Penis

Phimosis

• Note that physiological phimosis is present until 6yo in some cases - don't stress until then
• Inability to retract the foreskin without fissuring it, due to scarring of the prepuce
• May result in ballooning of the foreskin during micturition and can result in balanoposthitis
• Can rarely cause urinary obstruction if the aperture in the prepuce is extremely tight
• In adults, can occur secondary to inflammation (balanitis, posthitis, balanitis xerotica obliterans). As a result, difficult to keep the penis clean, and there may be recurrent balanitis.
• Treatment
  • When the foreskin is only mildly scarred, then preputioplasty is possible
  • Circumcision in all other cases
  • In emergencies due to urinary obstruction, it is possible to divide the foreskin dorsally under local anaesthetic - 'dorsal slit'

Frenulum breve

• Short frenulum causes pain when foreskin is retracted
• Treat with frenuloplasty - lengthen it

Paraphimosis

• Inability to reduce the foreskin once it has been withdrawn proximal to the glans
• Icebags, gentle manual compression, injection of a solution of hyaluronidase in normal saline
• Circumcision if careful manipulation fails
• Dorsal slit may be enough in an emergency

Posthitis

• Inflammation of the prepuce

Balanitis

• Inflammation of the glans

Balanoposthitis

• Treat with broad-spectrum antibiotics and local hygiene measures
• If associated phimosis, may need circumcision

Fracture

• Rupture of tunica albuginea with immediate extravasation of blood from within the penis
• Typically a loud cracking sound with immediate loss of the erection
• Rapid bruising in penis and scrotum
• Generally needs early exploration and repair

Strangulation

• Usually with a ring
• Just need to remove the constricting item with a ring cutter or hacksaw
• Aspirating corpora cavernosa may help temporarily

Erectile dysfunction

• Commonest cause is vascular disease
• a/w diabetes, hypertension, dyslipidaemia, smoking
• Treatment generally involves sildenafil

Priapism

• Most commonly side effect of medication, but also seen with intra-cavernosal injections, hypercoagulable blood disorders such as sickle cell and leukaemia, and very rarely malignant disease in corpora cavernosa or pelvis
• First aspirate the blood from corpora cavernosa
• Then try intra-cavernosal injection of phenylephrine
• Then it may be necessary to create a shunt between corpus cavernosum and either the glans penis or the corpus spongiosum
• Can also develop as painless (non-ischaemic priapism) after trauma, which is not as much of an emergency - often needs selective arterial embolisation

Carcinoma of the penis

• Risk factors
  • HPV 16 and 18
  • BXO
  • Smoking
  • Phimosis
  • Chronic balanoposthitis
• Protective - circumcision soon after birth confers immunity
• Pathophysiology
  • Typically SCC arising in the skin of the glans penis or the prepuce
  • Can be either flat and infiltrating (starts as PeIN or leucoplakia) or warty (starts as papilloma)
• Penile intraepithelial neoplasia - red cutaneous patch on penis
  • Known as erythroplasia of Queyrat when it occurs on the glans
  • Known as Bowe's disease on the shaft
  • There are several benign causes of red patches, so biopsy is indicated
  • Treatment - topical 5-FU cream, CO2 laser ablation, or surgical excision
• Staging
  • T1 - confined to skin
  • T2 - corpus cavernosum/spongiosum
  • T3 - urethra
  • T4 - adjacent structures
  • N1 - inguinal nodes (50% have nodes at presentation, which can be infective rather than malignant)
  • N3 - iliac nodes
  • Only rarely metastasises
• Management:
  • Treatment of tumour
    • Surgical excision - often penile preserving surgery. If it affects the glans, glansectomy will be required. More advanced tumours require partial penectomy.
  • Treatment of inguinal lymphadenopathy
    • Delay until 3/52 after treatment of primary tumour - if enlargement is caused by infection, then it will show signs of improvement by then
    • USS FNA will confirm diagnosis
    • Requires block dissection of both groins if positive
    • If no clinical nodes, needs SLNB
• Prognosis
  • 5 year survival >80% if confined to penis
  • 40% if node positive