William Aiken

Deformity of the erect penis in adult men is not uncommon. This may have been present from birth (congenital) or may have developed after having had a normally-shaped penis (acquired).

Abnormal congenital curvature is almost invariably downward and is called chordee and may coexist with an abnormal location of the opening of the urethra which opens anywhere along the underside of the head (glans) or shaft of the penis and is known as hypospadias. This condition typically presents in infancy, is due to mal-development of the urethra or its surrounding chamber (corpus spongiosum) or skin on the undersurface of the penis.

Acquired abnormal curvature of the erect penis presents in adulthood, and when it arises spontaneously without any obvious prior trauma to the penis (for example, a fracture of the penis) is known as Peyronie's disease, named after Francois de la Peyronie, French surgeon to Louis XVI, who first described it.

Shapes and sizes

Before discussing Peyronie's disease, understand that the normal adult penis comes in a range of different shapes and sizes when erect. Some penises curve gently towards the floor, others point straight out, and some curve gently upwards, toward the abdomen when fully erect. These variations in shape of the erect penis are all considered normal and do not interfere with intercourse although certain coital positions may be favoured depending on the particular angle of the erection.

Recall that the penis is composed of three chambers of erectile tissue called corpora running through its length, with two on top and one underneath through which the urethra runs. These chambers expand and fill with trapped blood to produce an erection and are covered by a thick layer made of fibrous and elastic tissue called the tunica albuginea.

Angular deformity of the erect penis develops when there is a focal area of scarring of the tunica albuginea resulting in tethering of one of the chambers, thereby, preventing it from maximally expanding. This scar exerts a pulling force toward it and causes the erect penis to curve towards it as it becomes erect. For example, a focal area of scarring on the right side of the right erectile chamber would cause the erect penis to bend acutely toward the right. This abnormal scarring is thought to be due to an excessive response to microtrauma to the penis in some men, resulting from sexual intercourse.

Pain on erection

Early in the course of Peyronie's disease, the man may present with pain on erection, hard nodules of scar tissue felt under the skin of the penis called 'plaques' and angular erectile deformity. Later, when the scar has 'matured' (no longer evolving), there is no pain on erection but an angular deformity of the penis is present, plaques may be felt and sometimes erectile dysfunction co-exists. Rarely, Peyronie's disease may be the penile manifestation of a systemic disease called Dupuytren's contracture.

Pain relief

In the early phase of the disease, anti-inflammatory/analgesic medication is prescribed to limit pain and inflammation. A special drug called Potaba (potassium amino benzoate) is sometimes used empirically. Other approaches to treatment in the early phase include calcium channel blocking drugs, steroid injections, use of a drug called colchicine, and focused high energy sound waves directed at the plaques.

Treatment in the late phase is indicated if the deformity prevents intercourse or makes it difficult or uncomfortable. If the deformity is unacceptable to the patient or erectile dysfunction exists, surgical treatment should be considered. Surgical treatment involves placing 'gathering' stitches (plicating - essentially tethering) on the side opposite to the scar to straighten the penis.

This simple technique results in some degree of shortening of the penis and is unsuitable for men with a short penis. The alternative technique is more technically demanding and involves removing the plaque and placing a vein patch obtained from the leg over the site. If erectile dysfunction is unresponsive to oral agents or injections, an inflatable penile prosthesis may be surgically implanted that results in high rates of patient satisfaction.

Dr. William Aiken is the head of Urology at the University Hospital of the West Indies and president of the Jamaica Urological Society; email: yourhealth@gleanerjm.com.