Hourglass & Hinge Deformity in Peyronie’s Disease
Peyronie’s disease does not always produce a simple curve. Some men develop a narrowed or indented segment that creates an hourglass appearance or causes the penis to bend and buckle at a weak point during erection.
Treatment depends on more than the degree of curvature. Penile stability, girth, erection quality, length and the exact pattern of deformity all influence the appropriate pathway.
What is an hourglass deformity?
An hourglass deformity describes a localised reduction in penile girth during erection, creating a narrowed segment between wider areas of the shaft.
The narrowing develops because Peyronie’s scar tissue does not expand normally as the penis becomes erect.
Some men have a relatively symmetrical narrowing around the shaft, while others have a more localised indentation on one side.
The appearance itself may be concerning, but the more important issue is whether the narrowed area compromises rigidity, stability or penetration.
If a narrowed segment bends or buckles during intercourse, correcting curvature alone may not solve the functional problem.
Hourglass, indentation and hinge deformity are not exactly the same
These terms are sometimes used together, but they describe different aspects of penile shape and mechanical stability.
Hourglass deformity
A narrowed segment creates an hourglass-like contour during erection.
The narrowing may involve several sides of the shaft and can be associated with shortening, curvature or instability.
Penile indentation
A focal depression develops on one side of the shaft rather than a circumferential narrowing.
Some indentations are mainly a shape concern, while deeper defects can affect stability.
Hinge deformity
The penis bends or buckles at a weakened narrowed segment despite being otherwise erect.
This can make penetration difficult even when the overall curvature angle is modest.
Why does a hinge deformity matter?
Sexual function depends on both erection rigidity and structural stability. A narrowed area may act as a weak point even when the penis is otherwise fully erect.
The penis becomes erect
Blood fills the erectile bodies and produces overall rigidity.
The narrowed segment is less supported
Loss of girth can reduce the mechanical strength of one portion of the shaft.
Buckling can occur during penetration
Force applied during intercourse may cause the penis to bend at the narrowed segment rather than remain stable.
A man with relatively little curvature but substantial hinging may have more difficulty with intercourse than a man with a larger but stable curve.
What needs to be assessed?
The deformity needs to be assessed during a sufficiently rigid erection. A flaccid examination can identify plaques but may underestimate the hourglass shape or hinge effect.
Surgical planning commonly considers:
- location and depth of indentation
- whether narrowing is unilateral or more circumferential
- presence and direction of penile curvature
- whether the penis buckles at the narrowed segment
- stretched and erect penile length
- erection firmness
- response to erectile dysfunction medication if relevant
- whether the deformity is still changing
- previous injections, surgery or other treatment
Erection photographs are particularly useful for hourglass deformity
Hourglass narrowing and hinge instability can be difficult to judge when the penis is flaccid.
If you are comfortable doing so, photographs of a full erection stored on your own phone can help document the deformity.
Useful views can include:
- from above
- from each side
- from the front if narrowing is circumferential
- an angle that demonstrates any indentation or unstable segment
Do not intentionally force the penis to buckle in order to photograph a hinge deformity.
Non-surgical management of hourglass deformity
Not every hourglass deformity needs surgery. Management depends on stability, erectile function and how much the shape affects sexual activity.
Observation
If the deformity is mild, erections remain stable and sexual activity is not significantly affected, observation may be reasonable.
Erectile function treatment
Improving erection firmness can sometimes improve functional stability when incomplete rigidity contributes to buckling.
Treatment does not remove the underlying Peyronie’s scar.
Penile traction
Traction may be discussed in selected men with Peyronie’s disease, particularly when length preservation is a priority.
Evidence specifically for correcting hourglass or hinge deformity remains limited.
Which operation treats hourglass or hinge deformity?
There is no single operation for every hourglass deformity. The choice depends on whether the primary problem is curvature, girth loss, instability or erectile dysfunction.
Penile Plication
Plication can correct associated curvature but does not restore girth at an hourglass segment.
It may be useful when narrowing is minor and the main problem is a stable curvature.
Explore plication →Plaque Incision & Grafting
The shortened tunica is released and a graft is used to cover the resulting defect.
This may be considered for selected men with complex deformity and good erectile function.
Explore incision & grafting →Extra-Tunical Grafting
Graft material is placed outside the tunica to reinforce or fill the narrowed area without opening the tunica itself.
It has been described for selected hourglass and indentation deformities.
Learn more below ↓Penile Implant Surgery
When erectile rigidity is significantly impaired despite appropriate treatment, implant surgery may address both rigidity and the complex Peyronie’s deformity.
Explore penile implants →Is the main problem shape, instability or erectile rigidity?
Correctly identifying the functional problem helps avoid selecting an operation that improves one feature but leaves the patient's main difficulty unchanged.
Good rigidity but structural deformity
When erectile function is good, reconstructive treatment can focus on contour, curvature and stability.
- plication for selected curvature-dominant cases
- tunical incision and grafting for selected complex deformity
- extra-tunical grafting for selected indentations or hourglass deformity
Poor rigidity plus complex deformity
If the penis is not sufficiently rigid despite appropriate treatment, correcting contour alone may not restore sexual function.
