Congenital isolated penile torsion in adults: untwist with plication

Severe penile torsion of 180 degrees in an adult patient: a uro-radiological case report

Penile torsion is the abnormal three-dimensional twisting of penile corporal bodies. It can be classified as mild, moderate, or severe, depending on the degree of torsion. Severe penile torsion (>90°) is a very rare condition, with an estimated incidence of 0.4%-1% among all penile torsion cases. Our patient was a 37-year-old man complaining of a 2-year history of lower urinary tract symptoms. These symptoms appeared after the patient sustained an iatrogenic injury during Foley catheter insertion. Physical examination incidentally revealed an obvious counterclockwise penile rotation of 180°. Several theories have been proposed to explain the etiology of penile torsion, including theories based on genetic factors, abnormal urethral development, and abnormal attachment of the dartos fascia to the skin. Penile torsion may be associated with other penile anomalies, including chordee, hypospadias, and epispadias; however, it is often detected as an isolated finding. Clinical examination is sufficient to confirm its diagnosis without the need for further imaging. While no standardized procedure has been indicated for all penile torsion cases, the severity of torsion and the presence of other anomalies determine the most suitable procedure. No reports on the imaging features of penile torsion (irrespective of the degree of torsion) are available. We present the first such report on the imaging features, including advanced magnetic resonance imaging findings, of a 180° penile torsion in an adult patient.

Using two “V” shaped flaps in penile torsion treatment

Introduction:

Penile torsion is a congenital malformation that causes a rotational deformity of the penile shaft. Several techniques have been considered for penile torsion repair. In this study, we described our experience using two separate “V” dartos flaps, which leads to a more satisfying result.

Patient and methods:

Two young men with severe penile torsion aged 24 and 28 years old were candidates for surgery. During our novel method for penile torsion repair, we degloved the penis and dissected the dartos fascia from the penis shaft, then cut it distally from the sub-coronal region with a longitudinal cut to make two dartos flaps in a “V” shape. With these two flaps, we corrected penile torsion in a more satisfying way without crossing the urethra.

Results:

Penile torsion and concurrent chordee were completely corrected after surgery. Urine culture was sterile and uroflowmetry indicated a maximal urinary flow of 12 ml/s 3 months after the operation. Both patients were satisfied with ejaculation and their follow-up indicated complete resolution of penile torsion.

Conclusions:

Penile torsion is a challenging congenital anomaly. We used a two “V” shaped flap passage method to complete penile rotation and chordee correction without performing any plication techniques. Our penile torsion correction procedure resulted in the successful repair of torsion and excellent outcomes.

Level of evidence:

Not applicable for this multicenter audit.

Penile Degloving and Dorsal Dartos Flap Rotation Surgery in the Management of Severe Isolated Penile Torsion in a 6-Year-Old Boy

Penile torsion is a rare congenital anomaly that is usually characterized by a counterclockwise rotation of the penile shaft or glans. Although several surgical techniques for its correction have been proposed, the consensus of choosing the most efficient technique remains controversial. Herein, we report our operational approach that successfully corrected a severe (>90 degrees) isolated penile torsion in the form of penile degloving and dorsal dartos flap rotation surgery.

180° congenital penile torsion with distal hypospadias mistaken for an epispadias: Optimal outcome with tubularized incised plate urethroplasty and dartos flap rotation

INTRODUCTION

Severe penile torsion of 180° associated with hypospadias is a rare entity. Knowledge of penile anatomy and pathology are necessary as the diagnosis could be missed.

CASE PRESENTATION

We report a case of severe 180° penile torsion with distal hypospadias that was mistaken for an epispadias which was corrected with surgery.

CONCLUSION

Tubularized incised plate urethroplasty and dartos flap rotation provided satisfactory result for this association.

Procedures used for correction of isolated penile torsion: are they competitive or complementary?

OBJECTIVES

To report our experience in starting the correction of penile torsion, whatever its degree (moderate or severe) with one or more simple procedures either separately or complementary in the same session.

PATIENTS AND METHODS

Between 2013 and 2018, 62 patients who have significant isolated penile torsion (> 45°) were involved in this study. Those patients were subjected to either simple degloving with skin reposition, degloving with skin overcorrection and/or dartos flap procedures. Those procedures were performed either separately or complementarily. All patients were examined postoperatively after 7 days and followed up at 3, 6, and 9 months postoperatively.

RESULTS

37 out of 62 patients had a moderate degree (45-90) of penile torsion; 21 of them were corrected using skin degloving-reattachment technique, 11 patients were corrected by degloving with skin overcorrection, and in the remaining 4 patients dartos flap technique was used for correction. In 25/62 patients who had severe degree (> 90°) of torsion; 9 patients were managed by degloving with skin overcorrection, while in 13 patients the procedure was shifted to dartos flap technique, and the remaining 3 patients, 2 of whom had 180° torsion, were managed by dartos flap with added skin overcorrection.

