Causes of a bent penis
Since the erection bodies of the penis stretch to a pre-defined length during erection, a shortening of one side will result in a bend to that side (This can be demonstrated by taping a piece of sellotape onto the side of a long balloon ).
In Peyronie’s disease the top surface of the penis is usually affected, but both Peyronie’s disease and congenital curvature can cause the penis to bend in any direction. Generally speaking, a gentle bend of up to 25 degrees will often not cause too many problems, and indeed most men do have a penis which bends a little bit. If there is a sharp angulation however the problem may be more troublesome with only a minor degree of bend as seen from above.
In the early stages of Peyronie’s disease pain is often a problem, due to an active inflammation in the affected area.
We do not know what causes Peyronie’s disease, but in some men it can be associated with other scar-like conditions (e.g. Dupuytren’s contracture of the hand). Most frequently however there is no obvious cause and the current thinking is that in many men an injury to the penis when erect (which may pass unnoticed) causes an exaggerated inflammatory response in the tunica albuginea.
Initial treatment in the painful phase of the disease is controversial, with few properly conducted studies showing a benefit of one treatment over simple rest. There appears to be a place for anti-oxidant vitamin therapy and I usually advise a three month initial course of high dose anti-oxidants which may help by reducing free radicals in the developing scar tissue. Intercourse should be avoided if pain is a major feature, and if a man continues to have sex then extra lubrication is helpful to reduce the risk of further stressing the erection.
If pain persists despite the above I usually prescribe the anti-hormone drug Tamoxifen in conjunction with a course of anti-inflammatory medicine. Occasionally pain will persist long term and in this case it may be appropriate to consider removal of the painful are, but this is rare and complete resolution of the pain is the rule.
A non-invasive option is the use of shock wave therapy to the penis: while this is not yet proven it may help some men.
Once the bend has stabilised an assessment if the degree of bend and its exact location is made using an artificial erection in the clinic. This would be explained to you at the time.
The commonest and simplest operation is a procedure called the Nesbit’s operation. This involves reducing the length of the normal side of the penis to straighten it. In patients with Peyronie’s disease I usually use a modification of this technique which reduces the risk of creating an "hour glass" appearance.
While this procedure leaves the affected area in place it is much less complex than the alternatives and few men find they are bothered by the residual scar tissue if the penis is straight in erection.
Nearly always the procedure can be done under local anaesthesia with only minor discomfort at the time of the operation, although if patients prefer a general anaesthetic this can be arranged without any trouble. It may be necessary to carry out a circumcision at the time of the operation or it may be possible simply to make a small cut over the area to be shortened: this would be discussed at the time. After the operation you will probably need a few days off work depending on what you do and the penis may look bruised for a few weeks. Pain is not usually a major problem and most men can go home on the day of the operation with simple painkillers, but men often complain of waking at night with pain in the penis. This is almost certainly due to the natural process of night-time erections and this is beneficial for the penis since it allows the penis to stretch and fill with blood as it should. To reduce this however I usually recommend an anti-inflammatory suppository to be taken at night for the first five days.
Obviously any operation on the penis has some risk, and as in any operation infection and bleeding can rarely occur. If treated this is unlikely to have any long term problems, but in rare cases long term damage may lead to impotence. After a Nesbit’s procedure the penis will be one to three centimetres shorter than originally. In some cases the Peyronie’s disease may recur, leading to further bending in the penis: this is why surgery should not be undertaken until the problem has stabilised. Very rarely, particularly if the penis is bent downwards, the nerve supply to the head of the penis may be damaged, leading to numbness.
If there is a major bend, a persistent painful plaque, or the penis is short, a Nesbit’s procedure may not give a good result. It may then be necessary to consider removing the plaque and putting in a replacement tissue. In this situation I use a modification of the technique of Professor Austoni of Milan, Italy. Here a piece of skin is removed from the thigh or abdomen and, after preparation (creating a deep dermal graft), sewn into the defect left by the removal of the Peyronie’s disease. General anaesthesia is needed and usually patients stay in hospital for several nights. This is much more major procedure than a Nesbit’s procedure and in my hands is reserved for men who would simply be left with a small non-functional penis following a more simple operation.
The risks specific to this operation are of nerve damage to the head of the penis when removing the plaque, and contracture of the graft with recurrent angulation. These would be discussed in detail prior to any surgery. Post operatively I recommend using a vacuum pump to create regular artificial erections with the aim of reducing any scar formation within the penis.
If Peyronie’s disease occurs in association with a weak erection there will need to be considerable discussion as to the best option, which may involve either one of the above procedures in conjunction with medical therapy following the operation. Another option is the possibility of using a penile prosthesis to treat both the bend and the weak erection in the same procedure.
Copyright (c) 1999-2001 GH Muir. All rights reserved.