Anatomy of the Dorsal Nerve of the Penis, Clinical Implications

doi:10.1016/j.urology.2013.07.075

Urology

Volume 83, Issue 1, January 2014, Pages 121-125

https://doi.org/10.1016/j.urology.2013.07.075 Get rights and content

Objective

To show the branching patterns and the anatomic variations of the dorsal nerve of the penis (DNP) along the penile shaft, particularly the relation with the tunica albuginea.

Methods

The penises of 22 adult cadavers were dissected. The number and the diameters of the branches, the presence of anastomoses between the main trunks, the positioning of the nerves before entering the glans penis, and the presence of branches emerging from the body of the DNP and perforating the tunica albuginea were noted and photographed. The compartments where the anatomic findings were located were noted.

Results

The DNP was composed of 2, 3, 4, 5, and 6 main branches in 6 (27.3%), 6 (27.3%), 6 (27.3%), 1 (4.5%), and 3 (13.6%) of 22 dissections, respectively. We could trace 2, 3, 4, and 5 terminal branches of the DNP going into the glans penis in 4 (18.2%), 8 (36.4%), 7 (31.8%), and 3 (13.6%) dissections, respectively. In 2 dissections (9.1%), fine branches were present between the main trunks crossing the midline. Anastomosing branches between ipsilateral main trunks of the DNP were identified in 5 dissections (22.7%). In 16 (72.7%) dissections, branches emerging from the inferior aspect of the body of the DNP, which perforated the tunica albuginea, could be identified.

Conclusion

The exact anatomic knowledge of the DNP is mandatory during penile reconstructive surgeries. The presence of branches perforating the tunica albuginea is the most important finding of this cadaveric study, together with the other documented variations, which must be taken into consideration during penile reconstructive surgeries.

Section snippets

Materials and Methods

The study was conducted in the Dokuz Eylul University Department of Anatomy and was approved by the Dokuz Eylul University Ethical Committee. The penises of 22 adult cadavers fixed in formaldehyde were dissected. The cadavers had no anatomic penile abnormality and no finding of a penile surgery. The exact causes of death were unknown.

The penile skin, the superficial penile fascia, and the superficial dorsal veins were removed according to the standard practices of anatomic dissection. The

Results

The DNP was composed of 2, 3, 4, 5, and 6 main branches in 6 (27.3%), 6 (27.3%), 6 (27.3%), 1 (4.5%), and 3 (13.6%) of 22 dissections, respectively. And we could trace 2, 3, 4, and 5 terminal branches of the DNP going into the glans penis in 4 (18,2%), 8 (36,4%), 7 (31,8%), and 3 (13,6%) dissections, respectively. The mean diameter of the main branches beneath the symphysis pubis was 2.39 ± 0,54 mm (range, 1.65-3.55 mm), and the mean diameter of the terminal branches at the level of the corona

Comment

The PN, which is responsible for the somatic innervation of the penis, is the longest and the thickest arm of the plexus pudendalis, which is formed by the union of the anterior rami of the S2-4 nerves. It divides into 3 branches after it passes through Alcock's canal: inferior rectal nerve, perineal nerve, and the DNP or the clitoris. The DNP runs anteriorly above the internal pudendal artery along the ischiopubic ramus deep to the perineal membrane. Penile reconstructive surgeries necessitate

Conclusions

The exact anatomic knowledge of the DNP is mandatory during penile reconstructive surgeries. The detailed information about the far lateral positioning of the nerves entering the glans penis, the anastomosing branches between the trunks of the DNP, and particularly, the presence of branches emerging from the inferior aspects of the DNP that perforate the tunica albuginea are the important findings of this cadaveric study that must be taken into consideration during penile reconstructive