Penile implant surgery may then form the foundation of treatment, with additional straightening or reconstructive manoeuvres when required.
What is extra-tunical grafting?
Extra-tunical grafting is a reconstructive technique designed to support a narrowed or indented penile segment without making an incision into the tunica albuginea.
Graft material is positioned outside the erectile bodies, beneath the superficial penile tissues, to add structural support to the area of contour loss.
The technique has been described particularly for selected men with hourglass deformity or unilateral indentation who have satisfactory erectile function.
Why might it be considered?
This avoids the tunical incision required during traditional plaque incision and grafting.
The aim is to reinforce the narrowed region rather than primarily correct a large curvature.
Associated curvature may still require plication or another straightening manoeuvre.
Published studies are mainly retrospective specialist series. It is therefore best viewed as one reconstructive option for selected anatomy rather than a universally preferred treatment for hourglass deformity.
Plaque incision & grafting
This approach releases the shortened tunica on the concave or restricted side of the penis.
A tunical defect is deliberately created and covered with graft material.
It may help correct:
- severe curvature
- complex multiplanar deformity
- selected hourglass deformity
- selected hinge deformity
- significant shortening where further plication shortening is undesirable
Good baseline erectile function is particularly important because postoperative erectile dysfunction is a recognised risk.
When might tunical incision and grafting be considered?
Traditional grafting is more invasive than extra-tunical reinforcement because the tunica itself is opened.
It may be more appropriate when the narrowing forms part of a broader severe deformity requiring true tunical lengthening.
The operation is most often considered when erections remain sufficiently reliable without a penile prosthesis.
Why plication alone may not correct a major hourglass deformity
Plication straightens a curvature by shortening the longer side of the penis.
It does not expand a narrowed segment or restore lost girth.
Therefore, if the main problem is significant indentation or hinge instability, the penis may become straighter after plication while the narrowed or unstable segment remains.
What if the penis is both unstable and not rigid enough?
Hourglass deformity can coexist with erectile dysfunction.
When erectile rigidity remains inadequate despite appropriate medical treatment, reconstructing the contour alone may leave the penis insufficiently firm for intercourse.
Penile implant surgery may therefore become the preferred surgical pathway.
Implant cylinders provide internal rigidity. Residual curvature or contour abnormalities can then be assessed and additional straightening or reconstructive techniques used where necessary.
Can surgery restore the girth or length lost to Peyronie’s disease?
Girth
Grafting-based surgery may improve the contour of a narrowed segment, but exact restoration of the original circumference cannot be guaranteed.
Length
Complex Peyronie’s disease may already have caused true shortening. Correcting the deformity can improve functional length, but surgery cannot reliably recreate the exact pre-disease length.
Stability
For many men, improvement in stability is more important than a specific circumference or length measurement because the main goal is comfortable, reliable sexual function.
Recovery after surgery for hourglass or hinge deformity
Recovery depends on whether treatment involves plication, extra-tunical grafting, tunical incision and grafting or penile implant surgery.
Swelling and bruising
Temporary swelling, bruising, discomfort and tenderness are expected after penile reconstructive surgery.
Erections
Spontaneous erections may initially feel uncomfortable while deeper tissues heal.
Sexual activity
Penetrative sex and masturbation are avoided during the initial healing period and resumed according to postoperative review.
Work
Timing depends on discomfort, surgical extent and the physical demands of your occupation.
Exercise
Heavy lifting, strenuous activity and pressure on the genital area are restricted during early recovery.
Rehabilitation
Penile rehabilitation or traction may be recommended in selected cases once sufficient healing has occurred.
Possible risks and limitations
General surgical risks
- pain
- swelling or bruising
- bleeding or haematoma
- infection
- wound healing problems
- anaesthetic complications
- need for further treatment
Penile and functional risks
- residual indentation or narrowing
- persistent hinge instability
- residual or recurrent curvature
- altered penile sensation
- erectile dysfunction
- penile shortening
- graft-related contour change where a graft is used
- result not meeting expectations
From complex deformity assessment to treatment
Confirm Peyronie’s disease
The history, plaque and pattern of penile change are reviewed.
Document the erect deformity
Curvature, indentation, hourglass narrowing and any hinge instability are documented using erection photographs or induced erection assessment when appropriate.
Assess erectile function
Rigidity is reviewed because reconstructive surgery and penile implant surgery serve different groups of patients.
Identify the main functional problem
The discussion distinguishes curvature, girth loss, shortening, instability and erectile dysfunction.
Compare treatment options
Observation, traction, plication, extra-tunical grafting, plaque incision and grafting or implant surgery are considered where relevant.
Treatment and follow-up
Healing, penile stability, shape, erection quality and sexual function are reviewed after treatment.
Dr Jack Crozier
Dr Jack Crozier is a Brisbane urologist and fellowship-trained andrologist with a subspecialty practice in Peyronie’s disease, penile reconstruction, erectile dysfunction and penile implant surgery.
His advanced andrology fellowship at University College London Hospitals included Peyronie’s disease surgery, reconstructive andrology and complex penile prosthetic surgery.
