0022-5347/01/1665-1766/0

THE JOURNAL OF UROLOGY

Copyright 2001 by AMERICAN UROLOGICAL ASSOCIATION, INC.

Vol. 166, 1766 1768, November 2001

Printed in U.S.A.

ULTRASTRUCTURE OF THE TUNICA ALBUGINEA IN CONGENITAL

PENILE CURVATURE
BARBARA DAREWICZ, JACEK KUDELSKI, BEATA SZYNAKA, HENRYK F. NOWAK
JANUSZ DAREWICZ

AND

From the Departments of Urology and Pathology, Medical Academy of Bialystok, Bialystok, Poland

ABSTRACT

Purpose: We investigated the ultrastructure of the tunica albuginea in individuals with

congenital penile curvature to explain the pathology of this disease.
Materials and Methods: Included in our study were 15 patients 17 to 24 years old with
congenital penile curvature. Study material consisted of samples of the tunica albuginea excised
from the greater curvature of the corpus cavernosum during surgical correction. Control samples
were obtained from the lesser curvature on the side opposite the study material during the same
operation. The 2 types of tissue were analyzed using transmitter electron microscopy.
Results: Ultrastructural examination of the control material revealed numerous collagen fibers
that were homogenous in size and organization on cross section. Periodic striation was typical in
collagen that produced fibers. In the study group the tunica albuginea structure had a chaotic
pattern of collagen fibers that formed bundles with disrupted 3-dimensional organization. Diameter of the fibers differed greatly on cross section. We observed periodic widening and
fragmentation of collagen fibers with the complete disappearance of striation and transformation
into electron dense, fibrous granulated material. Disrupted fibroblasts without cell membrane
and cellular organelles between collagen fibers were also visible. There was elastin accumulation
without any morphological differences in the control and study groups.
Conclusions: Our results show that ultrastructural changes in the tunica albuginea may cause
congenital penile curvature, possibly by altering mechanical properties.
KEY WORDS: penis, abnormalities, anatomy, collagen

By definition congenital penile curvature is an altered penile

shape that results in axial deviation of the distal penis compared with its proximal portion. Curvature becomes visible
during penile tumescence and it is completely painless. It may
cause difficult intercourse or make it completely impossible.
Pure congenital penile curvature due to corporeal asymmetry is
considered type IV according to the Devine and Horton classification.1 It occurs in approximately 0.37/1,000 males.2
A condition of normal penile shape during erection is equal
resilience of the tunica albuginea. The structure of the tunica
determines its mechanical properties and penile extensibility. Its impairment may alter penile shape and cause erectile
dysfunction. The tunica albuginea is composed mainly of
collagen fibers and to a lesser extent of elastic fibers, of which
90% is elastin. Collagen fibers are durable with little elasticity. On the other hand, elastic fibers may extend up to 150%
to 200% and they are responsible for the elastic properties of
the tunica.3 Tunica albuginea thickness differs at different
sites.4 The mid dorsal part has been described as the thickest
and most resistant section.5, 6
To our knowledge the etiology and pathogenesis of congenital penile curvature remains unexplained. Several hypotheses have been proposed but none has been proved by biochemical and ultrastructural studies. Since the possible
causes of disease is asymmetrical development of the tunica
albuginea of the corpora cavernosa,711 unilateral excessive
or impaired growth of the corpora cavernosa has been proposed.1215 The defect in the ultrastructure of the tunica
albuginea has also been suggested.7, 10, 11, 16
Treatment of congenital penile curvature involves surgical
correction. The unknown etiology causes a lack of specific
therapy options. We investigated the ultrastructure of the
Accepted for publication June 15, 2001.

tunica albuginea in individuals with congenital penile curvature to explain the pathology of this disease.
MATERIALS AND METHODS

Included in our study were 15 patients 17 to 24 years old

(mean age 19.2) with congenital penile curvature. Specimens of
the tunica albuginea excised from the greater curvature of the
corpus cavernosum during surgical correction according to the
modified Nesbit procedure served as study material.9 Control
samples were obtained during the same operation from the
lesser curvature on the side opposite the study material. Approximately 1 mm.3 tissue was excised from each specimen and
fixed immediately in 3.6% glutaraldehyde. After 2 hours samples were post-fixed in 2% osmium tetroxide. Tissues were then
dehydrated in graded alcohols containing propylene oxide and
embedded in Epon 812. Initial tissue evaluation was performed
under light microscopy after staining with toluidine blue. Ultrathin sections were stained with lead citrate and uranyl acetate, and analyzed under transmitter electron microscopy.
RESULTS

