Penile torsion is a common malformation of the shaft of the penis where the urethra undergoes a rotational defect, usually to the side. While it is commonly congenital and affects around 1 out of 80 young male infants, it can be acquired and occur in response to blunt trauma.
Since the urethral opening of the penis is at a six o’clock position, a rotational malformation of the penile shaft can cause it to be displaced to a wider angle. If the penile opening undergoes torsion to a three o’clock position, it can impede urination that leads to abnormal deflection or spraying of urine.
The penile shaft can also appear roughly twisted around its longitudinal axis, which does not lead to the worsening of urinary symptoms. Penile torsion is most commonly observed when a child undergoes circumcision for the first time.
It is advised to consult a pediatric urologist to diagnose the severity of the condition before circumcising the foreskin in the first place. In cases where the penile torsion is observed before circumcision, both the surgical correction of the penile shaft along with the removal of the foreskin can be performed side by side for better prognosis.
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Congenital Associations with Penile Torsion
According to estimates, isolated torsion of the penis can affect around 1.7 to 27% of the male community, out of which approximately 0.7% of cases are of a severe level. While urinary symptoms can arise even if the penile shaft rotates along a median axis to 45 degrees, severity is often reported in counter-clockwise malformations of the urethra.
A counter-clockwise mal-rotation of the penis causes the urethra to open to the left side which incidentally, is also the most common and severe type of congenital penile torsion.
Penile torsion can occur in isolation and can also arise in association with frequently occurring penile deformities. Some of the common deformities are:
Penile torsion can occur with hypospadias – a condition where the urethral meatus opens on the ventral shaft or, in simpler terms, the underside of the penis. Hypospadias can cause hindrance during micturition. Due to this, a male child has to remain seated to ‘prevent spraying’ or a ‘double stream of urine.’
But, severity arises when the penile torsion is associated with distal hypospadias, which means that the meatus is situated close to the scrotum. It has been concluded that there are around 33% of penile torsions cases associated with distal hypospadias, making surgical correction of penis a dire need.
Both penile torsion and hypospadias can occur in association with chordee. In chordee, the penis usually curves downward. Chordee can make erection painful, leading to reduced sexual prowess and failure to engage in intercourse properly.
· Hooded Prepuce
At times, penile torsion is also associated with a hooded prepuce where the foreskin of the penis is not formed correctly. For parents opting for circumcision, removing the prepuce, along with surgical correction of penile torsion is not a big deal.
Modern Technique of Penile Torsion Repair
When the urethra is rotated to 90 degrees, it can open up to the left side and hinder a child’s daily act of micturition. However, with the growth of the boy, various other worries become a part of his life that are not only medical. Penile dysfunction also results in embarrassment due to peer pressure regarding cosmetic appearances, resulting in poor self-esteem.
However, the fact of the matter is that there is little to no evidence regarding the effect of penile torsion on a reproductive male’s sexual prowess.
In severe cases of penile torsion, urologists usually recommend opting for surgical correction of the penile shaft to improve the act of micturition as well as cosmetic appearances.
In order to understand the concept of modern surgical correction of penile torsion, it is necessary to study the pathogenesis behind the condition.
The ‘dartos fascia’ is a layer of subcutaneous connective tissue of skin that expands from the penis to the scrotum. During the development of the genitalia, the dartos fascia undergoes incomplete formation – either due to genetic disturbances or hormonal imbalance – leading to penile torsion.
Surgical Correction Techniques
Penile Skin Degloving Technique
Skin degloving and realignment is a standard procedure for penile torsions that are remotely severe or are less than 90 degrees in deflection from the normal position. Skin degloving is a surgical technique that is usually carried out by pediatric urologists as an initial remedy for isolated penile torsions.
In most cases, patients are observed for recurrent and persistent penile torsion. If torsion persists even after degloving of the penile shaft, urologists proceed towards a modern technique of repair involving the rotation of the dorsal dartos flap of the penile skin.
Dorsal Dartos Flap Rotation
The application of dorsal dartos flap for the surgical correction of moderate to severe penile torsion is a relatively modern technique. It is preferred due to its low cost and progressive results. The dartos flap application requires general anesthesia as well as the penile block for safe and catheterized operative surgery.
Usually, the dartos flap application is performed when degloving surgery is unsuccessful in correcting the penile torsion of the patient. The circumcision is corrected with the help of bipolar cauterization, after which the penile shaft undergoes degloving till the base of the penis. An artificial erection is usually induced with the help of a tourniquet that allows the penis to correct its degree of mal-rotation.
If degloving is remotely unsuccessful, the right side of the penile shaft serves as the site for the preparation of the dorsal dartos flap. The dorsal dartos flap is mobilized so that it can undergo clockwise rotation around the right side of the penis. The flap is then attached to the underside of the penis, leading to the completion of the clockwise penile rotation.
Once the dorsal dartos flap undergoes rotation from the right side of the penis to the left side, the shaft is observed for residual penile torsion. Once the penile detorsion is successful, the skin flaps can be closed with the help of vicryl sutures.
The dorsal dartos flap application is also used in penile enhancement as well as other composite augmented surgeries of the penis.
Penile dysfunction can preclude a boy from living a happy and contented life. There are reasons for it that go beyond medical and biological deformities. It is the societal pressure that sometimes riles up more agony on the patient.
Therefore, it is ideal for getting your child diagnosed by a reputable pediatric urologist at the first sign of penile deformity. Getting it corrected at an early age goes a long way in improving the self-esteem of the patient.