Causes of Penile Shaft Shortening
Peyronie's disease is the most common pathological cause of penile shaft shortening in middle-aged men, typically presenting in the mid-50s with curvature, plaque formation, and progressive length loss. 1, 2
Primary Pathological Causes
Peyronie's Disease
Repetitive microvascular trauma during sexual activity initiates a cascade of extravascular protein deposition, fibrin trapping, macrophage recruitment, and cytokine overexpression, shifting tunical collagen from type I to predominantly type III. 1, 2
Penile shortening results directly from plaque formation and becomes more pronounced during the stable (chronic) phase of the disease, when symptoms have been clinically unchanged for at least three months. 1, 2
The typical presentation includes recent onset of penile curvature with mild-to-moderate penile pain; many patients do not recall a specific inciting sexual or non-sexual event. 1, 2
Curvature may be uniplanar or biplanar and is not always dependent on the size and magnitude of the plaque; plaques may be palpable on examination or apparent on ultrasound. 1
Veno-occlusive dysfunction secondary to the plaque itself occurs in 87% of Peyronie's patients who present with loss of penile rigidity, as decreased compliance of underlying corporal smooth muscle prevents venous compression. 3
Ischemic Priapism Complications
Untreated or prolonged ischemic priapism leads to permanent corporal fibrosis and penile shortening through irreversible loss of smooth-muscle tissue. 2, 4
Smooth-muscle edema and atrophy can be detected as early as six hours after priapism onset; episodes lasting longer than 36 hours result in permanent erectile dysfunction with no functional recovery and marked penile shortening due to fibrotic remodeling. 2
Acute ischemic priapism is a medical emergency requiring immediate intervention to prevent these irreversible structural changes. 4
Surgical and Iatrogenic Factors
Surgical correction of Peyronie's disease itself causes penile shortening, particularly when tunical shortening (plication) techniques are employed. 2, 5
Even tunical lengthening procedures (grafting) may produce net length reduction, especially when combined with plication for complex deformities. 2, 5
Penile prosthesis implantation for concurrent erectile dysfunction in Peyronie's patients yields lower overall satisfaction compared with prostheses placed for non-Peyronie's erectile dysfunction, primarily because of persistent length concerns. 2
Age-Related and Vascular Changes
Aging is associated with fewer smooth muscle cells and increased fibrosis within the corpora cavernosa, preventing adequate penile engorgement and contributing to perceived shortening. 6
Metabolic impediments to nitric oxide production from aging and poor lifestyle choices reduce blood flow into the penis, affecting erectile quality and perceived size. 6
Penile nerve injury that accompanies even "nerve-sparing" radical prostatectomy causes rapid structural changes with smooth muscle loss and fibrosis, leading to penile shortening. 6
Evaluation Approach
History and Physical Examination
Obtain a careful history assessing penile deformity, interference with intercourse, penile pain, and psychological distress; document symptom onset, progression, and any recalled trauma. 1
Perform a physical examination of the genitalia to assess for palpable abnormalities, plaques, induration, and penile deformity in the flaccid state. 1
Distinguish between active disease (characterized by dynamic symptoms, penile pain with or without erection, and progressive deformity) and stable disease (symptoms unchanged for at least three months, minimal pain, established curvature). 1
Exclude rare pathologies such as penile tumors when assessing penile changes in middle-aged men. 2
Objective Documentation
Curvature and deformity are best documented by patient self-photograph or pharmacologically induced erection during office intracavernosal injection testing. 7, 5
Correlation between patients' subjective perception of penile size and objective measurements is limited; rely on careful physical examination and appropriate imaging rather than perception alone. 1, 2
For patients with erectile dysfunction, stretched penile lengths are typically shorter (mean 11.2 cm vs 12.9 cm in potent men), and this should be considered during evaluation. 7
Imaging Studies
Ultrasound examination is the diagnostic modality of choice for evaluating palpable penile abnormalities and documenting plaque characteristics. 1, 5
Color Doppler and duplex ultrasonography are used to evaluate Peyronie's disease and assess vascular function. 8
In select patients with very large masses, MRI may be appropriate, though gadolinium-based contrast use should be evaluated critically depending on specific patient factors. 1
Vascular and Erectile Function Assessment
Evaluate arterial input into the penis by penile Doppler studies, duplex ultrasound, or cavernosal occlusion pressures to determine the presence of arterial insufficiency. 3
Perform dynamic cavernosometry and cavernosography when veno-occlusive dysfunction is suspected, particularly in Peyronie's patients with loss of rigidity. 3
Measure penile sensation to determine if an underlying neurological problem is present. 3
Management Strategies
Conservative and Medical Treatment
For active Peyronie's disease, pharmacotherapy options include oral potassium para-aminobenzoate, intralesional treatment with verapamil, clostridial collagenase or interferon, topical verapamil gel, and iontophoresis with verapamil and dexamethasone, though none carry a grade A recommendation. 5
Steroids, vitamin E, and tamoxifen cannot be recommended for Peyronie's disease treatment. 5
Penile traction devices may be used to reduce penile deformity and mitigate further length loss. 2, 5
Post-operative penile rehabilitation using vacuum erection devices and penile traction therapy can mitigate further length loss after surgery. 2
Erectile Dysfunction Management
For patients with arterial insufficiency, consider self-injection with vasoactive agents or a vacuum constrictor device before surgical options. 3
Phosphodiesterase type 5 inhibitors are the mainstay of medical treatment for erectile dysfunction and should be tried prior to considering penile prosthesis implantation. 4, 1
Early chronic use of a PDE5 inhibitor largely prevents rapid structural changes following penile nerve injury in animal models. 6
Surgical Intervention
Surgery for Peyronie's disease is indicated when the disease is stable for at least three months based on either patient report or clinician documentation. 1, 5
Tunical shortening procedures, especially plication techniques, are the first surgical treatment options for Peyronie's disease. 5
Tunical lengthening procedures (grafting) are preferred in more severe curvatures or complex deformities. 5
Penile prosthesis implantation is recommended in patients with erectile dysfunction not responding to pharmacotherapy; three-piece inflatable devices may provide more natural erections, while semirigid prostheses offer simpler implantation and use. 1, 5
Psychosocial Impact and Counseling
54% of men with Peyronie's disease report relationship difficulties, and depressive symptoms remain consistently high over time, suggesting lasting psychological impact. 1, 2
Men express concerns about the physical appearance of their penis and report negative impacts on masculine self-image, sexual satisfaction, increased anxiety in sexual situations, and decreased sexual confidence. 1
Comprehensive evaluation and counseling are warranted regardless of measured dimensional change, as penile shortening significantly affects masculine self-image, sexual satisfaction, and relationship quality. 2
Psychosocial interventions including sexual skills training and cognitive behavioral therapy, delivered individually or online, complement medical treatment effectively. 1
Critical Clinical Pitfalls
Do not dismiss patient concerns about penile shortening as purely psychological; underlying pathology such as Peyronie's disease, priapism sequelae, or post-surgical changes may be present and requires thorough evaluation. 2
Do not delay evaluation when symptoms are progressive or accompanied by pain, as early intervention in active Peyronie's disease may prevent further deformity. 1
Do not assume that all penile shortening is irreversible; addressing underlying erectile dysfunction with PDE5 inhibitors and penile rehabilitation may improve functional length. 6
Do not proceed with surgery for Peyronie's disease until the disease has been stable for at least three months, as spontaneous improvement may occur, particularly in younger men and those with symptoms present for less than six months. 1, 5