Peyronie’s Anatomy of the Penis and Related Areas

Peyronie’s Disease – Special Interest Anatomy of the Penis and Related Areas

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The penis is the male organ of reproduction and urinary elimination, located on the mid-line of thet lower abdomen at the level of the pubic bone, above the scrotum. It develops in the male embryo from a small mass of tissue that also forms the clitoris in the female embryo.  If you want to get the most from your Peyronie’s treatment it is necessary to understand the anatomy of the penis.

The Penis

Peyronie's disease and penile curvature are easier to understand if you understand anatomy
Notice that the tunica albuginea – where the PD plaque or scar is located – is below the surface of the skin. Therefore the PD scar or plaque is an internal structure and cannot be seen from the exterior.

The penis is actually made of three separate cylinders (two on top and one on bottom) of a special type of erectile tissue that are capable of filling with blood and becoming rigid. Each of the three cylinders is covered with a thin layer of thin but tough connective tissue, as well as being bound together as a group with that same type of thin tissue. The two top cylinders are called the “corpora cavernosa” because of the thousands of tiny caverns, or open spaces in the tissue that fill with blood during erection. The bottom cylinder is called the “corpora spongiosum” because it is composed of soft and spongy tissue; it has the “urethra” or urinary passage tube running through it from the bladder, and ends at the tip of the penis. As the corpora spongiosum nears the end of the penis, it flares out to form the “glans” or head of the penis that looks like a mushroom or cap on top of the two corpora cavernosa.

If you are interested in learning about Peyronie’s disease, then you must understand the special connective tissue layers below the skin surface of the penis.  A particular tissue that is so important in any discussion of PD is a very thin membrane, called the tunica albuginea.  It is made of connective tissue and it covers or wraps around the two corpora cavernosa cylinder bodies. Under the microscope it is possible to see that the tunica albuginea is not a solid structure but it is a laminated, or multilayer structure like pages of a book or layers of an onion. The tunica albuginea not only covers the penis structure once with this laminated tissue, it covers it twice. The first deep layer, shaped like a tube, encloses each of the two corpora cavernosa. Since the corpora cavernosa are located closely side-by-side, where the two cylinders touch along the mid-line the inner layer forms a band of tissue called a septum. The second layer of the tunica albuginea, also shaped like a tube but twice as large, goes around the pair of the corpora cavernosa. (Think of it this way: the two corpora cavernosa are like two hot dogs, side by side; each hot dog has a casing or cover on it; the two hot dogs and their casings are held together with another layer of casing to bind them together in a pair. Where the two hot dogs and casings touch each other, the two casings fuse to make the septum; the septum fuses also to the second casing layer to make a very strong and secure structure.)

Back to the penis : The septum of the deep inner layer attaches along the mid-line to the top and bottom section of the superficial outer layer, creating a structure that is almost like an I-beam. In addition, there is another or third layer of connective tissue around the two corpora cavernosa that is even more superficial than the tunica albuginea. It is another tubular layer of tissue, called Buck’s fascia, that gives the penis added rigidity when the corpora cavernosa fill with blood during erection. There are no nerve endings in the tunica albuginea, but there are nerve endings in Buck’s fascia. Any pain associated with PD comes from stretching or inflammation of Buck’s fascia, not the tunica albuginea.

The blood supply to the penis, by way of the internal pudendal artery, is abundant. Good blood circulation is required for the corpora cavernosa and corpora spongiosum to produce an erection. However, not all parts of the penis have or need a good supply of blood. As is typical of most connective tissue in the body, the tunica albuginea does not have a good blood supply – it doesn’t need it for the most part, although this poor blood supply works against it. When injured, the poor blood flow to the tunica albuginea causes it to heal slowly or poorly in some cases. The limited blood supply to the tunica is an important aspect of the anatomy of the penis that affects the outcome of Peyronie’s disease.

Therefore, keeping the blood flow to the penis as full as possible is vital to the health of this tissue and improves chances for its recovery after injury; lack of blood flow favors scar development. It is perhaps no coincidence that a study showed that out of 76 cases of PD 36% had arterial disease and 59% had obstructed venous drainage in the blood circulation to the penis.(1) Other research has also shown a mixture of circulation problems with the arteries and veins of men with PD.(2,3)

For these very important reasons, PDI treatment recommendations strongly emphasize therapy that will increase blood circulation to and from the penis. No where else have we found any authority to draw attention to, or correlate, this important anatomical or therapeutic factor.