Ultrastructural evaluation of the control material from the

lesser curvature revealed elongation of the fibroblasts and
small blood vessels. Collagen fibers had equal diameters on
cross section and showed typical periodic striation for collagen types I and III. They were also normal in quantity,
quality and organization (fig. 1).
The ultrastructure of the tunica albuginea of the study material obtained from the greater curvature showed an irregular
and chaotic pattern of collagen fibers with a disrupted
3-dimensional configuration. There was a prominent difference
in fiber diameters on cross section (fig. 2). We observed periodic
widening and fragmentation of the collagen fibers with the

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1767

FIG. 1. Longitudinal section of Collagen fibers in controls. A, longitudinal section shows fibers homogenous in size, periodicity and
organization, characteristic of type I collagen. B, cross section demonstrates even diameter of collagen fibers. Reduced from 20,000.

FIG. 2. Collagen fibers of different diameters in tunica albuginea of study group. A, longitudinal section. Arrows indicate fibers. B, cross
section. Reduced from 30,000.

complete disappearance of striation and transformation

into electron dense, fibrous granulated material (fig. 3).
Some collagen fibers were bent at a right angle (fig. 3).
Disrupted fibroblasts without a cell membrane and cellular organelles between collagen fibers were also visible
(fig. 4). Elastin accumulation was evident in the control
and study groups (fig. 4).
DISCUSSION

The main interest in the ultrastructure and immunohistochemical results of the tunica albuginea is related to Peyronies
disease and vasculogenic erectile dysfunction. Tunica albuginea
samples are usually compared with healthy tissue. The results
of those studies are inconsistent. When studying those 2 diseases, Gentile et al noted similar ultrastructural and immunohistochemical alterations in the tunica but no pathological
changes in the corpora cavernosa.17 Of the possible explanations altered fibroblast metabolism and modified intracellular
substance were considered. During ultrastructural examination hypercellular activated fibroblasts with hypertrophic rough
endoplasmic reticulum were visible. The collagen fibers had
different diameters and 3-dimensional arrangements. Fibroblasts contained intracytoplasmic vacuoles that were filed with
partially degraded collagen fibers. An amorphous extracellular
substance composed of glycoprotein and proteoglycan was also
identified. Gentile et al suggested that vasculogenic erectile

dysfunction and Peyronies disease may be characterized by

similar structural and immunohistochemical modifications of
the tunica albuginea. Akkus et al studied the ultrastructure
of Peyronies plate and noted disorganization and hialinization
of the collagen fibers with a dense arrangement and minimal
ground substance between them. The number of elastic fibers
was decreased and they were irregular in shape.18 Our studies
of the tunica albuginea of the corpora cavernosa in the control
material obtained from the lesser curvature showed an ultrastructure typical of normal tissue.1719 The morphology of the
tunica albuginea samples obtained from the study group from
the greater curvature was different. Chaotic alignment of the
collagen fibers with different diameters, periodic widening,
signs of disintegration and angulation was predominant. Numerous disrupted fibroblasts were also visible. We observed
elastin accumulation without any morphological differences in
the control and study groups.
Our results imply that the diseased portion is the tunica
albuginea of the corpora cavernosa along the greater curvature,
which is too yielding and allows the penis to curve. This process
is not diffuse throughout the tunica albuginea. Disordered collagen contributes to change the biomechanics of the tunica
albuginea of the corpora cavernosa. Ultrastructural images of
the tunica albuginea from our study group resembled to some
extent the pathological changes characteristic of the tunica
involved by Peyronies disease. However, the less intense des-

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ULTRASTRUCTURE OF TUNICA ALBUGINEA IN PENILE CURVATURE

FIG. 3. Collagen fibers with chaotic arrangement, different diameters, periodic widening and disintegration (arrow) in electron dense
material along fiber course of tunica albuginea in study group. Some
fibers were bent at right angles (arrowheads). Reduced from
30,000.

