We present a novel approach to the management of significant penile girth discrepancy, the “Christmas tree deformity,” with a modified plication/reduction corporoplasty technique.

Case Presentation

A 43-year-old male patient presented with new-onset dorsal penile curvature and crescendo shaped proximal girth discrepancy. He subsequently reported a decrease in penile length and was bothered by his abnormal increase in proximal penile girth. He felt this inhibited him from having successful penetrative intercourse, secondary to the physical limitations and psychosocial effects. He denies prior trauma, surgery or inciting factors. He was initially managed with conservative therapy consisting of 5 mg tadalafil every other day, 400 mg Trental (pentoxifylline) orally twice daily and 1,000 mg L-arginine orally daily. At the time of presentation, a penile Doppler was performed, which demonstrated mild venous insufficiency, micro-calcifications throughout the corpora and intracavernosal fibrosis bilaterally in the mid-proximal phallus.

He continued to follow up regularly in clinic with little improvement and persistent life-limiting complaints of proximal penile girth discrepancy consistent with what we describe as a “Christmas tree deformity” because of the smooth crescendo increase in girth proximally. We also encouraged him to seek out several opinions throughout the country with regard to management, and we continued to follow him for the next 5 years. At this time point, the dorsal curve had resolved, and he wanted to proceed with surgical reconstruction to decrease the proximal girth and make his shaft symmetrical.

Despite his morphological abnormality, he continued to have adequate erections, orgasms and ejaculation with masturbation without significant penile pain. He strongly wished to be sexually active, and he felt that the abnormal increase in girth toward the proximal base prohibited his ability to engage in sexual intercourse. His pathology ultimately impacted him significantly on a psychosocial level, and he was previously referred to a mental health expert for evaluation and management.

Surgical Management

After risks, benefits and alternative treatment options were discussed with the patient, informed consent was obtained for a modified horizontal penile plication/reduction corporoplasty. In the operating room, an artificial erection was obtained with an intracavernosal injection of 20 μg prostaglandin E1 (PGE1). A circumferential incision was made over his previous circumcision scar and his penis was degloved in standard fashion. After degloving proximally, it was easy to appreciate the bilateral proximal aneurysmal dilatation of the penis (fig. 1), most prominent at the proximal to mid phallus with a girth discrepancy of more than 5 cm.

Figure 1. Degloved penis demonstrates width discrepancy mid-proximal shaft, characteristic “Christmas tree penis.”

To correct the asymmetry, we then started placing transverse (horizontal) 2-dot fashion plication sutures (3-zero Ti-Cron™) in the proximal aspect of the penile shaft (fig. 2). These 2-dot plication sutures were placed in staggered fashion, tapering each plication as we progressed more distally (fig. 3). Twenty 2-dot plication sutures were placed on each corporal side with correction of the girth asymmetry, creating a more symmetrical shaft (fig. 4). The incision was closed with 4-zero Monocryl® suture in an interrupted fashion. He was monitored overnight and discharged uneventfully on postoperative day 1, with dressing removal 48 hours postoperatively.

Figure 2. Placement of transverse (horizontal) 2-dot plication sutures.

Figure 3. Illustration of staggered transverse (horizontal) 2-dot plication sutures allowing for width discrepancy correction.

Figure 4. Correction of width asymmetry after placement of staggered transverse (horizontal) 2-dot plication sutures.

Results

Outcome was determined by assessing the cosmetic morphology of the phallus and the patient’s self-reported sexual function and satisfaction. On his initial postoperative visit, he reported good erectile function, although had yet to proceed with any type of sexual activity. He had not had any recurrence of his aneurysmal deformity and denied any penile pain. Six months postoperatively, the patient was seen without any recurrence of his previous girth discrepancy, denied erectile issues and admitted to successful intercourse. He was pleased with his symmetrical morphology with erections.

Discussion

Penile morphology is a critical assessment variable, evaluated by the patient, the partner and the provider. Nowadays men and women are more uninhibited to discuss their sexuality and their genitalia due to the increased exposure and openness to these topics in the media as well as the social and cultural advancement.¹ This in turn makes men, regardless of sexual preference, scrutinize themselves more regarding their physical attributes, especially their genitalia.¹

It is not uncommon to have patients come in for evaluation of their penis due to unsatisfaction or unrealistic expectations regarding penile size and morphology.² As physicians, especially practicing urology, andrology and sexual medicine, we must be aware of the diagnosis of body dysmorphic disorder. These patients are excessively preoccupied with a perceived flaw or abnormality that is not noticeable or barely noticeable to others.³ On the other hand, there are a variety of organic causes and clinical scenarios that can affect “normal” morphology and possibly function, such as Peyronie’s disease, hypospadias, trauma and obesity. The strategies that are commonly employed to further expose the penis and improved the perceived length, including ventral phalloplasty, suspensory ligament release and repair of buried penis, differ completely from the focus of this patient and his needs, since his main issue is not a perceived problem.^4-6

For this patient we employed plicating sutures to employ a reduction corporoplasty technique. Plicating sutures to correct anatomical variations can be performed efficiently with a high success rate and low morbidity. The typical “vertical” plication performed for correction of curvature differs from the process we describe, as our goal was not to correct angulation, but to correct tunical laxity and aneurysmal dilatation causing the significant girth discrepancy. Using a similar approach typically performed for penile plications, ours differed mainly with the direction in which the plicating sutures were placed, since our approach employed transverse (horizontal) 2-dot sutures. The outcome was successful in terms of achieving a symmetrical shaft and confirmed patient satisfaction.

Conclusion

This is a novel technique for a rare, but present, phenomenon regarding penile girth discrepancy. While limited investigation has been performed, we believe this is a safe and technically feasible technique that provides excellent cosmetic and functional results with minimal risk. Strategies to alter penile morphology, specifically for correction of aneurysmal dilation with the use of reduction corporoplasty,⁷ have been reported, but this arena remains challenging for patients and providers alike.