THE
Vol. 115, May
JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
HEMIHYPERTROPHY OF THE HUMAN CORPUS CAVERNOSUM TERENCE J. FITZPATRICK* From the Department of Urology, Southern California Permanente Medical Group and Kaiser Foundation Hospital, Los Angeles, California
ABSTRACT
Hemihypertrophy of the right corpus cavernosum and its accompanying thickened tunica albuginea are responsible for the left lateral deviation in congenital curvature of the penis. Surgical correction is more predictable when the lengths of the dorsal and ventral curvatures of the corpora cavernosa are known. Etiological factors for congenital curvature of the penis have coincided with the site of maximum enlargement of the right been described as the disproportion between the length of the corpus cavernosum. However, the penile urethra itself was not corpora cavemosa, causing lateral deviation, or the dispropor- foreshortened (fig. 3, B). An 8 cm. difference existed between the longitudinal penile tion between the corpora cavernosa and the corpus spongiosum, causing ventral curvature. 1 Nesbit believes that the dorsal and ventral curvatures. The penis was placed on apparent defect is caused by the asymmetry in the develop- traction by suturing a No. 1 silk suture through the dorsal ment of the encompassing fascia of the corpora cavernosa. 2 portion of the glans penis. This suture was fastened to a rubber With the aid of a percutaneous cavernosogram 3 it can now be band and adjacent drapes. A No. 14 Foley catheter was inserted stated that congenital left lateral deviation and its sometimes for drainage purposes. accompanying ventral curvature of the penis are caused by A circular skin incision was made just proximal to the corona hemihypertrophy of the right corpus cavernosum. The shorter of the glans penis. The penile skin and Buck's fascia were left corpus cavernosum becomes hypoplastic and displaced to freed to the base of the penis from the underlying tunica albuthe left of the midline, causing left lateral deviation on ginea. A tourniquet was applied to the base of the penis. Three erection. No cases of congenital right lateral deviation of the pairs of diamond-shaped ellipses of tunica albuginea, 2 cm. in length, 1 cm. across and 1 cm. apart, were excised from the penis have been reported. The greater the length and breadth of the right compared to thickened tunica albuginea about the dorsal surface of the hythe left corpus cavernosum, the greater the left lateral curva- pertrophied right corpus cavernosum. 2 The ellipses of tunica ture of the penis. Longitudinal enlargement of the right corpus albuginea removed were from that portion of the right corpus cavernosum may also result in ventral angulation of the penis cavernosum that was contributing most to the left lateral penile and angulation of the penile urethra but it is not in itself curvature (fig. 3, A). These incisions were closed transversely with 1-zero silk suture. Only those segments lateral to the midforeshortened. line were removed to avoid injury to the more medially placed CASE REPORTS deep dorsal nerves and vessels to and from the glans penis. In addition, a 1 cm. pair of transverse tunica albuginea Case 1. C. F., an 18-year-old black man, had had left lateral deviation and ventral angulation of the penis for as long as he elliptical excisions were made over the most angulated ventral could remember. Satisfactory coitus was impossible. Examina- surface of the left corpus cavernosum. The incisions were tion revealed a left lateral deviation and a ventral curvature in closed longitudinally. 1 The result was a shortening of the longer the vicinity of the proximal third of the penis (fig. 1). The right dorsal surface and a lengthening of the shorter ventral surface corpus cavernosum was enlarged along its longitudinal and with straightening of the penis on erection. The erection was transverse axes. As a result the usual dorsal midline longitudi- produced by injecting normal saline into the base of the nal sulcus was displaced to the left of the center. No fibrous corpora cavernosa. Buck's fascia and the overlying penile skin were closed with 3-zero chromic interrupted sutures and a plaques suggestive of Peyronie's disease could be identified. With the patient under local anesthesia and in a right pressure dressing was applied. Case 2. V. J ., a 32-year-old white man, complained of left oblique urethrogram position, serial cavernosograms of the penis were obtained by slowly injecting 5 cc meglumine lateral penile deviation and ventral curvature of approximately iothalamatet in 30 seconds through a No. 21 butterfly needle 20 degrees. On physical examination it was noted that the inserted into the distal part of the cavernosum. 