorsal/upward or lateral curvature may occur as well. Typically there is no palpable scar, no pain, no traumatic event that preceded the deformity, and rarely any associated indentation, shortening of the shaft, or other deformities of the penis. In the children who also have hypospadias and chordee this is typically associated with a ventral curve.

CAUSES:

The cause of chordee remains unknown, but it does appear that there is excessive elasticity on one aspect of the penis vs. the rest of the penis. So for example, in the man who has a ventral/downward curvature, there is more elasticity on the dorsal/top surface of the penis which expands more than the underside during erection, resulting in the downward curvature. This is different than the curvature associated with Peyronie’s disease, which may follow trauma during sexual activity, and is therefore an acquired scar of the tunica albuginea causing curvature, shortening, and indentation of the erect penis. Typically for the man with chordee there is no pain with erection, but there can be discomfort with intercourse because of the deformity for both patient and partner.

DIAGNOSTIC TESTS:

Evaluation of the man with chordee typically starts with a physical examination. The stretched length of the flaccid penis should be measured. Penile sensation can be assessed with biothesiometry, a test of vibration sensation, and if curvature needs to be assessed before initiating treatment, then a penile duplex ultrasound is performed, during which time an erection is induced by an injection of a vasodilating agent. This is typically done with a tiny, painless needle and the curvature then can be measured accurately with a goniometer or protractor.

TREATMENT:

Treatment is surgical. To date no non-surgical treatment including oral medications, injections or topical therapy have been used to correct congenital curvature/chordee. External penile traction therapy has been used successfully with some success for Peyronie’s disease to correct not only curvature, but may recover some lost length and improve indentation. This has not been tested yet in the congenital curvature/chordee population and it would seem intuitive that this technique would likely not work, as the tissues are not restricted by scar upon which the traction forces would be working as in the Peyronie’s patient.

A variety of surgical procedures have been used, but all essentially work on the principle of shortening the convex side to equal the concave aspect. The initial maneuvers are similar, usually by making a degloving circumferential incision proximal to the head of the penis. Historically a formal circumcision was performed in those men who were uncircumcised, but recent evidence indicates that if there is no evidence of foreskin scarring or other irregularities of the foreskin then circumcision is not necessary. Once the phallus is degloved, an artificial erection is created to identify the deformity, and then Buck’s Fascia is elevated over the opposite side of the curve to expose the tunic of the penis. A variety of plication or tucking procedures can be performed.

1. Historically the first corrective operation is known as the Nesbit procedure that was developed in the 1960’s and remains popular today. In this procedure a portion of the tunica albuginea is excised so as to shorten the convex side.
2. The Yachia procedure is performed by making a full thickness vertical incision on the area opposite to the curvature, and then it is closed transversely, thereby shortening the convex side. This procedure may worsen underlying shaft narrowing and therefore tends to be less desirable in the Peyronie’s patient than in the chordee patient.
3. The Essed-Schroeder procedure is performed without incisions but instead shortens the convex side by applying sutures to “reef up,” or tuck, the tissue.
4. A more recent form of non-incision plication is the so-called “16 dot procedure” which uses permanent suture to reef or tuck the tissue. This procedure can be done under local anesthesia and has a high rate of success, but significant shaft shortening has been noted. It also completely relies on permanent sutures for initial healing which can result in failure as well as more palpable knots which may disturb some men.
5. The tunica albuginea plication (TAP) procedure is also used. This procedure was initially developed to correct pediatric chordee. Here a pair of partial transverse incisions through the superficial layer of the tunic is made. The tissues between two parallel incisions are brought together so as to shorten the convex side. This procedure can be performed with permanent or with absorbable sutures.

All of these procedures have a low risk of penile shortening, chronic postoperative pain, infection, bleeding, change in penile sensation, and erectile dysfunction. Clearly the primary advantage is that it can be done quickly, as an outpatient, with minimal blood loss and a high rate of penile straightening with a low rate of new erectile dysfunction.

The postoperative concern for loss of penile length following surgical straightening has gained a good deal of attention. A previously published study looking at the TAP procedure demonstrated that two factors predict the potential loss of functional shaft length. One is the direction of curvature. Men with ventral (downward) curvature will tend to have more loss of length than those with lateral or dorsal (upward) curvature. The second is degree of curvature. Men with greater than 60 degrees of curvature in any direction are apt to lose more length compared to those with less severe curves. Therefore preoperative counseling regarding loss of penile length is necessary prior to surgery. It should be remembered that this patient population tends to have longer, more elastic penises and therefore length loss tends to be less of a concern as compared to the Peyronie’s population.

Postoperatively external penile traction therapy may be offered to those men with chordee who are concerned about post-surgical loss of length. It also does appear to help the penis heal in the desired straight configuration much like a splint. Traction is typically recommended to begin 2-3 weeks after surgery when the wound is adequately healed and then daily application of the device is recommended for 4-6 hours for 3 months.