Chapter 113: Disorders of the penis

The most common penile disorders are those of psychosexual dysfunction and STIs, but there are many other problems and these are most often related to the foreskin.

DISORDERS AFFECTING THE FORESKIN AND GLANS

Phimosis

Phimosis is tightness of the foreskin (prepuce), preventing its free retraction over the glans penis. The foreskin is normally attached to the glans and is non-retractile in most newborns; it may remain so until puberty.^1,2 The proportion of boys with retractile foreskins is: 40% at 1 year, 90% at 4 years and 99% at 15 years.³ Forceful retraction of the penis should be avoided until spontaneous separation occurs.¹ Once the foreskin easily retracts, the boy should learn to do this as part of normal washing, ensuring he rinses off any soap and pushes the foreskin back over the glans afterwards.⁴

‘True’ phimosis is caused by forceful retraction, infection or balanitis xerotica obliterans (see later in this chapter).^1,2 Indicators of true phimosis (rather than simple non-retractile foreskin) are:³

• foreskin not retractile by the time of established puberty

• previously retractile foreskin becomes non-retractile

• obvious ring of scar tissue at foreskin opening

• inability to visualise the urethral meatus when foreskin opening is lifted away from glans

• ballooning during and after micturition, with pinhole foreskin opening and a squirting urinary stream (though mild ballooning during micturition is common and normal)

Treatment

Inflammatory phimosis can be treated by local corticosteroid cream (e.g. 0.05% betamethasone valerate cream qid for 2–4 weeks)³ applied generously to the tight, shiny part of the foreskin where the inner skin meets the outer skin. If the tip of the foreskin is inflamed, gently retracting it will cause the inflamed opening to ‘cauliflower’ up so the cream can be applied. A stronger steroid cream can be tried if this fails.

True scarring that fails to respond to steroid creams may require circumcision, though this is uncommon.^1,2 Some patients with true phimosis may have problems once they start to have intercourse and will require circumcision.

Paraphimosis

Paraphimosis occurs when a tight foreskin is forcibly retracted over the glans, gets stuck in the sulcus and cannot be pulled forward again. The glans and the foreskin distal to the tight area become swollen and painful (see FIG. 113.1) and this demands urgent resolution.¹ This problem occurs in boys aged 8–12 and the elderly, especially if a mild degree of phimosis is already present. Typically it occurs when the penis is erect or after catheterisation.

Management

Paraphimosis can usually be corrected without surgery, and urgent manual reduction should be attempted first.³ It is usually performed without anaesthesia but a penile block (remembering never to use adrenaline in LA), systemic analgesia ± sedation or a generous application of 2% lignocaine gel or EMLA cream may be appropriate depending on the geographic location and the clinical circumstances. Local anaesthetic infiltration before manual reduction should be avoided as it increases the swelling.

Note: Do not apply ice.

Method 1: Squeeze and manual reduction A

The glans penis and oedematous tissue distal to the constricting ring of foreskin are gently squeezed for several minutes to reduce the oedema. Using a lubricating jelly, manual reduction can then be performed by trying to advance the prepuce over the glans with the index fingers while gently compressing the glans with both thumbs (see FIG. 113.2).

Method 2: Squeeze and manual reduction B

• Take hold of the oedematous part of the glans in the fist of one hand and squeeze firmly. A gauze swab or cool towelette will help to achieve a firm grip (see FIG. 113.3).

• Exert continuous pressure until the oedema passes under the constricting collar to the shaft of the penis.

• The foreskin can then usually be pulled over the glans.

Note: If these simpler methods are successful, educate the patient about proper foreskin management as this may prevent further attacks.

Method 3: Dorsal slit

Immediate referral is necessary if manual reduction methods fail. As an emergency, a dorsal slit incision can be made in the constricting collar of skin under local or general anaesthetic (see FIG. 113.4). The incision allows the foreskin to be advanced and reduces the swelling. Circumcision can be considered some days later when the inflammation has settled and any phimosis assessed, but a single episode of paraphimosis is not an absolute indication for circumcision.³

Method 4: The Dundee puncture method⁵

Under a ring block local anaesthetic or general anaesthetic, make approximately 20 puncture holes in the oedematous prepuce with a 26 gauge needle (outer diameter 0.45 mm). Then, using firm but gentle pressure, express fluid from the foreskin until it is decompressed. Consider subsequent circumcision.

