INVESTIGATIVE UROLOGY

The Penile Suspensory Ligament: Abnormalities and Repair
Li CY, Agrawal V, Minhas S, Ralph DJ
St Peter’s Hospital and Institute of Urology, London, UK
BJU Int. 2007; 99: 117-20

• Objective: To assess men presenting with abnormalities of the penile suspensory ligament (PSL) and its correction.
• Patients and Methods: In all, 35 men presenting with abnormalities of the PSL that were subsequently repaired were included in this series. The causes included; sexual trauma (15 men), congenital absence of the PSL/congenital penile curvature (14), and two each with venogenic erectile dysfunction, Peyronie’s disease and penile dysmorphic disorder. The diagnosis was made clinically by the presence of a palpable gap between the symphysis pubis and the penis, together with medical history and examination of penile torsion or instability. The surgical repair used nonabsorbable sutures placed between the symphysis pubis and the tunica albuginea of the penis.
• Results: A ‘good’ surgical outcome was defined as correction of the penile deformity or instability and achieving normal sexual function. There was a good surgical outcome in 91% of men as defined, and 86% of the men were happy with the outcome. There were no significant complications, but three men needed a repeat PSL repair.
• Conclusion: Men with abnormalities of the PSL can present with a variety of clinical symptoms, but when correctly diagnosed the repair is a simple technique with a successful cosmetic and functional outcome.
  
  
• Editorial Comment
  This is a welcome original contribution dealing with a neglected and poor recognized urological pathology. Anatomists and urologists well recognized that penile suspensory ligament (PSL) is important because it supports and maintains the erect penis in an upright position during sexual intercourse, and its defect would cause significant deformations hindering normal erections and intercourse (1). Since 1979, patients with defects in the suspensory ligament were recognized in the urological literature (2), including congenital etiology. Nevertheless, the authors of the present paper, in the best of my knowledge, described systematically by the first time the clinical history, physical findings and treatment of suspensory ligament abnormalities.
  Here, I would like to highlight some points described by the authors in the article. The PSL has susceptibility to trauma following sexual intercourse, particularly with forced downwards pressure, leading to penile instability, deformity and a variable degree of erectile dysfunction (ED). Penile pain was the predominant symptom in 11 of the 15 patients who presented after sexual trauma, and ED was the presenting symptom in 13 of the 35 men. Other symptoms were penile instability and deformity. Concerning diagnosis, the authors showed that it is made clinically, characterized by the presence of a palpable gap between symphysis pubis and the penis. Nevertheless, this is not always present, and in this series only 15 of the 35 men had this sign; thus, the authors emphasize that a supportive history such as penile trauma or evidence of penile deformity/instability on examination also helps in formulating the diagnosis. The surgical technique for treating PSL abnormalities presented here is simple and offers good results.
  The authors pointed out that a fractured penis is one of the differential diagnoses to PSL trauma since the mechanism of injury is usually similar in both conditions and both can present with the patient complaining of hearing a “snap”. Nevertheless, the authors teach us that men with a fractured penis usually have significant swelling and immediate detumescence; whereas men with PSL rupture usually do not have these signs.
  The final message of the authors from the present series is that abnormality of the PSL is a subtle diagnosis and men with this injury could present with a variety of symptoms and a variable degree of ED.
  I recommend this paper for all urologists involved with andrology and reconstructive surgery.

References

1. Hoznek A, Rahmouni A, Abbou C, Delmas V, Colombel M. The suspensory ligament of the penis: an anatomic and radiologic description. Surg Radiol Anat. 1998; 20: 413–7.
2. Pryor JP, Hill JT. Abnormalities of the suspensory ligament of the penis as a cause for erectile dysfunction. Br J Urol. 1979; 51: 402–3.

Dr. Francisco J.B. Sampaio
Full-Professor and Chair, Urogenital Research Unit
State University of Rio de Janeiro
Rio de Janeiro, RJ, Brazil