Penile Curvature (IPP) - Treatment & Correction of Congenital and Acquired Penile Curvature

Generally, a distinction is made between congenital and acquired penile curvature. The causes of acquired penile curvature usually stem from small, often unnoticed injuries to the tunica albuginea—the firm sheath surrounding the erectile tissues. During the healing process, these small injuries lead to the formation of scar tissue and plaques, which cause the tissue to harden and lose its elasticity.

Repeated strain, such as during sexual intercourse or due to mechanical pressure, can intensify this process. This results in a curvature of the penis, which is particularly noticeable when the penis is erect. Depending on the location of the plaques, the penis may bend upward, to the side, or downward.

Congenital penile curvature, as the name suggests, is present from birth. Problems usually do not become apparent until puberty, when men become sexually active and notice that something is wrong with their penis. According to estimates, congenital penile curvature affects about 1 to 4 percent of men.

The cause of congenital penile curvature stems from a defect that occurred during embryonic development.

The following factors can prevent the penis from developing properly, leading to asymmetry:

• The urethra does not develop fully
• Scarring occurs in the connective tissue layers of the penis

Acquired penile curvature, medically known as Induratio Penis Plastica (IPP), is, however, significantly more common: Up to 10 percent of men are affected by acquired penile curvature at some point in their lives.

The exact cause of IPP is not yet fully understood. Medical experts believe that in genetically predisposed individuals, repeated stress and micro-injuries lead to the formation of scar tissue (plaque). As the condition progresses, this results in calcification.

Patients often notice the plaque as elongated nodules on the penis that can be felt when the penis is flaccid.

These plaque deposits alter the elasticity of the erectile tissues, leading to classic symptoms such as:

• Curvature of the penis
• Indentations on the shaft of the penis
• A loss of penile length and
• In advanced stages, erectile dysfunction

 

Erectile dysfunction is the inability to achieve and maintain an erection sufficient for sexual intercourse @ Wasan /AdobeStock

Acquired penile curvature typically progresses in two phases.

1. It begins with the “acute” phase of the disease. During this phase, plaque forms, and the penis begins to change shape and curve. This can lead to indentations or even a “hourglass” appearance. Up to 80 percent of patients report a significant loss of penile length due to IPP. In addition, about 40 percent of those affected experience penile pain during the acute phase of the disease.

2. The second phase of the disease is the “chronic” phase. During this phase, the disease stabilizes and the pain subsides. The penile curvature no longer changes and remains stable. The timing of the onset of the chronic phase varies from person to person. In some patients, the chronic phase begins as early as 3 months after the first signs of the disease. In others, it takes 2 years.

Distinguishing between the acute and chronic phases is important in order to differentiate treatment options for each phase of the disease.

Medical guidelines from various professional societies recommend correcting penile curvature when the degree of curvature reaches 30 degrees. However, the degree of curvature should not be the sole criterion for deciding on treatment.

In some cases, individuals with a pronounced curvature experience no problems. In other cases, even a slight degree of curvature can lead to pain, significant problems in sexual life, and reduced self-esteem. Withdrawal from sexual activity and relationship problems are not uncommon.

Treatment for penile curvature should therefore be initiated as soon as the patient perceives it as a problem—even if, objectively speaking, the curvature is not particularly severe.

Patients with a congenital curvature usually see a doctor during adolescence.

Men over the age of 40 are more likely to have the acquired form. This does not mean, however, that an acquired curvature cannot also occur at a younger age.

A congenital penile curvature requires surgery. For the treatment of an acquired curvature, however, various treatment options are now available depending on the stage of the condition.

Treatment for IPP depends on the stage of the disease. During the acute inflammatory phase, the primary focus of treatment is on pain relief. Treatment at this stage is conservative and involves medication and/or physical therapy.

In addition to oral medication, injections and iontophoresis treatments are used here. Extracorporeal shock wave therapy is also employed to break up plaque deposits using sound waves.

While these approaches do provide pain relief, scientific studies have not been able to demonstrate that plaque formation can be halted or that the curvature can be reduced.

The most promising conservative treatment in recent years has been injection therapy with XIAPEX in combination with penile extenders or vacuum pumps. 

In this procedure, the doctor injects a specific enzyme directly into the plaques to break them down. Unfortunately, the pharmaceutical company has discontinued the sale of this medication in Europe.

Once IPP has come to a halt, the focus shifts to correcting the curvature. At present, surgery remains the only option for this as well.

The vacuum pump creates a vacuum inside the cylinder surrounding the penis, enabling erectile function @ HENADZY /AdobeStock

Various surgical techniques are available for correcting IPP, which can be divided into two categories:

• The classic surgical methods

There are the “traditional” surgical methods, such as the Nesbit procedure or the STAGE technique. These methods straighten the penile axis by tightening the healthy side of the penis. However, this tightening inevitably leads to a significant loss of penile length.

• The graft procedure

To prevent a loss of length, alternative approaches have emerged, also known as “graft surgery.” 

In this procedure, doctors make an incision in the plaque on the shortened side of the penis and suture in an artificial material (graft). This allows them to straighten the penis without any loss of length. Over time, the body usually breaks down the graft and replaces it with its own cells.

Since this procedure is more complex than a conventional Nesbit procedure, it requires a physician with specialized training. The appropriate surgical technique always depends on the individual case.

In very advanced stages of IPP, erectile dysfunction often occurs. When this is the case, penile straightening alone usually cannot correct the underlying problem. 

In such cases, the doctor and patient should consider the implantation of a penile prosthesis.

Although many men are affected by penile curvature, the condition is rare in everyday urological practice.

This is because many affected men do not know what to do or are hesitant to seek professional help. However, it is important to detect and treat penile curvature early on.

Doctors can successfully treat Induratio Penis Plastica even in the acute phase. Conservative therapy is performed on an outpatient basis, so the patient can go home after the injection.

Even with surgery, the recovery time is limited. If surgery is performed for penile curvature, the man should expect a 6-week period of sexual abstinence. 

However, he can resume sports activities after 7 to 10 days. The hospital stay lasts no longer than 1 to 2 days.

Because doctors often mistakenly diagnose congenital penile curvature as IPP, those affected should consult an andrologist or a specialized urologist.

Untreated penile curvature can lead to long-term pain in the penis, impaired sexual function, and psychological distress. Men with a progressive condition, in particular, frequently report problems during sexual intercourse as well as insecurity regarding their genital area.

As with any surgery, surgical procedures carry risks such as infections, postoperative bleeding, or sensory disturbances. In rare cases, erectile dysfunction or a residual curvature may also occur. Conservative treatments, such as medication or enzyme injection therapy for penile curvature, are also not free of side effects, as they can cause local swelling, bruising, or tissue irritation.

At what degree of penile curvature should treatment be considered?
Treatment is usually recommended if the angle exceeds 30 degrees or if functional problems are already present.

Can a mild curvature resolve on its own?
In the acute phase, a mild curvature may stabilize or subside slightly, but it rarely disappears completely without treatment.

Is there a treatment for penile curvature that does not involve surgery?
Yes, in the early stages, medication is an option, primarily intended to relieve pain.

When is surgical correction of penile curvature recommended?
Surgery is recommended when the condition is in a stable phase and conservative measures do not yield sufficient results.