Chordee is a congenital condition characterized by a noticeable downward, or less commonly upward, curvature of the penis. This results from an abnormality in the development of the penile structure during gestation. Parents often observe this bending, which can range from mild to severe, and wonder if it will resolve naturally. This article explores the anatomical basis of chordee and details its natural progression to clarify when observation is appropriate and when medical intervention is necessary.
Understanding Chordee and Its Causes
Chordee occurs due to a structural imbalance within the tissues that make up the penis. The curvature is caused by a disparity in length or elasticity between the dorsal (top) and ventral (bottom) sides of the penile shaft. The underlying cause is generally classified into distinct anatomical issues.
Fibrous Tissue
One common factor is the presence of fibrous tissue, which is non-elastic scar-like tissue that tethers or restricts the underside of the penis. This dense tissue, such as in the dartos or Buck’s fascia, pulls the shaft downward, creating the bend.
Corporal Disproportion
Curvature can also result from a disproportionate length of the two main erectile chambers, known as the corpora cavernosa. In this scenario, one side of the chambers is structurally shorter than the other, causing the penis to bend when it is erect.
Associated Conditions
Chordee is frequently associated with hypospadias, a birth defect where the urinary opening is located on the underside of the penis instead of at the tip. However, chordee can also occur in isolation. Less severe cases may be due to simple skin tethering or webbing. Understanding the specific cause influences the likelihood of self-correction.
Natural History and Likelihood of Self-Correction
The likelihood of chordee correcting itself spontaneously depends entirely on the underlying structural cause. Curvatures caused by true structural abnormalities, such as fibrosis or corporal disproportion, will not resolve as the child grows. These fibrotic bands are non-elastic and will continue to restrict the penis, maintaining the bend. If the chordee is due to an internal structural problem, it will remain or even worsen in appearance as the child’s penis develops and lengthens.
The curvature is always most pronounced during erection, as the restricted tissue prevents the penis from fully straightening. In many cases, the curvature may not even be noticeable until adolescence when the boy experiences his first erection. Minor curvatures due only to skin tethering may sometimes appear less noticeable as the child grows, but true structural chordee rarely corrects itself.
The role of the pediatrician in monitoring chordee is to observe the degree of the bend over time. If the curvature is mild and does not affect the ability to urinate, a period of observation may be recommended. However, parents should understand that if a structural issue is the source of the bend, medical intervention is the only effective way to achieve permanent correction.
Deciding When Medical Intervention is Necessary
The decision to pursue medical intervention for chordee is based primarily on the potential for functional impairment. The main concern for urologists is whether the curvature will interfere with two functions: voiding and future sexual activity. A bend severe enough to cause difficulty in aiming the urinary stream, or that forces the child to sit down to urinate, is a clear indication for correction.
The predicted impact on adult sexual function is another major determinant for intervention. A curvature likely to prevent comfortable penetration or cause pain during intercourse warrants surgical repair. While there is no single, fixed threshold, many specialists recommend correction for a bend exceeding 15 to 20 degrees. This degree of angulation is considered likely to cause issues later in life.
The typical window for evaluation and potential surgical repair is early childhood, often between 6 and 18 months of age. Repairing the condition during this time is advantageous because the tissues are pliable, allowing the penis to grow and develop normally. Early correction also removes potential psychological distress before the child reaches school age or puberty.
Overview of Surgical Correction
Surgery is the only definitive treatment for structural chordee and is highly successful in achieving a straight penis. The goal of the procedure, called an orthoplasty, is to straighten the penile shaft by addressing the underlying cause of the tethering. The first step involves a process called degloving, where the skin is peeled back to expose the underlying structures.
If the chordee is caused by fibrous tissue, the surgeon releases or excises these inelastic bands from the underside of the shaft. After this initial release, an artificial erection is induced by injecting saline into the corpora cavernosa to assess the remaining degree of curvature. If a significant bend remains, the issue is structural disproportion within the erectile bodies.
To correct this, two general principles are followed: either shortening the longer side or lengthening the shorter side. Plication techniques, such as the Nesbit or Tunica Albuginea Plication (TAP), involve placing sutures to tighten the tissue on the convex (longer) side of the penis. For severe cases, the shorter ventral side may be surgically lengthened by making an incision and placing a graft, such as a dermal or tunica vaginalis graft, to bridge the gap. If hypospadias is also present, the chordee correction and the repositioning of the urinary opening are typically performed simultaneously.