Please refer to Figure 1, below, for details of normal penis anatomy, as well as detail of a scar (plaque) in the tunica albuginea that is shown to be distorting the penis.

 

Peyronie’s disease as it relates to male anatomy

…and This is How It Works… With a better understanding of the anatomy of the male organ of reproduction, it should be easier to understand how the male anatomy “comes to attention” when erect. If you wish to understand how this complicated, but fascinating, process of erection occurs, click on How an Erection Happens.

Soft Tissue of the Pelvis

To understand how the curved penis of Peyronie's disease develops it is necessary to understand the soft tissue involved.
The strength and tone of the pubococcygeus muscle is importatn to the blood circulation of the pelvic organs. For this reason strengthening this muscle is important in any Peyronies treatment plan.

 

“Soft tissue” is a general anatomy term that refers to a broad group of supporting and connecting tissues of the skeleton that are not hard: skin, muscle, tendon, ligament and fascia (a thin delicate membrane of connective tissue found throughout the body that surrounds and covers internal organs, muscles and related soft tissue structures, almost like Saran plastic wrap ) . In particular, this discussion is most concerned with the soft tissue directly or indirectly associated with the penis. These soft tissues are the various layers of muscles, tendons, ligaments and fascia of the lower pelvic floor, inguinal or groin region and the lower abdominal wall around the pubic bone especially. Please refer to Figure 2, below, for a general idea of these different tissues, and their relationship to the male genital organ. What makes these soft tissues so important to PD is their influence on the blood supply and the lymphatic drainage (see below) to the genital area.

Lymphatic Drainage of the Pelvis

Simply, the lymph system is the sewer system of the body. It consists of a large network of lymph vessels (much like veins), that carry a clear fluid called lymph (much like plasma). Along the pathway of these lymph vessels, from place to place, there are small bean-shaped bodies of tissue (called lymph nodes) that serve as filters. Refer to figure 3, below, to see how all of this is connected. These are the same type of lymph nodes that become tender and swollen under your jaw when you have a sore throat.

Lymph nodes are distributed throughout the body, including the groin and deep in the lower pelvis where you cannot touch them. The purpose of the lymph system is to remove infection, cellular debris and toxins from every part of the body. The final destination of the lymph fluid in the lymph vessels is to enter into the liver for final disposal and elimination via the gall bladder. Every part of the body needs a full and uninterrupted movement of lymph fluid in both directions, in and out. If there is poor movement or flow of lymph, then toxins accumulate and fluid starts to collect, like a backed-up sewer.

The lymph fluid is moved along in the lymph vessels by gravity and by internal massage and pressure from those tissues that lay along side the lymph vessels. Spasm, contraction and shortening of various soft tissues can constrict the lymph vessels and cause backing up and stagnation of lymph – again much like a backed up sewer. For any tissue, organ or area of the body to be healthy – the penis included – a good lymph circulation must service it, just like your house needs a good sewer system. With poor lymph circulation, tissue becomes easily diseased and does not heal well. Figure 3, below, illustrates the abundant lymphatic supply to the lower pelvis and genital region. Lymphatic drainage is important to the repair of the curved penis of Peyronie's disease as it relates to blood circulation.

To view graphic pictures of Peyronie’s disease, click on Peyronie’s pictures

Summary of special discussion of Peyronie’s disease anatomy

The tunica albuginea normally has a limited blood flow, and therefore poor oxygen supply because it is more like a tendon in nature; tendons generally don’t need and don’t have a huge blood supply. This is critical in understanding how the scar develops in the tunica in first place and how treatment should proceed. Like all parts of the body, if the blood supply and lymphatic drainage of the lower pelvis and penis are not correct, trouble can start. PDI treatment suggestions take these things into account.

Various therapies are suggested in this website that improve the oxygen content and oxygen carrying capacity of the blood, improve blood supply and lymphatic drainage, increase nutrient support to the soft tissue structures of the genital area, and improve the capacity of the body to heal and repair damaged tissue. This is the connection of the anatomy and the therapy that is offered for your review. In the 14-part “Treatment Options” section you will find many different therapies that attempt to support and benefit the blood and lymphatic supply to and from the lower pelvis. With a better understanding of the structure and complexity of this area of your body, you should be able to participate in your treatment plan with a far better appreciation of your problem and your purpose in following your treatment plan.

