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The Penile Suspensory Ligament: Abnormalities And Repair

June 18, 2017

The penile suspensory ligament (PSL) supports and maintains the erect penis in an upright position during sexual intercourse. The suspensory apparatus of the penis consists of the fundiform ligament, the suspensory ligament proper and the arcuate subpubic ligament. The fundiform ligament is superficial and not adherent to the tunica albuginea, whilst the suspensory ligament proper bridges between the symphysis pubis and the tunica albuginea of the corpus cavernosum and circumscribes the dorsal vein of the penis. The arcuate subpubic ligament runs a similar course to the suspensory ligament proper; it is a slightly denser structure and lies further posterior. Functionally, the PSL maintains the base of the penis in front of the pubis and acts as a major point of support for the erect penis during intercourse.

A group from St. Peter's Hospital in London, UK led by Chi-Ying Li report on a group of 35 men with abnormalities of the PSL who subsequently underwent repair. The report is published in the January 2007 issue of BJU International.

Fifteen of the 35 men presented with PSL abnormalities after sexual trauma from forced downwards pressure of the erect penis. They complained of penile instability, deformity and variable degrees of erectile dysfunction (ED). The other men had similar complaints but no distinct history of a traumatic injury. All men underwent a detailed medical history and had the physical exam finding of a palpable gap between the pubis and the penis which was more evident when the men were given a pharmacologically induced erection.

The surgical technique of repair included identifying the PSL via a transverse suprapubic incision. Once identified, the PSL was reinforced or repaired using nonabsorbable no. 1 Nylon sutures placed from the midline of the tunica to the pubic symphysis, until the optimal functional penile position was achieved as documented by an artificial erection test. The mean number of sutures required was 4. When there was also penile curvature present (21 men), the curvature was corrected at the same time using a variety of techniques such as Nesbit's procedure or plaque incision and grafting. After surgery, men were asked to delay sexual intercourse for 6 weeks.

Analysis of results revealed that thirty-two of 35 men (91%) had a straight penis; two men had a residual curvature < 15 degrees and one had 25 degrees of residual curvature. Two men (6%) developed de novo ED, which was successfully treated with sildenafil. Both of these men had repair of the PSL and a Nesbit procedure for penile curvature. Two men who presented with venogenic ED were cured as were all of the men who presented with penile pain. There were no postoperative complications although three men had a repeat procedure for inadequate results including one who had penile dysmorphic disorder. The overall satisfaction rate was 86% (30 of 35 men).

This report describes the often overlooked problem of an abnormality of the penile suspensory ligament. The diagnosis is largely clinical and can be elicited by physical exam findings. This problem can be induced iatrogenically after the penile suspensory ligament is divided in penile lengthening surgery and the technique for repair described here can be useful in that clinical condition and those that are described in this report.

BJU Int. 2007 Jan.; 99(1): 117-20

Reviewed by UroToday Contributing Editor Michael J. Metro, M.D

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