3. Brock, G., Hsu, G. L., Nunes, L. et al: The anatomy of the tunica
albuginea in the normal penis and Peyronies disease. J Urol,
157: 276, 1997
4. Hsu, G., Brock, G., Von Heyden, B. et al: The distribution of
elastic fibrous elements within the human penis. Br J Urol, 73:
566, 1994
5. Baskin, L. S., Lee, Y. T. and Cunha, G. R.: Neuroanatomical
ontogeny of the human fetal penis. Br J Urol, 79: 628, 1997
6. Baskin, L. S., Erol, A., Li, Y. W. et al: Anatomical studies of
hypospadias. J Urol, part 2, 160: 1108, 1998
7. Baskin, L. S. and Duckett, J. W.: Dorsal tunica albuginea plication for hypospadias curvature. J Urol, 151: 1668, 1994
8. Lindgren, B. W., Reda, E. F., Levitt, S. B. et al: Single and
multiple dermal grafts for management of severe penile curvature. J Urol, part 2, 160: 1128, 1998
9. Nesbit, R. M.: Congenital curvature of the phallus: report of
three cases with description of corrective operation. J Urol, 93:
230, 1965
10. Poulsen, J. and Kirkeby, H. J.: Management of patients with
penile curvature. Eur Urol, Update Series, 5: 57, 1996
11. Yachia, D.: Early assessment of penile curvatures in infants.
J Urol, 145: 103, 1991
12. Baskin, L. S., Duckett, J. W. and Lue, T. F.: Penile curvature.
Urology, 48: 347, 1996
13. Fitzpatrick, T. J.: Hemihypertrophy of the human corpus cavernosum. J Urol, 115: 560, 1976
14. Perovic, S. V., Djordjevic, M. L. and Djakovic, N. G.: A new
approach to the treatment of penile curvature. J Urol, part 2,
160: 1123, 1998
15. Sislow, J. G., Ireton, R. C. and Ansell, J. S.: Treatment of congenital penile curvature due to disparate corpora cavernosa by
the Nesbit technique: a rule of thumb for number of wedges of
tunica required to achieve correction. J Urol, 141: 92, 1989
16. Watson, D. L. and Morgentaler, A.: Spontaneous corporeal herniation of the penis: a new abnormality of the tunica albuginea? J Urol, 153: 737, 1995
17. Gentile, V., Modesti, A., La Pera, G., Vasaturo, F., Modica, A.,
Prigiotti, G., Di Silverio, F. and Scarpa, S.: Ultrastructural
and immunohistochemical characterization of the tunica albuginea in Peyronies disease and veno-occlusive dysfunction. J
Androl, 17: 96, 1996
18. Akkus, E., Carrier, S., Baba, K., Hsu, G., Padma-Nathan, H.,
Nunes, L., and Lue, T. F.: Structural alterations in the tunica
albuginea of the penis: impact of Peyronies disease, ageing
and impotence. Br J Urol, 79: 47, 1997
19. Iacono, F., Barra, S., Cafiero, G. and Lotti, T.: Scanning electron
microscopy of the tunica albuginea of the corpora cavernosa in
normal and impotent subjects. Urol Res, 23: 221, 1995
EDITORIAL COMMENT

FIG. 4. Fragments of fibroblast (F) with disrupted cellular membrane and intracytoplasmic organelles between collagen fibers of
tunica albuginea in study group with local elastin accumulation (E).
Reduced from 7,000.

moplasia and lack of activated fibroblasts were the major differences in our study.18
The alterations in collagen fiber structure in our study may
have been a result of genetic changes or local damage during
gestation or after birth. Periodic widening and disintegration
of the collagen fibers with disrupted fibroblasts may be the
sign of active permanent metabolic alteration of the connective tissue. In conclusion, our study shows that the disrupted
structure of the tunica albuginea may have a role in the
etiology of congenital penile curvature, possibly by interfering with its mechanical properties.
REFERENCES

1. Devine, C. J., Jr. and Horton, C. E.: Bent penis. Semin Urol, 5:
252, 1987
2. Ebbehoj, J. and Metz, P.: Congenital penile angulation. Br J
Urol, 60: 264, 1987

The authors conducted important research on the ultrastructure of

the tunica albuginea in congenital penile curvature. They used samples
from the greater curvature and compared them to those from the side of
the lesser curvature (control). The conclusion was that the morphological abnormality is primarily in the larger curvature, which permitted
more expansion leading to the congenital deformity. Knowing the difference between the tunica albuginea on the larger curvature and its
ultrastructure on the lesser curvature is important in determining the
site of pathology and the best approach for management. Using samples
from the lesser curvature as a control, assuming that the lesser curvature side is perfectly normal, might not be completely accurate. It is
important to compare both sides of the curvature. However, full control
if taken from the straight segment of the penis would have been more
appropriate. Limiting the abnormality to the larger curvature means
that surgical attention should be definitely limited to that site also.
However, we did not get information on the extent of this abnormality
on the larger curvature. Is the entire corpora on that side defective,
while the other corpora is intact? Or it is just a patchy area in the tunica
of this particular side that is affected? Guided by these findings, which
are in accordance with clinical experience, limiting correction to the
greater curvature is probably the advisable approach. More work is still
needed to determine the extent of this lesion and its exact etiology.
Emil A. Tanagho
Department of Urology
University of California
San Francisco, California