CONCLUSION

Performing degloving and skin reattachment with or without skin overcorrection procedure and dartos flap procedure either separately or complementarily in the same patient whatever the degree of torsion (moderate or severe) is associated with good results and can protect some patients from exposure to more difficult and extensive procedures as corporopexy and corporeal plication.

The incidence of isolated penile torsion in North India: A study of 5,018 male neonates

OBJECTIVE

Congenital penile torsion is a three-dimensional deformity with helical rotation of the distal corporal bodies with the penile crurae remaining fixed to the pubic rami. The first case of congenital penile torsion (hypospadias) was described in 1857. Isolated penile torsion is an under-reported anomaly. The reported incidence of isolated penile torsion is 1.7-27% and severe torsion is 0.7%. There are no studies available from Indian subcontinent on the incidence of isolated penile torque. The objective of this study was to determine the overall incidence of isolated penile torque in a north Indian population.

MATERIALS AND METHODS

A prospective study of deliveries of male children was conducted at our institute between April 2014 and June 2015. Penile torsion was measured using a small protractor either by the deviation of the median raphae or the direction of the meatus. Data were collected on the incidence of congenital isolated penile torsion, including the degree and direction (left or right) of torsion. Torsion was classified as mild (<450), moderate (450-900), and severe (>900). Statistical analysis was done using the chi-square test with variables of age and parity of the mother and weight of the child.

RESULTS

There were 99 cases of isolated penile torque among 5018 male neonates assessed for penile torque. The incidence of isolated penile torque was 19.7 per 1000 births. The degree of torsion varied from 30 to 110° (average 51.46°). Seventy-nine percent (79%) of them had left side and 21% had right side torque (4:1). The degree of torsion was mild in 30%, with 20% having left side torque and 10% having right side torque (2:1). A moderate degree of torsion was seen in 69%: 84% of them had left torque and only 16% had right sided torque (5:1). Only one patient had severe left torque. The incidence of isolated congenital penile torsion was highest in the maternal age group of >30 years followed by the 26-30-year age group, and was lowest in 21-25 year age group. In multiparous women, the incidence of isolated congenital penile torsion was highest (2.54%), and it was lowest in primiparous women (1.36%).

CONCLUSION

The incidence of isolated penile torsion was 1.97% and the left-to-right ratio was 3:1, but for moderate torque it was 5:1. There was a strong association between incidence of penile torque with the age of the mother (p = 0.012) and parity (p = 0.008) but not with the weight of the baby (p = 0.415).

Penile degloving and dorsal dartos flap rotation approach for the management of isolated penile torsion

OBJECTIVE

Penile torsion is a counterclockwise rotational anomaly of the penile shaft or glans. We aimed to evaluate the outcomes of penile degloving and dorsal dartos flap rotation used for the repair of isolated penil torsion.

MATERIAL AND METHODS

During evaluation of the patients admitted to our polyclinic for circumcision between January 2013-December 2014, 5 cases of isolated penile torsion were determined. Following the circumcision procedure performed with bipolar cautery, patients undergoing penile degloving were checked whether penile torsion was relieved or not. In case of insufficient improvement, torsion was corrected with application of dorsal dartos flap. Penile torsion was corrected with dartos flap in 2, and penile degloving in 3 cases.

RESULTS

The mean age of the patients was 5.6 years (4-7), and the mean operative time 12 minutes (7-20), respectively. The mean operation time was 17.5 (15-20) minutes and 8.3 (7-10) minutes in the dorsal dartos flap and penile degloving groups, respectively. The preoperative mean degree of penile torsion was 50° (30°-70°). The mean degree of torsion was 65° and 40° in the dorsal dartos and penile degloving groups, respectively. During the postoperative follow up, 1 case of residual torsion (<10°) was observed in the dorsal dartos flap group. Residual torsion was not observed in other patients.

CONCLUSION

Exploration for isolated cases of penile torsion during the circumcision procedure should not be overlooked. Successful results can be obtained with penile degloving and dartos flap rotation in cases with low and moderate torsion.

Penile torsion repair in children following a ladder step: simpler steps are usually sufficient

OBJECTIVE

To evaluate the correction of different degrees of penile torsion following a ladder step so that simpler steps are used whenever possible. This can avoid the morbidity and complications of complex procedures.

PATIENTS AND METHODS

Cases of congenital and acquired penile torsion were repaired on a ladder step basis irrespective of the degree of torsion, starting with degloving and skin realignment, then a dorsal dartos flap and finally corporopexy. The torsion is checked with artificial erection after each step, and if corrected completely then the next step(s) is omitted.

