Chapter 113: Disorders of the penis

INTRODUCTION

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.