Circumcision is now performed in 10–20% of Australian males after peaking at 85% in the 1950s.7 True phimosis not resolving with steroid creams, paraphimosis, recurrent balanitis, BXO or boys at high risk of UTIs are potential medical indications for circumcision. However, improved personal hygiene and better management of some of these conditions has led to a reduced medical need for circumcision. Apart from these situations and circumcision for religious reasons, circumcision for social reasons is generally discouraged. A policy statement from the Paediatric and Child Health Division of the RACP recommends against routine infant circumcision.8
Circumcision is generally a safe procedure but there are risks of minor complications and some rare but serious complications. In newborns, because of their small blood volume, any bleeding is of major concern and blood loss over 25 mL can be life-threatening.1 A bleeding circumcision site can be the presentation of a coagulopathy disorder.3 Also, because of a newborn’s relatively poor immunity, septicaemia from coliform infection on the wound site is a risk. If circumcision is done, it is recommended that it be done after 6 months of age and ideally in an operating theatre under general anaesthetic and with careful surgical technique.1
Arguments for routine circumcision include a reduction in risk of UTIs (and their complications) in infancy, reduction of sexually transmitted infections (including HIV) and a possible reduction in the risk of penile cancer in men and cervical cancer in their female partners later in life.
Circumcision reduces the risk of UTIs by about 10-fold.9 However, because of the low baseline risk, 111 circumcisions would be required to avoid one UTI in boys without abnormal urinary tracts.8 The reduction in STIs including HIV has been shown to be a benefit in males in high-risk populations (such as men in Africa), but this benefit has not been consistently evident in studies in lower-risk populations such as Australia and New Zealand. While there have been some studies showing that circumcision provides a protective benefit against HPV transmission and subsequent cervical cancer risk, the introduction of HPV vaccination is likely to dramatically reduce the baseline risk of these conditions. Cancer of the penis is so rare that the overall benefit offered by circumcision would be very small, and is overshadowed by recent improved penile hygiene in men and management of phimosis. In summary, the RACP guidelines conclude the benefits do not warrant the risks in routine circumstances, but that it is reasonable for parents to weigh up the risks and benefits (after being fully informed), and to make the decision themselves with parental choice being respected.
Complications of circumcision:
hypospadias and other congenital abnormalities (the foreskin may be a vital source of skin for subsequent repair)
chordee (painful dorsolateral curvature of the penis during erection, which interferes with sexual intercourse)
sick, ‘unstable’ infants
family history of bleeding
inadequate experience of proceduralist
A congenitally tight frenulum may lead to a tear during intercourse. Repeated bleeding occurs. Division of the frenulum and suturing in the opposite direction is preferable to circumcision.
In the ‘buried’ penis syndrome (also known as the ‘concealed’ or ‘inconspicuous’ penis) the penis is not adequately exposed and looks small. There is failure of skin fixation at the base of the penis with possible excessive prepubic fat pad at the base. It is commonly seen in small children, especially chubby boys, and can cause parental concern. Manually pressing down the fat pad at the base of the penis back towards the pubic bone will allow a more reliable assessment of penile length (and often reassure the parents). This situation usually improves spontaneously over time. In adolescents and adults, a buried penis is usually associated with obesity and rarely can require surgical intervention for cosmetic or functional reasons.10
DISORDERS AFFECTING THE URETHRAL MEATUS
Meatal stenosis or stricture may be congenital or acquired. It may be acquired in the circumcised child due to abrasion and ulceration of the tip of the glans. The incidence can be reduced by the application of moisturising cream for 2 weeks on the glans after circumcision.1 Uncommon causes are direct trauma during circumcision and irritation from ammoniacal dermatitis. Meatal ulceration predisposes to meatal stenosis. It usually presents as pain during micturition or as slight bleeding on the nappy or underpants. Significant stenosis requires surgical correction by meatotomy.
Catheter trauma is the usual cause in adults.
