Conditions of the Penis

Question 1

2 primary functions of the penis

Answer 1

*micturition
*sexual intercourse

Question 2

3 main parts of the penis

Answer 2

1. root - proximal part of penis; contains 2 crura & 1 bulb, as well as ischiocavernosus & bulbospongiosus
2. body - 3 cylinders of erectile tissue; 2 corpus cavernosa & the corpus spongiosum
3. glans - distal expansion of corpus spongiosum; contains external urethral meatus

Question 3

fascia of the penis - overview

Answer 3

*3 layers of fascia
*from superficial to deep:
1. superficial fascia (Dartos fascia of the penis)
2. deep fascia (Buck’s fascia)
3. tunica albuginea
*blunt trauma to the penis can result in injury to the different fascial layers

Question 4

fascia of the penis: Dartos fascia

Answer 4

*most superficial fascial layer of the penis
*continuous with Scarpa’s fascia of abdominal wall

Question 5

fascia of the penis: Buck’s fascia

Answer 5

*deep fascia of the penis
*collectively surround ALL 3 erectile bodies (corpus cavernosum, corpus spongiosum)
*contains deep penile neurovasculature and helps generate the erect state (dorsal vein, etc are within the Buck’s fascia

Question 6

fascia of the penis: Tunica Albuginea

Answer 6

*deepest layer of penile fascia
*strong, bilayered fibrous tissue
*hydraulic seal to keep blood in engorged corpus cavernosum uniformly
*injuries typically happen when penis is erect during intercourse

Question 7

urethral trauma

Answer 7

*mechanism: often blunt or penetrating trauma (including iatrogenic)
*location is key - anterior vs. posterior
1. posterior urethra injury: involves prostatic and membranous urethra; commonly associated with pelvic fractures
2. anterior urethra injury: involves bulbar and penile urethra; commonly associated with perineal straddle injury or motor vehicle accident
*BOTH can present with: 1) blood at urethral meatus; 2) difficulty voiding or inability to void

Question 8

anterior vs. posterior urethral trauma - clinical presentations

Answer 8

*BOTH can present with: 1) blood at urethral meatus; 2) difficulty voiding or inability to void

1. anterior urethral injury:
   -more commonly injured (often straddle injury or iatrogenic [traumatic catheter])
   -bulbar urethra pushed against pelvis
   -high yield clinical features: perineal hematoma, urine in superficial perineal space
2. posterior urethral injury:
   -HIGH energy blunt trauma
   -association with pelvic fractures
   -bulbomembranous junction > prostatomembranous junction
   -high yield clinical features: pelvic hematoma, high riding boggy prostate, urine in retropubic space

Question 9

Peyronie disease - overview

Answer 9

*abnormal curvature of the penis due to FIBROUS PLAQUE within the TUNICA ALBUGINEA
*fibrotic disorder of the tunica albuginea → penile deformity, pain, +/- erectile dysfunction

Question 10

Peyronie disease - clinical presentation

Answer 10

*painful erection with a curved penis
*often a hard, palpable mass near the dorsal midline of the shaft

Question 11

Peyronie disease - pathophysiology

Answer 11

*disorganized collagen deposition after microtrauma → fibrotic plaque, loss of elasticity, curvature

Question 12

Peyronie disease - treatment

Answer 12

*medical: treatment with collagenase injections once curvature stabilizes
*surgical repair / plaque excision
*50% resolve spontaneously

Question 13

Peyronie disease - classic vignette

Answer 13

“A 52yo male presents with penile curvature, pain, and a palpable nodule over 6 months, making intercourse difficult”

Question 14

hypospadias / epispadias - overview

Answer 14

*embryological malformation of the urethra, characterized by abnormal position of the opening of the penile urethra
1. HYPOspadias: urethral meatus located on the VENTRAL (bottom; closer to the ground) side of penis
-may be accompanied by chordee
2. EPIspadias: urethral meatus located on the DORSAL (top) side of penis
-associated with bladder extrophy

Question 15

hypospadias / epispadias - pathophysiology

Answer 15

1. hypospadias (ventral = bottom of penis) - incomplete fusion of the URETHRAL FOLDS
2. epispadias (dorsal = top on penis) - failure of midline fusion of GENITAL TUBERCLE

Question 16

hypospadias / epispadias - treatment

Answer 16

*surgically repaired, ideally when the patient is 6-12 months old

Question 17

hypospadias / epispadias - classic vignette

Answer 17

“2 day old male infant found on routine check to have meatus on dorsal/ventral aspect of penis”

Question 18

penile condyloma acuminata - overview

Answer 18

*commonly known as genital warts
*BENIGN epithelial growths caused by human papillomavirus, primarily HPV types 6 and 11 (low-risk HPV types)
*flesh-colored, verrucous, or cauliflower-like lesions

Question 19

penile condyloma acuminata - pathology

Answer 19

*koilocytes: epithelial cells that have been transformed by HPV
*large, dark, wrinkled (rainsinoid) nuclei
*clear cytoplasm around the nucleus (perinuclear halo)

Question 20

penile condyloma acuminata - treatment

Answer 20

*PREVENTION IS KEY
*HPV vaccine protects against 6, 11, 16, 18
*goal age to vaccinate is 11-12 (can start at age 9)
*no definitive treatment
*high rate of recurrence

Question 21

penile condyloma acuminata - classic vignette

Answer 21

“A 24yo male presents with multiple, painless fleshy growths on the penile shaft. No pain or discharge. He has a history of multiple sexual partners and inconsistent condom use”

Question 22

squamous cell carcinoma of the penis - overview

Answer 22

*malignant neoplasm arising from the squamous epithelium of the penis, most commonly the glans, foreskin, or shaft
*most common primary penile cancer
*risk factors: uncircumcised, phimosis, smoking
*prevalence: 1 in 100,000

Question 23

squamous cell carcinoma of the penis - pathophysiology

Answer 23

*HPV 16, 18, 31, 33 (high risk HPV types) responsible for 2/3 of cases
*PRECURSOR LESIONS in situ have a high risk of developing into squamous cell carcinoma of the penis (NO invasion of the dermis):
-Bowen Disease: red scaly patches on penile shaft
-Erythroplakia of Queyrat: redness on the glans

Question 24

squamous cell carcinoma of the penis - pathology

Answer 24

*composed of malignant keratinocytes forming solid clusters/cords of cells as it invades the dermis

Question 25

squamous cell carcinoma of the penis - treatment

Answer 25

*depends on disease extent (laser/radiation therapy, penile resection, chemo)

Question 26

squamous cell carcinoma of the penis - classic vignette

Answer 26

“A 58yo male smoker presents with a non-healing ulcerated lesion on the glans penis x4 months. Never been vaccinated for HPV. A biopsy of the lesion reveals atypical squamous cells.”