3 A right larger right corpus cavernosum displaced the smaller left corhemihypertrophied corpus cavernosum enlarged along its lon- pus cavernosum across the midline. Because of the magnitude of the operative repair 2 there gitudinal and transverse axes was observed along with a tortuous deep ventral venous drainage system (fig. 2). The should be significant measurable differences between the massive hypertrophic right corpus cavernosum displaced the transverse and longitudinal axes of the right and left corpora left hypoplastic corpus cavernosum across the midline. The cavernosa (fig. 4). If these preoperative parameters cannot be hypertrophy was most pronounced within the proximal third of simply and accurately measured from the penis itself then the the penile shaft, ~he site of the maximum ventral curvature measurements should be taken from a cavernosogram, which will prevent overcorrecting the defect. Therefore, surgical and left lateral deviation (fig. 3, A). To determine any discrepancy between the length of the correction in this case was deferred since only a 3 cm. corpora cavernosa and the urethra, a right oblique urethrogram difference existed between the right and left corpora cavernosa was obtained. The site of maximum penile urethral angulation longitudinal ventral and dorsal penile curvatures and coitus was possible without discomfort. The ventral curvature and the left lateral deviations were less since the hypertrophy Accepted for publication August 22, 1975. within the right corpus cavernosum was not as pronounced. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975. * Requests for reprints: Kaiser Foundation Medical Center, 1510 N. Edgemont St., Los Angeles, California 90027. t Conray 60, Mallinckrodt Chemical Works, St. Louis, Missouri 63160.
DISCUSSION
In human embryos 10 mm. in length a vertical midline endodermal urethral plate grows forward into the mesenchyma 560
·""" {'1
HEivHHYPERTROPHY Of' HUMAN CORPUS CAVERNOSUM
Q01._
FIG. 1. Congenital penile left lateral deviation and curvature
F1G. 3. Case l. A, cavernosogram with arrow pointing to site of maximum hypertrophy of right corpus cavernosum. B, urethrogram demonstrates urethral angulation without foreshortening.
Elongated Dorsal Surioco----..__
H@mihyporfrophiod Righi Corpus Cavernosum
Fre-. 2. Case 1. Cavernosogram de1nonstrates hypertrophy of right corpus cavernosum. 4 In cases of left lateral deviation of the endodermal urethral grows forward and to the left of the dividing the penis into 2 uneven compartments. Within the right cavernous compartment the right corpus cavernosum hypertrophies, while on the left a hypoplastic corpus cavernosum develops. With penile development the endodermal urethral becomes the dividing septum between the right and left cavernosa. To date only 7 cases of congenital curvature of the penis have been reported. Many other cases undoubtedly have been diagnosed as being caused by a foreshortened urethra or Peyronie's disease. 5 All 7 cases have had either left lateral deviation or ventral curvatures. Since there is no hindrance to the longitudinal expansion of the hypertrophied right corpus cavernosum, left lateral deviation occurs. Ventral curvature occurs within the proximal third of the penile shaft, since it is here that the hemihypertrophy of the right corpus cavernosum and its encompassing fascia are more pronounced. No cases of congenital right lateral deviation of the penis have been
FIG. 4. Case 2. Cavernosogram with arrow illustrating lesser degree of hypertrophy and angulation of right corpus cavernosum.
reported since presumably only the right and not the left corpus cavernosum hemihypertrophies. REFERENCES
1. Saalfeld, J., Ehrlich, R. M., Gross, J. M. and Kaufman, J. J.: Congenital curvature of the penis: successful results with variations in corporoplasty. J. Ural., 109: 64, 1973. 2. Nesbit, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. J. Ural., 93: 230, 1965. 3. Fitzpatrick, T. J.: Spongiosograms and cavernosograms: a study of their value in priapism. J. Ural., 109: 843, 1973. 4. Hamilton, W. J. and Mossmau, H. W.: Human Embryology, 4th ed. Baltimore: The Williams & Wilkins Co., p. 414, 1972. 5. Correa, R. J., Jr.: Congenital curvature of the penis. J. Ural., 106: 881, 1971.
Vol. 115, May
JOURNAL OF UROLOGY
Copyright © 1976 by The Williams & Wilkins Co.
Printed in U.S.A.
