Penile Torsion: Symptoms, Types, Causes and Treatment

Penile torsion is a relatively under-recognized congenital condition that can have significant physical and psychological impacts if left unaddressed. Characterized by a rotational deformity of the penile shaft, penile torsion can occur alone or alongside other anomalies such as hypospadias and chordee. Although many cases are mild and may not require intervention, more severe forms can interfere with function, urination, or cause distress about appearance. This article offers a detailed, evidence-based overview of penile torsion, covering its symptoms, types, causes, and modern treatment approaches.

Symptoms of Penile Torsion

Penile torsion often presents subtly, especially in mild cases. Awareness of its symptoms is crucial for early detection and management, especially considering its association with other penile anomalies. Recognizing the signs can help parents, caregivers, and clinicians differentiate between normal anatomical variations and conditions warranting medical attention.

Symptom	Description	Severity Range	Source(s)
Shaft Rotation	Visible twisting of penile shaft (helical turn)	Mild (15–45°) to severe (>90°)	1, 2, 6
Meatus Deviation	Urethral opening not at typical ventral midline	Associated with torsion and hypospadias	1, 2
Dorsal Raphe Deviation	Skin line on top of penis is off-center	Common in torsion	2
Associated Curvature	Downward or lateral curve (chordee)	More likely in severe cases	1, 6

Table 1: Key Symptoms of Penile Torsion

Recognizing Penile Torsion

The most noticeable symptom is the twisting or rotation of the penile shaft. In newborns and infants, this may be observed during diaper changes, while in older children or adults, it may become more apparent during erections.

• Shaft Rotation: The shaft may rotate to the left (more common) or right. The degree can range from a barely perceptible twist to a dramatic rotation of over 90 degrees. Most cases are mild (15–45°), but moderate (45–90°) and severe (>90°) presentations are possible 1, 2.
• Meatus Deviation: The urethral opening (meatus) may point off-center, especially if torsion is associated with hypospadias. This can affect the direction of urination and may be noticed during toilet training 1, 2.
• Dorsal Raphe Deviation: The median raphe (the skin line running along the top of the penis) may appear shifted to one side, signaling underlying torsion 2.
• Associated Curvature: In cases where torsion coexists with chordee, there may be a noticeable bend, typically downward, further complicating the clinical picture 1, 6.

Severity and Impact

• Mild: Often asymptomatic, may not require treatment.
• Moderate to Severe: May cause cosmetic concerns, functional issues (urination, sexual activity), or psychological distress.

Types of Penile Torsion

Penile torsion does not present uniformly; its classification is based on the degree of rotation, direction, and association with other penile anomalies. Understanding the types is vital for diagnosis, prognosis, and treatment planning.

Type	Rotation Degree	Direction	Common Associations	Source(s)
Mild	15–45°	Left/right	Often isolated	1, 2
Moderate	45–90°	Mostly left	May co-occur with chordee/hypospadias	1, 2, 6
Severe	>90°	Usually left	Strongly associated with hypospadias	1, 2, 6
Isolated	Variable	Either	No other anomalies	2, 6
Complex/Associated	Variable	Either	With hypospadias, chordee	1, 6

Table 2: Classification of Penile Torsion Types

Degrees and Direction of Torsion

• Mild: Most common, usually does not interfere with function. Often detected incidentally.
• Moderate: More visible and more likely to prompt medical consultation.
• Severe: Defined as rotation greater than 90°, can result in significant cosmetic and functional concerns 1, 2.

Direction: Torsion most frequently occurs to the left, with studies reporting a left-to-right ratio as high as 5:1 1, 2.

Isolated vs. Associated Torsion

• Isolated Penile Torsion: Occurs without other penile anomalies. While underreported, its incidence in newborns is about 1.7-2% 2.
• Associated (Complex) Torsion: Found in conjunction with other congenital conditions, notably hypospadias and ventral curvature (chordee). The severity of torsion is often inversely related to the degree of ventral curvature: more severe torsion tends to occur with less pronounced curvature, and vice versa 1.

Special Cases

• Complex Deformities: Some rare presentations involve both significant torsion and pronounced curvature, requiring individualized surgical planning 7.

Causes of Penile Torsion

Understanding why penile torsion occurs aids in both prevention and effective management. While the exact mechanisms are not fully elucidated, several contributing factors have been identified, ranging from anatomical variations to developmental influences.

Cause	Description	Commonality	Source(s)
Congenital Malformation	Helical rotation during fetal development	Most frequent	1, 2, 8
Skin/Dartos Attachment	Abnormal skin or dartos fascia adherence	Common	3, 4, 8
Buck’s Fascia Anomaly	Abnormal Buck’s fascia connections	Less common	3, 8
Associated Anomalies	Hypospadias, chordee, or curvature	Increases risk	1, 6
Maternal Factors	Advanced maternal age, multiparity	Statistically significant	2

Table 3: Main Causes of Penile Torsion

Congenital Developmental Factors

The most widely accepted cause of penile torsion is a congenital malformation—essentially, the penis develops with a rotational twist during embryogenesis. This helical rotation can affect the distal corporal bodies while the penile base remains fixed 1, 2, 8.