Travelling for complex Peyronie’s assessment?
Hourglass and hinge deformities can be difficult to assess from a written description alone.
Where clinically appropriate, erection photographs, ultrasound reports, previous treatment information and operative reports can be reviewed as part of preliminary planning before major travel arrangements are made.
Physical examination or additional erectile assessment may still be required before a definitive surgical plan is made.
Explore related information
Peyronie’s Disease
Understand the condition, disease phases, assessment and overall treatment options.
Penile Plication Surgery
Learn about curvature correction using a tunical-shortening technique.
Plaque Incision & Grafting
Learn about tunical-lengthening surgery for selected complex Peyronie’s deformities.
Penile Implant Surgery
Explore treatment when Peyronie’s deformity occurs with significant erectile dysfunction.
Peyronie’s & Penile Length
Understand shortening, traction and what reconstructive surgery can realistically achieve.
Peyronie’s Treatment Explorer
Organise information about stability, curvature, shape and erectile function before specialist review.
Hourglass & hinge deformity FAQs
What is an hourglass deformity in Peyronie’s disease?
An hourglass deformity is a localised reduction in penile girth during erection that creates a narrowed segment between wider areas of the shaft. It may occur with or without significant curvature.
What is a hinge deformity?
A hinge deformity means the penis bends or buckles at a weakened narrowed segment during erection or penetration. The penis can therefore be reasonably straight but still mechanically unstable.
Is indentation the same as hourglass deformity?
Not exactly. Indentation may involve a focal depression on one side of the penis, while hourglass deformity generally describes a broader narrowed segment. Both can contribute to hinge instability if sufficiently severe.
Can Peyronie’s disease cause hourglass deformity without curvature?
Yes. Some men develop narrowing or indentation with little overall curvature. The main functional problem may instead be loss of girth, instability or buckling.
Can penile traction fix an hourglass deformity?
Penile traction can be useful for selected men with Peyronie’s disease, particularly for curvature and length. However, hourglass and hinge deformities have not been as well studied specifically, so correction of a major indentation or unstable segment cannot be assumed.
Can plication fix an hourglass deformity?
Plication can correct associated curvature but does not restore lost girth at the narrowed segment. When hourglass narrowing or hinge instability is the main functional problem, another reconstructive technique may be required.
What is extra-tunical grafting?
Extra-tunical grafting places graft material outside the tunica albuginea to reinforce or fill a narrowed penile segment without opening the tunica itself. It has been described for selected hourglass and indentation deformities.
Is extra-tunical grafting safer than plaque incision and grafting?
Because the tunica is not opened, extra-tunical grafting may avoid some of the erectile-function risks associated with tunical incision and grafting. However, the published evidence is mainly retrospective and the techniques treat somewhat different deformities, so they should not be considered directly interchangeable.
When is plaque incision and grafting used?
Tunical incision and grafting may be considered in selected men with good erectile function and severe curvature, significant shortening or a complex deformity such as hourglass or hinge abnormality.
What if I have hourglass deformity and erectile dysfunction?
Erectile function is central to treatment selection. If rigidity remains inadequate despite appropriate medical treatment, penile implant surgery may be preferable to a reconstruction that relies on natural erectile function.
Will surgery restore the lost girth?
Reconstructive surgery may improve penile contour and stability, but exact restoration of the original penile circumference cannot be guaranteed.
Will surgery restore penile length?
Surgery may improve functional length by correcting deformity and can avoid additional shortening in selected cases, but it cannot reliably restore the exact length present before Peyronie’s disease developed.
Does hourglass deformity mean I need surgery?
No. Surgery is generally considered when stable deformity causes meaningful functional difficulty, such as buckling, difficulty with penetration or substantial sexual impairment.
Can a hinge deformity increase the risk of penile injury?
An unstable penile segment may be more prone to buckling during intercourse, particularly if erection rigidity is reduced. Sexual activity should be controlled and stopped if the penis repeatedly bends sharply or causes pain.
Does surgery need to wait until Peyronie’s disease is stable?
Definitive reconstructive surgery is generally performed once the disease is stable and the deformity is no longer meaningfully changing.
Can I be assessed if I live interstate or overseas?
Potentially. Erection photographs, ultrasound reports, treatment history and previous operative reports may help with preliminary assessment. Physical examination or further assessment may still be required before a definitive surgical recommendation is made.
Is narrowing or hinging affecting penile stability?
If Peyronie’s disease has caused an hourglass deformity, indentation, buckling or loss of penile stability, specialist assessment can help determine whether observation, traction, plication, grafting, extra-tunical reconstruction, penile implant surgery or another pathway best matches your anatomy, erection quality and priorities.
Medical information disclaimer: This page provides general educational information and does not replace individual medical advice, diagnosis or informed consent. Hourglass, indentation and hinge deformities vary considerably between patients. Treatment depends on disease stability, penile contour, curvature, length, erectile function, degree of instability, previous treatment, medical history and individual priorities. Evidence for some reconstructive techniques is based mainly on retrospective surgical series. Surgical correction, restoration of penile girth or length, erectile function and patient satisfaction cannot be guaranteed.