HEMIHYPERTROPHY OF THE HUMAN CORPUS CAVERNOSUM TERENCE J. FITZPATRICK* From the Department of Urology, Southern California Permanente Medical Group and Kaiser Foundation Hospital, Los Angeles, California
ABSTRACT
Hemihypertrophy of the right corpus cavernosum and its accompanying thickened tunica albuginea are responsible for the left lateral deviation in congenital curvature of the penis. Surgical correction is more predictable when the lengths of the dorsal and ventral curvatures of the corpora cavernosa are known. Etiological factors for congenital curvature of the penis have coincided with the site of maximum enlargement of the right been described as the disproportion between the length of the corpus cavernosum. However, the penile urethra itself was not corpora cavemosa, causing lateral deviation, or the dispropor- foreshortened (fig. 3, B). An 8 cm. difference existed between the longitudinal penile tion between the corpora cavernosa and the corpus spongiosum, causing ventral curvature. 1 Nesbit believes that the dorsal and ventral curvatures. The penis was placed on apparent defect is caused by the asymmetry in the develop- traction by suturing a No. 1 silk suture through the dorsal ment of the encompassing fascia of the corpora cavernosa. 2 portion of the glans penis. This suture was fastened to a rubber With the aid of a percutaneous cavernosogram 3 it can now be band and adjacent drapes. A No. 14 Foley catheter was inserted stated that congenital left lateral deviation and its sometimes for drainage purposes. accompanying ventral curvature of the penis are caused by A circular skin incision was made just proximal to the corona hemihypertrophy of the right corpus cavernosum. The shorter of the glans penis. The penile skin and Buck's fascia were left corpus cavernosum becomes hypoplastic and displaced to freed to the base of the penis from the underlying tunica albuthe left of the midline, causing left lateral deviation on ginea. A tourniquet was applied to the base of the penis. Three erection. No cases of congenital right lateral deviation of the pairs of diamond-shaped ellipses of tunica albuginea, 2 cm. in length, 1 cm. across and 1 cm. apart, were excised from the penis have been reported. The greater the length and breadth of the right compared to thickened tunica albuginea about the dorsal surface of the hythe left corpus cavernosum, the greater the left lateral curva- pertrophied right corpus cavernosum. 2 The ellipses of tunica ture of the penis. Longitudinal enlargement of the right corpus albuginea removed were from that portion of the right corpus cavernosum may also result in ventral angulation of the penis cavernosum that was contributing most to the left lateral penile and angulation of the penile urethra but it is not in itself curvature (fig. 3, A). These incisions were closed transversely with 1-zero silk suture. Only those segments lateral to the midforeshortened. line were removed to avoid injury to the more medially placed CASE REPORTS deep dorsal nerves and vessels to and from the glans penis. In addition, a 1 cm. pair of transverse tunica albuginea Case 1. C. F., an 18-year-old black man, had had left lateral deviation and ventral angulation of the penis for as long as he elliptical excisions were made over the most angulated ventral could remember. Satisfactory coitus was impossible. Examina- surface of the left corpus cavernosum. The incisions were tion revealed a left lateral deviation and a ventral curvature in closed longitudinally. 1 The result was a shortening of the longer the vicinity of the proximal third of the penis (fig. 1). The right dorsal surface and a lengthening of the shorter ventral surface corpus cavernosum was enlarged along its longitudinal and with straightening of the penis on erection. The erection was transverse axes. As a result the usual dorsal midline longitudi- produced by injecting normal saline into the base of the nal sulcus was displaced to the left of the center. No fibrous corpora cavernosa. Buck's fascia and the overlying penile skin were closed with 3-zero chromic interrupted sutures and a plaques suggestive of Peyronie's disease could be identified. With the patient under local anesthesia and in a right pressure dressing was applied. Case 2. V. J ., a 32-year-old white man, complained of left oblique urethrogram position, serial cavernosograms of the penis were obtained by slowly injecting 5 cc meglumine lateral penile deviation and ventral curvature of approximately iothalamatet in 30 seconds through a No. 21 butterfly needle 20 degrees. On physical examination it was noted that the inserted into the distal part of the cavernosum. 