You now know the penis is made of several unique tissues, and these are directly affected in Peyronie’s disease.   Recall that specialized tissue of the penis has spaces like “caves” and one area is like a “sponge”, both of which fill with blood to create an erection. Even though the cavernosa and the spongiosum have a huge blood supply, right next to them is the tunica albuginea with a poor blood supply. Throughout this website we will refer over and over again to the tunica albuginea, the corpora cavernosa, the corpora spongiosum, lymphatic flow, and connective tissue. Understanding this anatomy will help you to later understand the unique therapies we suggest for Peyronie’s disease. Now you know.

1. Levine LA, Coogan CL: Penile vascular assessment using color duplex sonography in men with Peyronie’s disease. J Urol, 155: 1270-1273, 1996. 2. Lopez JA, Jarow JP: Penile vascular evaluation of men with Peyronie’s disease. J Urol, 149: 53-55, 199 3. Burford CE, Glen JE, Burford EH: Fibrous cavernositis: further observation with report of 31 additional cases. J Urol, 49: 350-356, 1943.

4 thoughts on “Peyronie’s Anatomy of the Penis and Related Areas

  1. Jerry Hayes says:

    I recently discovered my erection to be severely bent and am concerned about Peyronie’s disease. It may have been caused during sex. I didn’t experience any pain. My penis was pulled upward (toward my stomach) as my wife was on top. My next erection was bent. I had an indentation about an inch above the base and penis was curved sharply to the left. It has been 2 weeks since this occurred. The indentation is now about 3 inches above base and erection is stronger. Will this eventually straighten out or should I seek medical attention?

  2. Dr.Herazy says:

    Greetings Jerry,

    Your concern about the penile distortion is reasonable. The accident with your wife on top is perhaps the most common way to develop Peyronie’s disease through a direct injury. However, not all penile injury, even if severe, will result in Peyronie’s disease. Conversely, mild injury can result in Peyronie’s disease, so there is no way to predetermine if it will occur or not based on severity of trauma. When PD develops as a result of trauma time is required for the fibrous tissue to be deposited in the tissue layer of the penis known as the corpora cavernosae. Prior to that time, an acute injury, mild or severe, can cause common and simple tissue inflammation that can account for the immediate indentation and bending you noted. It is this same inflammation that can ignite a further tissue phenomenon that is somewhat peculiar to the tunica albuginea that results in a disproportionate response of collagen, fibrin and other scar tissue elements resulting in the much dreaded Peyronie’s disease plaque (that eventually matures into the further dreaded Peyronie’s disease scar).

    For all these above stated reasons it is imperative that you reduce the tissue inflammation as promptly as possible, so that the inflammation process is snuffed out early and does not advance into the horrific fibrous tissue stage, possibly avoiding Peyronie’s disease. To that end I suggest you do several things. First, that you treat the area to reduce tissue injury with frequent ice pack applications several times a day for the next week or so, use some NSAID drugs (aspirin or whatever you prefer), and you take some essential fatty acid supplements to get the inflammation down. Also, that you and your wife be forever more careful to never repeat that accident again. In regard to the latter, I suggest that if you engage in intercourse again with your wife in the top-missionary position that you keep one or both arms gently and loosely around her waist so as to limit and control her movement. Let her go sexually with all the abandon she might enjoy, but (since it happens to be your penis) that you keep a cool head and not allow her to lose you from within her or jeopardize you. Lastly, I also suggest that during this time you refrain from all sexual activity to avoid any possibility of re-injury and speed healing so as to avoid Peyronie’s disease. The worst and messiest cases of Peyronie’s disease I encounter are those in which some poor guy doubles up his woes by having a second penile injury soon after the first. 1 + 1 = 4 Ouch!