RESULTS

Twenty-five cases of penile torsion (30-180°) were repaired over a 4-year period. Three cases were corrected by degloving only, 12 by degloving and skin realignment, five by a dartos flap and four required a corporopexy. Postoperative complications included five cases of penile edema, one case of hematoma and one case of dorsal skin gangrene. Residual torsion of <15° occurred in three cases. No cases required redo surgery.

CONCLUSION

A ladder step approach is a good option for penile torsion repair, starting with simpler techniques until complete correction is achieved. There is no need to plan a complex procedure in advance.

Correction of penile torsion and chordee by mobilization of urethra with spongiosum in chordee without hypospadias

OBJECTIVE

To investigate the feasibility of correcting coexistent penile torsion and chordee without hypospadias by mobilization of the urethra and spongiosum.

MATERIALS AND METHODS

A retrospective study of nine patients with simultaneous penile torsion and chordee without hypospadias was undertaken between January 2006 and December 2012. During this period, a total of 364 cases of hypospadias and 38 of chordee without hypospadias were operated on, making a total of 402 patients with hypospadias-related complexes. The same steps were used for correction of both torque and chordee. After a circumcoronal incision, the penis was fully degloved and the spongiosum with urethra was lifted up off the cavernosa. Next, mobilization of the hypoplastic urethra with spongiosum was extended into the glans. If chordee or torque persisted, urethral mobilization was performed proximally up to the bulbar urethra, as required. Spongioplasty and glansplasty were done and a per-urethral stent was kept in for three to five days.

RESULTS

The age of the patients ranged from 5 to 16 years (median 6 years). Penile torsion ranged from 30° to 120°, with a median of 75°. Ventral chordee ranged from 45° to 100°, with a median of 50°. A ratio of 1:9.6 was found for chordee without hypospadias compared to the total hypospadias cases, with an incidence of 9.5%. The ratio of chordee without hypospadias with torsion compared to the total hypospadias cases was 1:29. There was an incidence of chordee without hypospadias with penile torsion of 3.5% in all patients with hypospadias. The ratio of chordee without hypospadias with torsion to only chordee without hypospadias was 1:1.71, with an incidence of 37.0%. Every step contributed to the correction of curvature and torsion. Chordee was corrected in two patients by penile degloving and lifting of the spongiosa off the urethral plate; three patients required additional mobilization of the urethra into the glans. Another two patients needed proximal urethral mobilization and one required a dorsal plication. In five patients, torque was corrected by penile degloving, lifting of the spongiosa and mobilization of the urethra into the glans; four patients required further proximal urethral mobilization. All patients had excellent functional and cosmetic results. No residual chordee or torque was observed in any patient on follow-up at 12-24 months.

CONCLUSION

The technique of distally mobilizing a hypoplastic urethra with spongiosum from the corpora into the glans, and proximally up to the bulbar region corrects moderate to severe chordee and torsion with excellent cosmetic results. The incidence of torsion with chordee without hypospadias was 3.5% of all cases of hypospadias.

Split median raphe: case series and brief literature review

We describe three cases of split median raphe of the penis (SMR) from our hospital newborn records from 2004 to 2013. One case was associated with median raphe cyst, one with skin hypochromia, and one with a scar-like aspect of the region of interest. SMR is thought to be the result of defective fusion of ectodermal tissue in the urethra and scrotum area or of defective growth of the perineal mesoderm around the urethra during gestation. Although SMR associated with other major penile congenital defects (epispadias, hypospadias, penile torsion, bifid scrotum, chordee) is common, isolated SMR is probably an underdiagnosed (although not rare) malformative condition. Recognizing SMR in a newborn may be of educational value to neonatologists because it leads to the search for and exclusion of the above-mentioned pathologic conditions.

The management of moderate and severe congenital penile torsion associated with hypospadias: Urethral mobilisation is not a panacea against torsion

Objectives

To evaluate the effectiveness of urethral mobilisation for correcting moderate and severe penile torsion associated with distal hypospadias.

Patients and methods

Nineteen patients with distal hypospadias and congenital moderate and severe penile torsion were treated surgically. The hypospadias was at the distal shaft, coronal and glanular in seven, eight and four patients, respectively, and six had mild chordee. The mean (SD, range) angle of torsion was 94.7 (19.9, 75–160)°. The urethra was mobilised down to the perineum. If the urethral mobilisation was insufficient the right border of the tunica albuginea was anchored to the pubic periosteum. The hypospadias was repaired using the urethral mobilisation and advancement technique, with a triangular plate flap for meatoplasty. The patients were followed up for 12–18 months.

