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Disorders of Penis



Disorders of Penis
Disorders that affect the penis include balanitis xerotica obliterans, balanoposthitis, erythroplasia, infectious penile lesions, phimosis, paraphimosis, hypospadias, epispadias, vascular disorders, Peyronie's disease, impotence of an organic origin, genital warts (condyloma acuminatum), cancer of the penis, and other conditions such as fibrosis, and ulcers.
Balanitis xerotica obliterans results from chronic inflammation of the head of the penis (glans). It presents as a blanched area near the tip of the penis that surrounds and often constricts the urinary passage (meatus).

Balanoposthitis is caused by bacterial and yeast infections beneath the loose fold of skin covering the end of the penis (foreskin of the penis) of the uncircumcised male.

Erythroplasia of Queyrat is common in uncircumcised men. It presents as reddish and velvety pigmentation on the glans. It is a premalignant lesion invading only the local tissues.

Rare infectious penile lesions include herpes zoster, TB, and fungal (mycotic) infections.

Phimosis is the most common form of penile malformation and refers to an abnormally tight foreskin. One is unable to retract the foreskin over the head of the penis. This condition can cause urination difficulty as well as painful erections. Phimosis prevents proper cleaning of the glans, leading to balanitis. It is also associated with an increased risk of penile cancer.

Paraphimosis often occurs as a complication of phimosis. Although the foreskin retracts at erection, it is too tight to move back over the glans. The penis becomes constricted, causing painful swelling of the glans and diminished blood flow. This is a medical emergency, as the glans can become gangrenous. Paraphimosis may cause urinary retention.

Hypospadias occurs when the urethra opens on the inferior (ventral) surface of the penis.

Epispadias occurs when the urethral opening is on the dorsal surface of the penis. This condition is rare.

Vascular disorders of the penis include the obstruction of a vessel by a blood clot (thrombosis or embolism), a localized swelling and mass of blood caused by a broken blood vessel (hematoma), or excessive bleeding (hemorrhage).

In Peyronie's disease, strands of dense, fibrous tissue form within the penis. This fibrosis causes the penis to curve during erection, interfering with intercourse. Peyronie's disease can also prevent erection distal to the area of fibrosis and can cause impotence. The fibrous areas have a gritty, bulky feel on palpation.

Painful and prolonged erection of the penis (priapism) is a dangerous condition requiring emergency treatment. It occurs when blood fails to drain from the spongy tissue of the penis, keeping the penis erect. Causes of priapism include damage to the nerves that control the blood supply to the penis, blood diseases that cause abnormal clotting of blood in the penis (leukemia, sickle cell anemia), testosterone replacement, infection, or inflammation that may block the normal outflow of blood from the penis (prostatitis, urethritis).

Condyloma acuminatum is a viral infection that may be transmitted during sexual intercourse. The infection is caused by the human papillomavirus (HPV) type 6 or 11. The lesions may be single or multiple and can involve the inner surface of the prepuce.

Cancer of the penis is rare and is much more common in uncircumcised men who practice poor hygiene.



Diagnosis

History: The individual may report pain in the flaccid penis, usually caused by inflammation (balanitis, phimosis), ulceration (balanoposthitis), swelling (vascular disorders), or painful enlargement of the glans constricted by paraphimosis. In an erect penis, pain may accompany curvature of the penis in Peyronie's disease, or the prolonged painful erection of priapism. Some individuals may notice soft, flat warts (condyloma acuminatum) on the penis. Redness and velvety pigmentation may be associated with erythroplasia. Hypospadias and epispadias can result in urinary incontinence.

Physical exam: The examination may reveal inflamed, moist glans (balanitis, phimosis). Ulcerated areas (balanoposthitis) may be identified. Swelling can be associated with vascular disorders or paraphimosis. In Peyronie's disease, the fibrous areas are gritty and bulky on palpation. Warts are soft and flat and may be difficult to distinguish visually (condyloma acuminatum). The foreskin is retracted to evaluate phimosis or paraphimosis. The dorsal (top) of the penile shaft is felt (palpated) for plaques of Peyronie's disease, and the ventral (bottom) surface for evidence of urethral tumors.

Tests: A culture may be necessary to identify the organism responsible for the inflammation or ulceration. To detect warts, the penis can be wrapped in a vinegar solution (acetic acid). Warts absorb solution at a different rate than surrounding skin, making them easily visible. Vascular function may be tested by injecting papaverine and phentolamine into the penis, causing an erection. Ultrasound may be performed to identify arterial abnormalities. These tests may be done to diagnose any of the penile disorders.





Treatment

Balanitis may be treated with a topical anti-inflammatory or antifungal cream, as well as by appropriate antibiotic therapy. If constriction has occurred, the opening of the penis may need to be surgically enlarged (meatotomy). Removing the foreskin (circumcision) will cure phimosis and paraphimosis, and prevent recurrence of balanitis when caused by an irritating foreskin. Circumcision also reduces the risk of cancer.

Treatment of priapism may involve spinal anesthesia or withdrawal of blood from the penis through a wide-bore needle. Additional surgery may be necessary. Treatment of certain underlying causes, such as sickle cell disease, may be effective. Drugs, such as antidepressants, antipsychotics, alpha-adrenergic blockers, antidiabetic agents, certain antihypertensive and anticoagulant drugs, as well as corticosteroids may be used to reduce priapism.

Antiviral agents may lessen the symptoms of herpes ulcers but will not cure the disease. Recurrence is expected, as the virus is difficult to eradicate. Gonorrhea and syphilis are effectively treated with appropriate antibiotic therapy. Genital warts may be removed by excision, electrocauterization, laser, use of cold (cryotherapy), or by the application of an acid solution (podophyllin).

Peyronie's disease may improve without treatment. Local injections of anti-inflammatory medications (corticosteroids) or calcium channel blockers are sometimes effective. If the condition persists, the thickened area can be surgically removed and replaced with a graft of normal tissue.

Phimosis and paraphimosis require circumcision. A preliminary dorsal slit may be required.

In epispadias, bladder outlet reconstruction may be required to achieve urinary control.

In hypospadias, functional and cosmetic correction may be needed. A new urethra (neourethra) may be constructed using penile shaft skin or foreskin.