Conditions Affecting the Penis
Hypospadias and epispadias are congenital anomalies of the ure-thral opening. In hypospadias, the urethral opening is a groove on the underside of the penis. In epispadias, the urethral opening is on the dorsum. These anatomic abnormalities may be repaired by various types of plastic surgery, usually when the boy is very young.
Phimosis, a condition in which the foreskin is constricted so thatit cannot be retracted over the glans, can occur congenitally or from inflammation and edema. With the trend away from rou-tine circumcision of newborns, early instruction should be given about cleansing the prepuce. If the preputial area is not cleaned, normal secretions accumulate, causing inflammation (balanitis), which can lead to adhesions and fibrosis. The thickened secretions become encrusted with urinary salts and calcify, forming calculi in the prepuce. In elderly men, penile carcinoma may develop. Phimosis is corrected by circumcision (see later discussion).
Paraphimosis is a condition in which the foreskin is retracted behind the glans and, because of narrowness and subsequent edema, cannot be returned to its usual position (covering the glans). Paraphimosis is treated by firmly compressing the glans to reduce its size and then pushing the glans back while simultane-ously moving the prepuce forward (manual reduction). Circumci-sion is usually indicated after the inflammation and edema subside.
Penile cancer occurs in men older than age 60 and representsabout 0.5% of malignancies in men in the United States (Stadler, Vogelzang, Elwell & Jones, 2000). In some countries, however, the incidence is 10% to 12%. Since most penile cancers occur in uncircumcised men, it has been suggested that the etiology of this cancer may be the irritative effect of smegma and poor hygiene. However, the “protective” effect of circumcision is seen only in males who are circumcised in the neonatal period; circumcision that occurs at puberty or after does not confer the same benefit (Herr et al., 2001). Cancer of the penis appears on the skin of the penis as a painless, wartlike growth or ulcer. Cancer of the penis can involve the glans, the coronal sulcus under the prepuce, the corporal bodies, the urethra, and regional or distant lymph nodes. Bowen’s disease is a form of squamous cell carcinoma in situ ofthe penile shaft. Typically, a man delays seeking treatment for more than a year, probably because of guilt, embarrassment, or ignorance.
Circumcision in infancy almost eliminates the possibility of penile cancer because chronic irritation and inflammation of the glans penis predispose to penile tumors (Herr et al., 2001; Pettaway & Dinney, 2001; Schoen et al., 2000). In uncircumcised men, per-sonal hygiene is an important preventive measure.
Smaller lesions involving only the skin may be controlled by exci-sion (Herr et al., 2001). Topical chemotherapy with 5-fluorouracil cream is an option in selected patients. Radiation therapy is used to treat small squamous cell carcinomas of the penis or for pal-liation in advanced tumors or lymph node metastasis. Partial penectomy (removal of the penis) is preferred to total penectomy if possible; about 40% of patients can then participate in sexual intercourse and stand for urination. The shaft of the penis can still respond to sexual arousal with an erection and has the sensory capacity for orgasm and ejaculation. Total penectomy is indi-cated when the tumor is not amenable to conservative treatment. After a total penectomy, the patient may still experience orgasm with stimulation of the perineum and scrotal area.
Priapism is an uncontrolled, persistent erection of the penis that causes the penis to become large, hard, and painful. It occurs from either neural or vascular causes, including sickle cell thrombosis, leukemic cell infiltration, spinal cord tumors or injury, and tumor invasion of the penis or its vessels. It may also occur with use of medications that affect the central nervous system, antihypertensive agents, antidepressant medications, and substances injected into the penis to treat erectile dysfunction. This condition may result in gangrene and often results in impotence, whether treated or not.
Priapism is a urologic emergency. The goal of therapy is to im-prove venous drainage of the corpora cavernosa to prevent is chemia, fibrosis, and impotence. The initial treatment is directed at relieving the erection and includes bed rest and sedation. The corpora may be irrigated with an anticoagulant, which allows stagnant blood to be aspirated. Shunting procedures to divert the blood from the turgid corpora cavernosa to the venous system (corpora cavernosa–saphenous vein shunt) or into the corpus spongiosum–glans penis compartment may be attempted.
Peyronie’s disease involves the buildup of fibrous plaques inthe sheath of the corpus cavernosum. These plaques are not vis-ible when the penis is relaxed. When erect, however, curvature of the penis occurs that can be painful and can make sexual inter-course difficult or impossible. Peyronie’s disease primarily occurs in middle-aged and older men. Although the plaques may shrink over time, surgical removal of the plaques may be necessary.
Urethral stricture is a condition in which a section of the urethra is narrowed. It can occur congenitally or from a scar along the urethra. Traumatic injury to the urethra (for example, from in-strumentation or infections) can result in strictures. Treatment involves dilation of the urethra or, in severe cases, urethrotomy (surgical removal of the stricture).
Circumcision is the excision of the foreskin, or prepuce, of theglans penis. It is usually performed in infancy. In adults, it is part of the treatment for phimosis, paraphimosis, and recurrent in-fections of the glans and foreskin and may be performed at the personal desire of the patient.
Postoperatively, a petrolatum (Vaseline) gauze dressing is ap-plied and changed as indicated. The patient is observed for bleed-ing. Because considerable pain may occur after circumcision, analgesic agents are administered as needed.