Congenital curvature of the penis among children is more often associated with hypospadias, even if it is not rare to diagnose “chordee without hypospadias”. [19]
When fully erected, phallus may present mild lateral, dorsal or ventral curvature; the latter is the most common bent appreciated in hypospadic complexes. An impairing or painful sexual function consequent to bent penis may have different thresholds of onset, depending on the grade and on the orientation of the curvature [19]. Reports regarding sexually active adult men affected by congenital bent penis indicate that those requiring surgical correction generally have a flexion greater than 30°, up to 90° [20].
In the contrary, adolescents with penile curvature may address to surgery because of the body image dissatisfaction that curvature cause, rather than a proven sexual impairing [14]. So, it seems to be clear that each patient or parents may perceive the degree of curvature in different ways. At present, to the best of our knowledge, there is no study specifically dealing with the curvature relevance in patients’ life. [15]
According to an old survey performed by Bologna et al. [21] among pediatric urologists, it is reported that hypospadic patients required surgery for bent penis in 92% of cases if curvature was around 10°, in 25% when curvature was around 20°.
Several surgical techniques could be proposed on the basis of curvature severity degree, setting 30° as a threshold between low-grade and high-grade curvature [15].
The dorsal or lateral glandular tilting may be corrected simply dissecting skin bridging or sectioning the frenulum responsible for ventral curvature. If skin bridge results thick and broad, accurate hemostasis and skin suture may be required. [1]
Low degrees of penile torsion may hesitate also from penile skin tethering. This condition is identified after full artificial erection and adequate degloving maneuvers [1].
Dorsal plication surgical technique for bent penis was firstly described by Nesbit in 1965 [23]. This technique consists in a diamond-shape resection of dorsal lateral albuginea in correspondence of the
point of maximum curvature during full artificial erection, followed by a defect suture afterwar.
Recent studies witness high risk of nerve fibers section when surgical procedures involve the ventral penile surface between 11 and 1 o’clock positions [24, 25]. The safest area to avoid nerve fibers is the 12 o’clock position, which coincide with the surface where tunica albuginea has the greater thickness [24, 26].
Penile shortening [28], limited efficacy in severe curvature, and the poor efficacy in older patients (because of the great tension on stitches due to rigid erections) are the main potential disadvantages of Nesbit technique [27, 28].
In 1975, Devine and Horton gave their contribute to the corrective surgery of the association between chordee and hypo- or epispadias describing a technique that encompasses the use of a dermal tissue graft on the tunica albuginea [29]. Since that time, many others have reported similar success. [30–32].
Dermal grafts coincided in elliptical segments of non–hair bearing skin, from which only the dermis is taken and sutured to the tunica albuginea [31, 33]. Dermal grafts employment has been proven to allow superior cosmesis and avoid penile shortening [31]. Besides the inguinal skin, further materials have also been used, but with worse results and without a long-term follow-up. [1]
For more complex curvature, Perovic and Djordjevic [34], described penile disassembly, which consists in corpora cavernosa, distal corpus spongiosum and urethral plate separation, proceeding distally from the glans and elevating off neurovascular bundles in order to avoid injuries. Further developments were achieved performing a series of transverse dorsal plication sutures. To prevent penile shortening, no corporal bodies incision is performed [35, 36].
It was reported a frequency of bent penis range of 3–33% in patients after degloving during a hypospadias surgery. [22] In the 31% of these patients, a simple dorsal plication was sufficient to correct the curvature [15].
Concerning proximal hypospadias, after degloving and erection test, 5–10% of them results associated with a still high-graded curvature. Given the high probability of complications and reintervention, these conditions embody a big challenge to pediatric urologist. [15]
According to Weber et al. [23] observations, among 137 patients with severe hypospadias, degloving alone was enough to correct the curvature in 77% of mild cases, 30% of moderate, and only 2% of severe cases.
Our experience resulted so to be in total agreement with what literature reports. Even if reported casuistry can be considered to be small, it provides a witnessing of the feasibility and, above all, of the efficacy of simple degloving technique in order to accomplish a satisfactory straightening of the penis, in both hypospadic and not-hypospadic situations.
In our opinion, to treat a bent penis, it should be considered highly suggested to firstly perform the least invasive technique, always checking the curvature modifications through an artificial full erection. If tests reveal a remarkable bending, surgeons could address to more complex procedures, considering the contextual higher risk of technique-related complications and request of reintervention possibility.
Another consideration that the authors consider noteworthy to share with the reader concerns the indication to suggest surgery.
Self-consciousness, individual aspirations, and interpersonal relationships between same-aged people are just three of the several points to take into account when a patient came to physicians addressing anatomical diseases, particularly if that patient is coming through a difficult phase like adolescence.
Especially when dealing with genital dissatisfaction, teenagers may require surgical treatment even if the anatomical anomalies do not affect the organ specific functionality or if they do not reach levels of complexity that mandatorily require surgery. These conditions underline the importance of a multi-disciplinary where psychologists are included, for the purpose of evaluating the complete sphere of the subject and fully understand the reasons that led to the request for surgery.
On the opposite site, it is appropriate that Clinicians measure if suggest a surgical approach and, eventually, when to suggest it in front of a patients with a noticeable pathology that determine neither functional nor self-perspective problems. In our opinion, these cases request an accurate evaluation too, trying to avoid falling into those conditions referrable to as an over-treatment.