Hypospadias is a condition where the urethra opens on the underside or ventral aspect of the penis. It occurs in 1 in 350 males. Hypospadias is classified based on the location of the proximally displaced urethral orifice:2
distal–anterior (located on the glans or distal shaft of the penis and the most common type)
proximal–posterior (penoscrotal, scrotal, perineal)
There is often associated chordee (a ventral bending of the penis associated with erection) due to a ‘bowstring’ effect from the lack of tissue on the ventral surface, and also a high incidence of cryptorchidism (10%) and open processes vaginalis or inguinal hernia (9–15%).2
Hypospadias may cause the stream of urine to be deflected downwards or splash or drip back along the penile shaft. Unless it is glandular, surgical repair is usually advised, using the available foreskin, and is usually done between 6 and 18 months.2 Chordee may be corrected at the same time to allow eventual successful sexual intercourse. These boys should not undergo routine circumcision.
OTHER DISORDERS OF THE PENIS
Penile warts are usually multiple fleshy, papillomatous outgrowths, commonly found around the coronal sulcus, the adjacent prepuce and the meatus (see FIG. 113.6). They are caused by human papillomavirus and usually transmitted sexually. Look for warts within the meatus by allowing gentle dilation of the distal urethra with mosquito forceps.
Penile (genital) warts caused by the human papillomavirus
Treatment is aimed at reducing any pain, bleeding, itch or embarrassment. Treatment options include:11
The following treatments12 can be used with or without periodic cryotherapy:
imiquimod 5% cream topically applied to each lesion, 3 times per week at bedtime (wash off after 6–10 hours) until the warts disappear (usually 8–16 weeks)
podophyllotoxin 0.15% cream or 0.5% paint topically applied to each wart, twice daily for 3 days followed by a 4-day break, then repeat weekly for 4–6 cycles until the warts disappear
These are very small, regular round lumps (actually angiofibromas) that appear on the corona of the glans of the penis (see FIG. 113.7). They are common and are often first noticed by adolescent males who should be reassured that they are normal variants. They are not premalignant and require no treatment.13
Fordyce spots of the penis: refer to CHAPTER 112.
A common cause of penile ulcers is trauma, related to sexual activity, to the frenulum if it is congenitally tight. Such traumatic ulcers may be slow to heal and the frenulum may need surgical division. The ulcers may resemble a venereal ulcer (e.g. syphilitic chancre or herpes simplex). Another important (although rare) cause is cancer of the penis. Various causes are listed in TABLE 113.1.
Table 113.1Causes of penile lesions |Favorite Table|Download (.pdf) Table 113.1 Causes of penile lesions
|Skin disease: |
|Fordyce spots |
|Venereal warts |
|Trauma (tender) |
|Cancer (non-tender) |
|Herpes simplex (tender) |
|Syphilis (non-tender) |
|Chancroid (tender) |
|Granuloma inguinale (donovanosis) |
Cancer of the penis is rare, occurring in fewer than 1 in 100 000 of the male population,14 though it can be much more common in the developing world. Some 95% of penile cancers are squamous cell carcinomas. Phimosis, smoking, multiple sexual partners and poor hygiene are the main risk factors for penile cancer.15 There is an association with being uncircumcised and HPV infection, particularly types 16, 18 and 31.14
Cancer usually starts as a nodular warty growth (or ulcer) on the glans penis or in the coronal sulcus.15 Initially it may resemble a venereal wart. Fungal balanoposthitis can be misdiagnosed as cancer. The presenting symptom may be a bloodstained or foulsmelling discharge as the lesion can be hidden by the foreskin. It is usually seen in elderly patients with poor hygiene. Associated lymphadenopathy, which is present in 50% of patients on presentation, may be infective or neoplastic. Metastases to distal sites are uncommon. Refer for management, which includes radiotherapy—usually effective.
Priapism is a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulation. It may follow penile injection. Typically, the corpora cavernosa are engorged but the corpus spongiosum and glans remain flaccid. It is a medical emergency, as it often leads to fibrosis of the cavernosal tissue and subsequent erectile dysfunction or impotence.
Subtypes of priapism include:
Ischaemic (veno-occlusive or low flow)—this results from a failure of the detumescence mechanism (relaxation of the outflow of blood from the penis). The corpus cavernosa are rigid and tender to palpation, and the patient is in discomfort. It requires emergency treatment, and there can be subsequent penile oedema, ecchymoses and partial erections.