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Most of the penile schwannomas affect the penile body or shaft (n = 16; 53.3%), and most of the lesions are located at the dorsum of the penis (n = 17; 56.7%) in the Buck's fascia. For known neuroanatomy,6–8 the schwannoma at the penile shaft or glans should originate from the dorsal nerve of the penis (DNP). The DNP provides branches to innervate the urethra ventrally and laterally, and its diameters are decreasing when it goes distally, which we believe may explain why schwannomas are present at the penile shaft more than at the glans and at the dorsum (main trunk) more than at the ventrum (branch).
Patients with penile schwannoma are rare and usually with variant presentations. No evidence-based clinical guideline exists for diagnosis or treatment. To put schwannoma into differential diagnoses of benign soft tissue lesions in the penis is important.
To analyze and categorize clinical, histopathological, and radiological presentations and apply possible explanation on several fields of penile schwannoma.
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We collected 40 cases. Data were arranged in tables. Clear descriptions were added on several fields of penile schwannoma in detail in Discussion.
Penile schwannomas are mostly located at the penile shaft and dorsum of the penis. Dyspareunia is the most reported complaint for sexual dysfunction. This study is the first study in the world to document the expressions of calretinin, SOX10, glial fibrillary acid protein, D2-40 (podoplanin), and cytokeratin AE1/AE3 in penile schwannoma and claims magnetic resonance imaging and pathologic presentations of penile schwannomas are synonymous with schwannomas from head to toe. The current patient may be the first to present with penile schwannoma with schwannomatosis.
Huang LC, Wang HZ, Chu YC, et al. Clinicopathological Presentation and Management of Penile Schwannoma. Sex Med Rev 2020;8:615–621.
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An incision is made into the corporal space just lateral to the corpus spongiosum bilaterally from beneath the glans to the level of the corporal bifurcation. The dorsal nerves branch and course more ventrally than may be expected,39 and the authors make the corporotomy just lateral to the urethra to maximally preserve that innervation. The spongiosum inside then is completely excised, along with the unneeded penile corpus spongiosum.
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Dorsal nerve courses and branches of the penis have been reported previously. Kozacioglu et al. demonstrated the macroanatomy of the dorsal nerve and found the presence of branches perforating the tunica albuginea.3 Conversely, and based on our findings, perforating nerves did not branch off from the dorsal nerve and enter the tunica albuginea toward the distal part of the corpus cavernosum.
The topographical anatomy of the composite nerve fibers in the human glans penis is poorly characterized. Therefore, histological methods were used to analyze nerves to the cavernous tissue at the distal end of the corpus spongiosum.
Immunohistochemical techniques were used to detect S100, neuronal nitric oxide synthase, tyrosine hydroxylase, and vasoactive intestinal polypeptide protein expressions in frontal or sagittal penile sections obtained from 20 donated, older male cadavers.
At or near the coronal sulcus at the dorsal midline, three to seven terminal branches of the unilateral dorsal nerve ran deeply or centrally along the distal dull end of the corpus cavernosum and entered the glans cavernous tissue. Once there, the nerve divided into thinner branches (neuronal nitric oxide synthase or tyrosine hydroxylase positive) and the major nerve section reached the surface skin of the glans. Several thin nerves took highly arduous paths, as evidenced in ventral subcutaneous tissue of the distal third of the penis.
Histological examination revealed a neurovascular bundle that penetrated the glans cavernous tissue toward the skin covering, with a rich nerve supply to the skin folds at and near the coronal sulcus.
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Of 215 patients who underwent penile plication, complete operative and patient-reported outcomes data were available for 118 (55%). Patients were grouped by location of plication: dorsal (n = 17 [14%]), ventral (n = 65 [55%]), and lateral (n = 36 [31%]). Mean age (52-58 years; P = .51) and preoperative curvature (36-51°; P = .78) were similar among the 3 groups. Each group required a similar number of sutures (8-9; P = .18) to achieve similar correction (37-45°; P = .33). Patients completed a satisfaction survey at a mean of 15 months (range, 1-41 months) after surgery. All groups reported equally high rates of satisfaction for penile curvature (P = .64), penile rigidity (P = .64), strength of erection (P = .98), and overall satisfaction (P = .75). Although each group reported subjective decrease in penile length (P = .10), objective length loss occurred on a small scale (mean length loss for all groups, 0.3-0.8 cm; P = .24).
Penile plication is a safe and effective technique for correcting all directions of curvature. Dorsal plication without degloving produces favorable objective and subjective results comparable to ventral and lateral plication.
Re: Kozacioglu et al.: Anatomy of the Dorsal Nerve of the Penis, Clinical Implications (Urology 2014;83:121-125)
2014, Urology

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Male Sexual DysfunctionAnatomy of the Dorsal Nerve of the Penis, Clinical Implications

Objective

Methods

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

Conclusions

J Sex Med

J Urol

Urology

J Urol

J Urol

J Urol

Urology

Neuroanatomy of the penile portion of the human dorsal nerve of the penis

BJU

Peripheral distribution of the human dorsal nerve of the penis

J Urol

Male Sexual Dysfunction
Anatomy of the Dorsal Nerve of the Penis, Clinical Implications