Results

All patients had a successful functional and cosmetic outcome, with no residual torsion. Two patients had a small subcutaneous haematoma that resolved after conservative treatment. Massive oedema occurred in three patients and was treated conservatively. Urethral mobilisation did not correct the penile torsion completely. Although the mean (SD, range) angle of torsion was reduced to 86.1 (14.3, 65–130)°, statistically significantly different (P = 0.001), it was not clinically important. The presence of chordee had no significant correlation with the reduction of penile torsion.

Conclusion

Urethral mobilisation cannot completely correct moderate and severe penile torsion but it might only partly decrease the angle of torsion. Periosteal anchoring of the tunica albuginea might be the most reliable manoeuvre for the complete correction of penile torsion.

Correction of penile torsion by mobilization of urethral plate and urethra

OBJECTIVE

To assess the feasibility of correction of torsion by mobilization of the urethral plate with the corpus spongiosum and the proximal urethra.

PATIENTS AND METHODS

Of 27 cases of congenital penile torsion, 18 had hypospadias, seven were chordee without hypospadias, and two were isolated penile torsion. Age of patients varied from 2 to 26 years (mean 6 years, 8 months). Correction of torsion was performed: (1) penile skin de-gloving; (2) mobilization of the urethral plate with the corpus spongiosum up to the corona; (3) mobilization of the proximal urethra up to the perineum; and (4) mobilization of the hypoplastic urethra/urethral plate into the glans. Tubularized incised plate urethroplasty with spongioplasty was done in cases of hypospadias, as compared to spongioplasty alone in cases of chordee without hypospadias.

RESULTS

Degree of torsion varied from 45 to 180 degrees (mean 68.70); 74% of the patients had left and 26% had right penile torsion. Correction of torsion was possible by penile de-gloving (4%), mobilization of urethral plate and spongiosum (26%), mobilization of proximal urethra (22%), and mobilization of urethral plate/hypoplastic urethra with spongiosum into glans (48%).

CONCLUSIONS

Extended urethral mobilization corrected penile torsion in almost all cases. The technique is simple, safe, reproducible and effective for correction of both torsion and chordee.

Penile torsion correction by diagonal corporal plication sutures

Penile torsion is commonly encountered. It can be caused by skin and dartos adherence or Buck's fascia attachments. The authors suggest a new surgical approach to solve both problems. If Buck's fascia involvement is demonstrated by artificial erection then a new diagonal corporal plication suture is described to effectively solve this problem.

Incidence and predictive factors of isolated neonatal penile glanular torsion

PURPOSE

To determine the incidence of isolated neonatal penile glanular torsion, describe the basic characteristics, and explore the relationship between foreskin and glans torsion.

METHODOLOGY

A prospective survey was conducted of all male newborns admitted to nursery after delivery, or neonates less than 3 months presenting for circumcision. Cases with associated genital malformations were excluded.

RESULTS

The incidence of isolated neonatal penile torsion was 27% (95% CI: 22.2%-31.84%), to the left in 99% of cases. In 3.5% of cases, the penis had an angle <10 degrees, and 9.5% >20 degrees. Using Spearman's correlational coefficient, deviation of penile raphe from the midline at the foreskin tip had a better correlation with glans torsion than deviation of raphe at the coronal sulcus (0.727 vs 0.570; both significant at p<0.01).

CONCLUSION

Isolated neonatal penile torsion is more common than reported. The median raphe of the penis may be normal and mask unexpected glans torsion. Median raphe torsion at foreskin tip can be used as a predictor for glans torsion. Clinical significance and relation to adult penile torsion are beyond the scope of the study.

Degloving and realignment--simple repair of isolated penile torsion

OBJECTIVES

To present the results of repairing congenital or acquired penile torsion by means of a simple surgical procedure that does not involve resection of corporeal tissue.

METHODS

Forty-six circumcised patients (mean age 27 months, range 6 to 119) presented with isolated penile torsion of a greater than 30 degree rotation. The surgical technique involved degloving the penile skin to the penoscrotal junction. Residual torsion was corrected using 5-6/0 polyglactin absorbable suture applied to the desired 12-o'clock position of the penile skin adjacent to the glans and to a location counter to the direction of the torsion in the degloved penile skin sleeve. A wedge of loose ventral penile skin was usually resected. The resultant tightening of the skin allowed for proper alignment of the penis and better cosmesis. The rest of the circumferential incision was closed using the same suture material. The success of the procedure was evaluated according to physician and parental satisfaction with the final outcome.

RESULTS

Thirty-seven patients were available for follow-up (mean 31 months, range 8 to 68). Satisfactory results were achieved in 35 (95%) of the 37 patients; the other 2 had residual torsion. Complications were minor and consisted of postoperative fever and a subcutaneous hematoma in 1 patient that resolved with conservative treatment.

CONCLUSIONS

The degloving and realignment procedure is a simple technique that may be applied safely and successfully in most cases of penile torsion.