Diseases of the penis Flashcards
Management of phimosis in a child under 2 years old
- non-retractile foreskin and/or ballooning during micturition in a child under two → an expectant approach should be taken in case this is physiological phimosis → will resolve in time
*forcible retraction can result in scar formation so should be avoided
- Personal hygiene is important
*If the child is over 2 years of age and has recurrent balanoposthitis or urinary tract infection then treatment can be considered
What’s ballooning in a boy under 2 y old?
Physiologically, a foreskin becomes retractible before age of 2
- ballooning during urination → collection of urine between the foreskin and a glans
- this is normal
Phimosis
- what is it?
- treatment
Phimosis = narrowing of the opening of the foreskin
- may result in balanitis
Treatment:
- usually circumcision
- may be conservative with topical betamethasone 0.05% cream
Paraphimosis
- what is this?
- possible cause
Paraphimosis = swelling of the gland as a result of a tight foreskin being retracted and not replaced
Cause: after catheterisation or erection
What happens: foreskin blocks the venous outflow → oedema and swelling of the glans
Pathological phimosis?
- other names (2)
- pathophysiology
aka Balanitis Xerotica Obliterans or Lichen Sclerosus of the Penis
Pathophysiology: dermatological skin condition of an unknown origin; affecting the glans and foreskin
- atrophic white patches appear and whitish ring of a harden tissue near to tip of the penis → prevents retraction
Treatment:
- Lichen sclerosus → high potency topical steroids (e.g. clobetasol).
- Circumcision
Peyronie’s Disease
- pathophysiology
- cause
Pathophysiology:
- connective tissue disorder → fibrous plaques in the tissue of the penis
- scar forms in tunica albuginea (surrounding corpora cavernosa)
Cause: not fully understood. Thought to be caused by a trauma or injury of the penis e.g. during sexual activity (patient may even not be aware the trauma has occured)
Presentation of Peyronie’s disease
- pain
- abnormal curvature
- erectile dysfunction
- indentation
- shortening
- reduced thickness
Management of Peyronie’s Disease
Conservative treatment: to help with pain and potentially slowing the disease progress (but no effect on the curvature) e.g. Verapamil, collagenase, interfreon
Mechanical modelling → a vacuum erection device and penile stretching and straightening exercises with the aim of reducing the curvature
Mechanical modelling on its own is unlikely to be beneficial but it is essential that it is performed after Xiapex injections or surgical correction of the penile curvature
Xiapex Injection therapy is the first non-surgical therapy that has proved effective in treating Peyronie’s plaque
Surgical correction →should only be performed after the disease progress has stopped which usually occurs 12 months from onset (chronic phase)
Balanitis
- pathophysiology
- cause
Pathophysiology: inflammation of the glans penis
Cause:
- most common causes are infective (both bacterial and candidal)
- autoimmune causes
Investigations for Balanitis
- majority diagnosed clinically based on the history and physical appearance of the glans penis
- if suspected infective causes a swab can be taken for microscopy and culture which may demonstrate bacteria or Candida albicans
- When there is a doubt about the cause and there is extensive skin change, then a biopsy can be helpful in confirming the diagnosis.
Treatment of balanitis
- gentle saline washes → to wash properly under the foreskin
- in the case of more severe irritation and discomfort then 1% hydrocortisone can be used for a short period
- When the cause is not clear, these measures can often resolve the condition alone
Treatment of balanitis if it is due to:
- candidiasis
- bacteria
- anaerobic bacteria
- candidiasis → topical clotrimazole which has to be applied for two weeks
- Bacterial balanitis ( Staphylococcus spp. or Group B Streptococcus spp.) → oral flucloxacillin or clarithromycin if penicillin allergic
- Anaerobic balanitis is managed with saline washing ; topical or oral metronidazole if not settling.
Management of balanitis if it is due to:
- dermatitis
- lichen sclerosus
- Dermatitis → mild potency topical corticosteroids (e.g. hydrocortisone)
- Lichen sclerosus → high potency topical steroids (e.g. clobetasol); circumcision can help
Organic and psychogenic causes of erectile dysfunction
Risk factors for erectile dysfunction
- increasing age
- cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
- alcohol use
- drugs: SSRIs, beta-blockers
Investigations for erectile dysfunction
- all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels
- Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment
Management of erectile dysfunction
PDE-5 inhibitors (such as sildenafil, ‘Viagra’):
- they should be prescribed (in the absence of contraindications) to all patients regardless of aetiology
- sildenafil can be purchased over-the-counter without a prescription
Vacuum erection devices → first-line treatment in those who can’t/won’t take a PDE-5 inhibitor
Other points
- for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
- people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
Medical benefits of circumcision
- reduces the risk of penile cancer
- reduces the risk of UTI
- reduces the risk of acquiring sexually transmitted infections including HIV
Medical indications for circumcision
Medical indications for circumcision
- phimosis
- recurrent balanitis
- balanitis xerotica obliterans
- paraphimosis
Prognosis of cryptorchidism
- up to 5% of boys will have an undescended testis
- postnatal descent occurs in most
Causes and associations of cryptorchidism
Most: unknown cause
Associaitons:
- Patent processus vaginalis
- Abnormal epididymis
- Cerebral palsy
- Mental retardation
- Wilms tumour
- Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)
When surgery is indicated for cryptorchidism?
- A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum
- If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated
Reasons for correction of cryptorchidism
Reasons for correction of cryptorchidism
- Reduce risk of infertility
- Allows the testes to be examined for testicular cancer
- Avoid testicular torsion
- Cosmetic appearance
Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis
The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes)
Management of cryptorchidism
- Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch
- Intra-abdominal testis should be evaluated laparoscopically and mobilised
- After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy
Vasectomy
- is it a complicated operation?
- what’s failure rate?
- simple operation, can be done under LA (some GA), go home after a couple of hours
- 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation
Does vasectomy work immediately?
- doesn’t work immediately
- semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
Complications of vasectomy
- bruising
- haematoma
- infection
- sperm granuloma
- chronic testicular pain (affects between 5-30% men)
Can we reverse vasectomy?
The success rate of vasectomy reversal is:
- up to 55%, if done within 10 years
- 25% after more than 10 years