3 A right larger right corpus cavernosum displaced the smaller left corhemihypertrophied corpus cavernosum enlarged along its lon- pus cavernosum across the midline. Because of the magnitude of the operative repair 2 there gitudinal and transverse axes was observed along with a tortuous deep ventral venous drainage system (fig. 2). The should be significant measurable differences between the massive hypertrophic right corpus cavernosum displaced the transverse and longitudinal axes of the right and left corpora left hypoplastic corpus cavernosum across the midline. The cavernosa (fig. 4). If these preoperative parameters cannot be hypertrophy was most pronounced within the proximal third of simply and accurately measured from the penis itself then the the penile shaft, ~he site of the maximum ventral curvature measurements should be taken from a cavernosogram, which will prevent overcorrecting the defect. Therefore, surgical and left lateral deviation (fig. 3, A). To determine any discrepancy between the length of the correction in this case was deferred since only a 3 cm. corpora cavernosa and the urethra, a right oblique urethrogram difference existed between the right and left corpora cavernosa was obtained. The site of maximum penile urethral angulation longitudinal ventral and dorsal penile curvatures and coitus was possible without discomfort. The ventral curvature and the left lateral deviations were less since the hypertrophy Accepted for publication August 22, 1975. within the right corpus cavernosum was not as pronounced. Read at annual meeting of Western Section, American Urological Association, Portland, Oregon, April 13-17, 1975. * Requests for reprints: Kaiser Foundation Medical Center, 1510 N. Edgemont St., Los Angeles, California 90027. t Conray 60, Mallinckrodt Chemical Works, St. Louis, Missouri 63160.
DISCUSSION
In human embryos 10 mm. in length a vertical midline endodermal urethral plate grows forward into the mesenchyma 560
·""" {'1
HEivHHYPERTROPHY Of' HUMAN CORPUS CAVERNOSUM
Q01._
FIG. 1. Congenital penile left lateral deviation and curvature
F1G. 3. Case l. A, cavernosogram with arrow pointing to site of maximum hypertrophy of right corpus cavernosum. B, urethrogram demonstrates urethral angulation without foreshortening.
Elongated Dorsal Surioco----..__
H@mihyporfrophiod Righi Corpus Cavernosum
Fre-. 2. Case 1. Cavernosogram de1nonstrates hypertrophy of right corpus cavernosum. 4 In cases of left lateral deviation of the endodermal urethral grows forward and to the left of the dividing the penis into 2 uneven compartments. Within the right cavernous compartment the right corpus cavernosum hypertrophies, while on the left a hypoplastic corpus cavernosum develops. With penile development the endodermal urethral becomes the dividing septum between the right and left cavernosa. To date only 7 cases of congenital curvature of the penis have been reported. Many other cases undoubtedly have been diagnosed as being caused by a foreshortened urethra or Peyronie's disease. 5 All 7 cases have had either left lateral deviation or ventral curvatures. Since there is no hindrance to the longitudinal expansion of the hypertrophied right corpus cavernosum, left lateral deviation occurs. Ventral curvature occurs within the proximal third of the penile shaft, since it is here that the hemihypertrophy of the right corpus cavernosum and its encompassing fascia are more pronounced. No cases of congenital right lateral deviation of the penis have been
FIG. 4. Case 2. Cavernosogram with arrow illustrating lesser degree of hypertrophy and angulation of right corpus cavernosum.
reported since presumably only the right and not the left corpus cavernosum hemihypertrophies. REFERENCES
1. Saalfeld, J., Ehrlich, R. M., Gross, J. M. and Kaufman, J. J.: Congenital curvature of the penis: successful results with variations in corporoplasty. J. Ural., 109: 64, 1973. 2. Nesbit, R. M.: Congenital curvature of the phallus: report of three cases with description of corrective operation. J. Ural., 93: 230, 1965. 3. Fitzpatrick, T. J.: Spongiosograms and cavernosograms: a study of their value in priapism. J. Ural., 109: 843, 1973. 4. Hamilton, W. J. and Mossmau, H. W.: Human Embryology, 4th ed. Baltimore: The Williams & Wilkins Co., p. 414, 1972. 5. Correa, R. J., Jr.: Congenital curvature of the penis. J. Ural., 106: 881, 1971.