Balanitis (balanoposthitis)

Balanitis is inflammation of the glans; inflammation of the foreskin is called posthitis and the combination is balanoposthitis, though balanitis is the most commonly used term. Urine trapped under the foreskin converts into ammonia compounds, and an ammoniacal dermatitis (similar to that of nappy rash) causes inflammation. Other causes of inflammation include irritation by soaps and other environmental substances, and trauma such as sexual activity. This inflamed area can become infected with commensal bacteria or fungi leading to infection.¹ Balanitis is common, affecting 6% of uncircumcised and 3% of circumcised males.³

Balanitis is actually a collection of disparate conditions with similar clinical presentation and varying aetiologies affecting a particular anatomical site.^6,7 These include:

• infections—Candida (the most common cause), Streptococcus pyogenes (uncommon but very severe), anaerobes, staphylococci, Gardnerella, herpes simplex

• inflammatory dermatoses—lichen sclerosis, lichen planus, psoriasis, Zoon balanitis, eczema (including irritant, allergic and seborrhoeic)

• premalignant—Bowen disease, Bowenoid papulosis, erythroplasia of Queyrat

Men presenting with balanitis should be considered for predisposing conditions such as diabetes or HIV.

Treatment

Treatment will be dependent on the cause, which will in turn be determined by the clinical picture, patient risk factors and potential culture results. Cultures can be useful, but may also pick up commensals unrelated to the aetiology so cannot always be relied upon.

• Mild cases felt to be caused by an inflammatory dermatosis may be treated with gentle saline bathing, a barrier cream or hydrocortisone 1% cream to tip of penis, and careful washing behind the foreskin.

• If there is a purulent discharge, take swabs for culture.

• Candidal balanitis is suggested by blotchy erythema with small papules that may be eroded, or dry, dull, red areas with a glazed appearance, and associated soreness ± itch.

If yeasts present:

• topical hydrocortisone + an imidazole (e.g. miconazole or clotrimazole) cream

If trichomonads present:

• metronidazole or tinidazole (oral treatment)

If bacterial infection is suspected:

• topical antibiotic ointments under the foreskin using a narrow, longish nozzle (e.g. chloramphenicol)

• severe cases caused by bacterial infection may have purulent discharge with spreading cellulitis down the penile shaft and require oral or intravenous antibiotics

Balanitis xerotica obliterans (BXO)

Thickening of the foreskin with skin pallor suggests balanitis xerotica obliterans. There is white, thickened scarring, giving an ‘icing sugar’ appearance to the glans. It results in progressive phimosis, typically in late childhood, usually 10–12 years. It may respond to corticosteroid cream if it is mild, but circumcision is usually indicated.

The normal foreskin in infants and children does not need special care and should be retracted for cleaning only after spontaneous separation of the foreskin has occurred. After this, males can practise proper hygiene by gently retracting the foreskin and washing the area as often as washing behind the ears.

Basic rules

• The foreskin should be retracted only by its owner (or a health professional)

• The foreskin should not be retracted forcibly

• Once retraction has spontaneously occurred, encourage daily retraction and gentle cleansing in the bath or shower

Instructions to patients

• During a shower or bath slide the foreskin back towards your body (see FIG. 113.5).

• Wash the end of the penis and foreskin with soap and water and then rinse off.

• After washing the area, dry the end of your penis and foreskin and then replace the foreskin.

• If the foreskin has a tendency to become irritated and smelly, slide the foreskin back sufficiently to allow free urination.

Smegma pearls

Smegma is made up of shed skin cells from the inner aspect of the foreskin and sebaceous gland excretion. Smegma cysts/deposits (yellow–white lumps beneath the foreskin) can be visible or palpable through the thin foreskin of boys whose foreskins have not retracted. They are sometimes called ‘smegma pearls’, and are normal and need no treatment. They can discharge a white ooze from under the foreskin. They can also be mistaken for sebaceous cysts and may cause concern for the boy or his parents, who can be reassured all is well.¹

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:

• bleeding

• infection (local/septicaemia)

• ulceration of glans/meatus

• meatal stenosis

• penile deformity

Absolute contraindications:

• 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)

• ‘buried’ penis

• sick, ‘unstable’ infants

• family history of bleeding

• inadequate experience of proceduralist

Frenuloplasty

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.

The ‘buried’ penis

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

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

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)

• intermediate–middle (penile)

• 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.

Treatment is aimed at reducing any pain, bleeding, itch or embarrassment. Treatment options include:¹¹

• no treatment

• self-applied treatments at home

• treatment at the surgery or a clinic

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.

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.

Refer to CHAPTER 116.

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.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Circumcision