Non-ischaemic (arterial or high flow)—this is from an unregulated cavernous arterial inflow. The penis is neither fully rigid nor painful. Trauma is often the cause. It does not require emergency treatment.
Stuttering—this occurs from intermittent ischaemic priapism, and is manifested by repeated painful erections with intervening periods of detumescence. It may require emergency treatment if the events are prolonged, severe or frequent. Urologist consultation is advised.
The assessment focuses on distinguishing ischaemic from non-ischaemic. Apart from the clinical features mentioned above, cavernosal blood gases can confirm ischaemic priapism.
Duplex ultrasound can also be used, with ischaemic priapism showing little or no flow in the cavernosal arteries, and non-ischaemic showing normal to high blood flow. It can also demonstrate anatomical abnormalities such as a cavernous artery fistula in the perineum from trauma. A full blood count and film can also be part of the assessment, looking for abnormalities such as sickle cell disease, leukaemia, acute infections or platelet abnormalities. Drug screening can also be performed if suspected.
Emergency treatment for ischaemic priapism can include intracavernous injection of sympathomimetic agents such as phenylephrine as well as aspiration via a 19 or 21 gauge needle into the corpus cavernosum. If this fails, a surgical (cavernoglanular) shunt can be considered.
Peyronie disease is a fibrotic process, sometimes associated with Dupuytren contracture, which affects the shaft of the penis and results in discomfort and deformity on erection. It may result from trauma while the penis is erect. It usually affects men between 45 and 60. Typically, the patient presents with painful ‘crooked’ erections. There is abnormal curvature of the erect penis. The penile deformity may prevent satisfactory vaginal penetration. On examination, a non-tender hard plaque may be palpable in the shaft of the penis at the point where the penis curves. Mild cases require reassurance. The problem may increase, remain static or spontaneously lessen over 1–2 years. If there is ongoing discomfort or sexual dysfunction that distresses the patient, surgical treatment by penile plication (a sutured tuck on the opposite side to straighten the deformity) may be warranted. In more severe deformities, incision and grafting of the scar or implants can be considered. Steroid injections are not recommended. Oral vitamin E has been used for treatment with unclear outcomes apart from one positive study.18
Chordee is ventral or rotational curvature of the penis where the penile head usually curves upwards or downwards. It is a congenital abnormality usually caused by a ventral deficiency in the foreskin. It is usually detected soon after birth to about 18 months of age. It is often associated with hypospadias. The deformity is most apparent on erection. Early referral to a paediatric surgeon is advisable.
A ‘fractured’ penis describes sudden rupture of the penile erectile tissue during intercourse, usually with a woman in the superior position, resulting in a snapping sensation with severe pain. The management is urgent urological consultation for possible surgical repair. The disruption can affect the corpus spongiosum (has a better prognosis) or the corpora cavernosa, which may be treated by drainage of the blood clot, in which case permanent erectile dysfunction is a possible complication.
Injuries to the penis are not uncommon and one is the entrapped foreskin in the trouser zipper, when attempts to free the zipper aggravate the problem. In the office, cut the zipper from the trousers (see FIG. 113.8) and under local anaesthetic (no adrenaline), crush the zipper with pliers to open the teeth of the zipper and free the foreskin. Another method is to use a scalpel to cut the zipper immediately below the metal tag.
Entrapped foreskin in trouser zipper
Photo courtesy of Bryan Walpole
Haematospermia, which is blood in the semen, presents as a somewhat alarming symptom. It is sometimes encountered in young adults and middle-aged men. The initial step is to determine that the blood is actually in the semen and not arising from warts inside the urethral meatus or from the partner.
It usually occurs as an isolated event but can be secondary to urethral warts or prostatitis, or can occur with prostatomegaly or prostatic tumour (especially in elderly patients). If a micro-urine shows no accompanying haematuria, and prostate-specific antigen and blood pressure are normal, reassurance and a 6-week review are appropriate as spontaneous cessation of haematospermia is the rule.
Red flags for haematospermia
Symptoms lasting longer than 4 weeks
Palpable lesion in the prostate or along the epididymis
Recent travel to schistosomiasis-prevalent region