    I suggest you seek out medical attention to have your situation evaluated, treated and monitored. Use the best and most experienced urologist you can locate. Hopefully he or she will take your problem seriously. Historically, most do not. Peyronie’s disease is a lose-lose situation from the MDs perspective: Peyronie’s disease patients tend to be unhappy for a variety of reasons – they are not given much information because a lot of it tends to be contradictory and variable, they are not given much hope because outcomes are so variable, treatment is iffy and surgery can be at times disastrous when it goes bad and so-so when it goes well, and lastly it is the MD who gives them all this good news; MDs are frustrated with only a small and weak drug and surgical arsenal to work with, patients hold the MD responsible when they see their penis get shorter, and their patient and wife are usually unhappy no matter what is done. Under these circumstances most MDs try to make the office visits as brief as possible. These are the reasons for all the complaints you will read about medical care for Peyronie’s disease on the PD forums. However, I say, for sure, you should get your penis injury checked out medically, but know what you are getting into. TRH

  3. Paul says:

    Hi Dr. Herazy, I was diagnosed with Peyronie’s disease 2 years ago, i took pentoxyfilene for about a year, i have a noticeable plaque that is fairly hard and stretches about 1.5 cm on the left side about 2 inches below the head, this has caused a minor curve of maybe 10-15 degrees, and i havent had erectile problems throughout this time. My question is: since it’s been 2 years and this hasn’t changed at all, might it be safe to say that my Peyronie’s disease/erectile function will just remain the same from now on and not worsen (since i’m past the active phase)? Thanks very much,

    Paul

  4. Dr.Herazy says:

    Greetings Paul,

    Happy to hear from someone who takes his Peyronie’s disease so seriously that he has taken the time to evaluate it well and has taken the time to learn about it; many men panic so deeply that they ignore the problem until it ruins their lives.

    Your speculation for how your Peyronie’s disease might progress is fundamentally correct if nothing else changes within the confines of your shaft. However, as you have already learned, the events that affect the physical condition of your penis are not at all in your control; this is why you developed Peyronie’s disease. There are three things that can occur that have the capacity to change your PD even after it matures, hence the degree of curvature and erectile dysfunction you develop — for the better or for the worse. The first is additional trauma to your penis, either during sexual activity or during the course of life (being hit in the groin, car accidents, wearing tight clothing, work related injury, etc.). Even minor penis trauma on top of a case of pre-existing Peyronie’s disease can be disastrous; insult to injury. As with any kind of accident, additional injury to the penis can happen as fast and unavoidably as slipping on the ice. Secondly, side effects from a prescription or non-prescription drug. Not much to say here, because so many MDs who prescribe the big offending PD-causing drugs (statins, and many others) seem to take a cavalier attitude about this issue. They say: “I am prescribing this drug anyway because it is important. You may or may not get Peyronie’s disease as a side effect, we will have to see. If you get PD we can always do surgery. You will be fine. Take the drug” I hear this story a lot.) Lastly, as what might be a surprise to you, is that any improvement or reduction of the Peyronie’s disease scars within the shaft as part of the maturation process can cause an alteration of the balance of the that now exists that is creating the mild 10-15 degree bend you have. This is so because a small curve is not necessarily caused by a small scar, and a large curve is not necessarily caused by a large scar. The size of the curvature (or the degree of ED) in Peyronie’s disease, is caused by the unique placement and interplay of the odd-shaped scars and how they impact the internal support structures of the shaft (curvature), and how or if the valves of the penis veins can close tightly to create an erection (erectile dysfunction). I have seen men with multiple significantly sized Peyronie’s disease scars that are so balanced and so placed within the shaft that the curvature and ED created is minimal; and I have seen relatively small but imbalanced or asymmetrically placed Peyronie’s disease scars that wreck havoc in terms of curvature and ED. Thus, it is possible that a favorable and desirable reduction of the size, thickness or density of the PD scar can cause an imbalance to a previously balanced arrangement that will increase the curvature or initiate a partial or complete ED phenomenon to occur. It happens.

    For the first two factors, trauma and drugs, there is certainly something you can do (at least to some extent). For the last factor, scar change over time, there is not as much that can be done to avoid that since the body always attempts to heal, repair and eliminate foreign scar tissue if it can. At PDI we work to promote those changes early for the benefit of the man with Peyronie’s disease.

    These are the reasons and explanation for why I have communicated many men over the years who reported their mild case of PD suddenly going severe after 5-10 years of peaceful co-existence. Peyronie’s disease is a wicked problem. Paul, be careful. All I am saying here is that with Peyronie’s disease there always seems to be a hitch, and a mild case will not always stay mild. No one can confidently predict much about PD. You might consider looking at my book, “Peyronie’s Disease and Sex,” that goes into great detail how a man with PD can avoid further injury while conducting an active sex life. TRH

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