Skin, Dartos, and Fascia Attachments

• Skin and Dartos: Abnormal adherence of the penile skin and the dartos fascia can “pull” the penis into a twisted configuration. This is a frequent finding during surgical repair and is one of the primary correctable factors 3, 4, 8.
• Buck’s Fascia: In some cases, abnormal attachments of Buck’s fascia (the deep penile fascia) contribute to the rotational deformity. This is less common but has important implications for surgical correction 3, 8.

Associated Anomalies

Penile torsion often occurs with other congenital anomalies:

• Hypospadias: The degree of torsion is often higher in distal hypospadias 1.
• Chordee: Ventral curvature is frequently present in cases with more significant torsion 1, 6.

Maternal and Perinatal Factors

Population studies indicate that the incidence of isolated penile torsion is higher in infants born to older mothers and those with multiple previous pregnancies (multiparity), although the exact biological mechanism is unclear 2.

Treatment of Penile Torsion

Treatment strategies for penile torsion have evolved significantly, offering effective correction with minimal complications. The choice of method depends on the severity of torsion, presence of associated anomalies, and the patient’s age and needs.

Treatment Method	Indication	Success Rate/Outcome	Source(s)
Observation	Mild/asymptomatic torsion	Often sufficient	2, 8
Penile Degloving	Mild/moderate torsion	Variable, less reliable	1, 5, 6
Urethral Plate Mobilization	Associated with hypospadias/chordee	High, effective	1, 6
Dorsal Dartos Flap Rotation	Moderate/severe torsion	High, few complications	4, 8
Diagonal Corporal Plication	Buck’s fascia involvement	Effective	3
Tunica Albuginea to Pubic Periosteum	Severe/recurrent torsion	Reliable, especially in children	5
Nesbit Procedure (Modified)	Complex curvature with torsion	Effective for unique cases	7

Table 4: Main Treatments for Penile Torsion

When Is Treatment Needed?

• Observation: Mild, asymptomatic torsion may not require intervention, especially if it does not affect function or appearance 2, 8.
• Surgical Correction: Indicated for moderate to severe torsion, functional impairment, or significant cosmetic/psychological distress.

Surgical Techniques

Penile Degloving

• Involves circumferentially freeing the penile skin to allow realignment of the shaft.
• Effective for mild torsion, but less reliable for severe deformities 1, 5, 6.

Urethral Plate Mobilization

• Particularly useful when torsion is associated with hypospadias or chordee.
• Mobilizing the urethral plate and surrounding tissues allows for correction of both torsion and curvature.
• High success rates with minimal complications 1, 6.

Dorsal Dartos Flap Rotation

• A modern, versatile technique where a flap of the dorsal dartos fascia is rotated to counteract the twist.
• Can be performed alongside other reconstructive procedures.
• Studies show high efficacy and low complication rates 4, 8.

Diagonal Corporal Plication

• Used when Buck’s fascia is the main contributor to torsion.
• A diagonal suture is placed to “untwist” the shaft, providing a targeted correction 3.

Tunica Albuginea to Pubic Periosteum Suturing

• For severe or recurrent cases, a suture is placed between the tunica albuginea and the pubic bone’s periosteum.
• Offers reliable long-term correction, especially in children 5.

Modified Nesbit Procedure

• Reserved for complex cases where torsion coexists with significant curvature.
• Involves excision or plication of tunica albuginea to straighten and untwist the penis 7.

Outcomes and Prognosis

• Most surgical techniques are highly successful when properly selected for the patient’s type and severity of torsion.
• Modern techniques (e.g., dorsal dartos flap rotation) are associated with excellent cosmetic and functional results and can be combined with repairs for hypospadias or chordee as needed 4, 8.
• Early intervention in severe cases prevents complications and improves psychosocial outcomes.

Conclusion

Penile torsion, while often overlooked, is a significant congenital condition that can impact both function and self-image. Early recognition and tailored treatment are key to ensuring optimal outcomes. Here’s what we covered:

• Symptoms include visible shaft rotation, deviation of the meatus or dorsal raphe, and sometimes associated curvature.
• Types range from mild to severe, with most cases rotating to the left and often associated with other anomalies.
• Causes are primarily congenital, involving abnormal skin, fascia, or developmental factors; maternal age and multiparity may increase risk.
• Treatment is individualized: mild cases may need no intervention, while moderate to severe torsion is effectively managed with modern surgical techniques such as dorsal dartos flap rotation or urethral plate mobilization.

Key Takeaways:

• Penile torsion is more common than often recognized, especially in newborns.
• Most cases are mild and benign, but moderate/severe torsion should be evaluated by a pediatric urologist.
• Surgical correction is highly effective, especially when customized to the underlying anatomical cause and associated conditions.

By fostering awareness and understanding, clinicians and families can ensure timely, compassionate, and effective care for those affected by penile torsion.