What Is Penile Torsion?

Introduction 

Penile torsion is a congenital condition whereby the penis can abnormally rotate or twist .¹ While many variations in penile anatomy are considered to be clinically normal, penile torsion becomes a concern when there is a significant deviation from the typical alignment. It is a condition that can manifest in various directions and degrees of severity; thus, comprehension of this condition is imperative for both healthcare professionals and individuals to mitigate the impacts on physical and psychological well-being. 

This article aims to delve into the details of penile torsion, exploring its types, potential causes, clinical manifestations, diagnostic approaches and available treatment options. By shedding light on this condition, we hope to provide valuable insights for individuals affected, their families and healthcare providers, thus fostering awareness, comprehension and the facilitation of informed decision-making regarding potential interventions.

Anatomy of the penis 

Overview of penile anatomy 

The penis is divided into two continuous areas: the body (external portion) and the root .² The root of the penis originates inferior to the bulbourethral glands with a body of tissue (the corpora cavernosa).² This tissue persists through the body of the penis, up to the tip, where it encompasses the formation of a mushroom-shaped structure called the glans penis.² 

The corpus spongiosum, the tissue that surrounds the urethra, facilitates the passage of urine and semen through an opening at the end of the urethra at the tip of the glans penis.² 

In addition to the cavernosum urethrae, another pair of cylindrical bodies also originate at the bulbourethral glands, through the body of the penis.² These are known as the corpora cavernosa penis, they occupy the lateral and superior aspects of the corpus spongiosum and terminate before the glans penis.² 

The corpora cavernosa and corpus spongiosum are enclosed by a circular layer of elastic tissue. Subsequently, this elastic tissue is enclosed in a thin layer of darker coloured skin. The beginning of the glans penis is covered by a circular fold of skin, called the foreskin (prepuce) and extends over the glans penis.² 

Normal variations in penile alignment 

Variations in the curvature of the penis are common and it can slightly deviate to the left or right when it is erect.³ One study documented that 20% of men are born with a curved penis, accounting for a large variation in penile shape.⁴ 

Penile torsion anatomical variance

In congenital penile torsion, the penis rotates along its longitudinal axis,⁵ and can occur in conjunction with chordee (congenital penile curvature)⁶ and hypospadias (the opening of the urethral meatus on the underside of the penis).⁷

Types of penile torsion 

Directional classification

As mentioned previously, the penis has normal directional variance, this can be in the left, right, dorsal or ventral directions. Unless there are severe directional deformities, congenital torsion is frequently passed unnoticed and individuals rarely present with this condition as a complaint as there is not usually any hindrance to sexual activity or functioning of the penis.⁸ 

Degrees of severity 

Penile torsion is classified into three grades of severity:⁵

• Grade 1: rotation angle <45 degrees
• Grade 2: rotation angle between 45-90 degrees
• Grade 3: rotation angle >90 degrees

Depending on the grade of severity, penile torsion can be managed and treated in different ways. 

Prevalence in different age groups 

The epidemiology of penile torsion is contained within new-born males, due to the predominantly congenital nature of this condition. The reported incidence of congenital, isolated penile torsion in North India is around 1.7-27% (9). It can, however, be left unnoticed until later when the individuals undergo puberty and notice changes in erect appearances of the penis, or abnormal symptoms during intercourse. 

Causes and risk factors

The causes of penile torsion are threefold; congenital, trauma and iatrogenic.¹⁰ Congenital is a condition that is present at birth. Traumatic causes of penile torsion can result in acquired lesions that cause deviation of the penis from its normal anatomy. Iatrogenic causes are medical procedures that result in injury or illness. Such procedures include circumcision and urethral reconstruction. 

Although the exact pathophysiology of penile torsion is unknown, there are several proposed theories. For instance, abnormal skin attachment or abnormal development of the dartos fasica.¹¹ Excessive adhesions between the pubic bone and corpus cavernosa have also been a proposed theory.¹² 

Clinical presentation and complications 

Signs and symptoms 

As we have covered previously, the presentation of penile torsion is hinged upon the direction and severity of rotation. This is commonly the only aesthetic complaint that individuals present with. However, in some cases of severe penile torsion, some individuals can experience psychological distress and complications.⁸ 

Complications 

In significant penile torsion, commonly above 90 degrees of rotation, complications involving control of the urinary stream can arise.¹³ this can present as changes in the pressure of the urinary stream, a stream that points up, down or to either side and a stream that splits into two different directions.¹⁴

Diagnosis 

The diagnosis of penile torsion is that of a clinical one, meaning that a trained, specialist healthcare professional (specifically a urologist) will ascertain the extent of the penile torsion through clinical examination.¹⁴

Treatment 

Penile torsion does not usually require treatment, especially in cases of <90 degrees of rotation.¹⁴ In such cases, patients can remain under observation for any significant changes in the extent of the torsion. However, in congenital cases, many parents or children at a later age may want to discuss treatment options for cosmetic reasons. 

Grade 1 penile torsion is indicated during circumcision or when the penile torsion is not isolated, for instance, if there is a presentation with chordee or hypospadias.⁵  Grade 2 torsion can be treated using a dorsal dartos flap (DDF). This is when a flap of skin around the right side of the penis is rotated and attached to the ventral aspect, to mitigate the anti-clockwise rotation of the penis.¹⁵ Grade 3 torsion are ideally treated with the fixation of the corpus cavernosum to the pubic periosteum, this is called a corporo-periosteo-pexy (CPP).⁵

Psychological aspects

The psychological implications of penile torsion extend beyond the physical aspects of the condition, impacting the emotional well-being and self-esteem of individuals. Men experiencing penile torsion may struggle with feelings of self-consciousness, anxiety, and concerns about body image. The deviation from the perceived societal norm may give rise to apprehensions regarding intimate relationships and sexual encounters. A study revealed that men with untreated ventral penile curvature had worse perception scores, more mentally unhealthy days and increased difficulty with intercourse, thus suggesting dissatisfaction with penile appearance and increased difficulty with mental health concerns regarding this condition.¹⁶ 

It is crucial to recognize and address the psychological aspects of penile torsion, emphasizing open communication, counselling, and support networks to help individuals navigate and overcome the emotional challenges associated with this condition. By fostering understanding and empathy, healthcare providers and support systems can play a pivotal role in alleviating the psychological burden and promoting holistic well-being for those affected by penile torsion. 

Summary 

In conclusion, penile torsion is a nuanced aspect of men’s health which extends past its anatomical dimensions. The physical, psychological and interpersonal dynamics are intertwined in this condition, which makes the significance of its comprehension that much more important. Throughout this article, we have explored the various facets of penile torsion, ranging from its anatomical variations, severity and causes to its physical and psychological manifestations, as well as available treatment options. This article strives towards the creation of a holistic environment where individuals feel comfortable reaching out for medical help, encompassing both the physical and emotional aspects of their experiences.