Penile Problems
Many men will have problems with their penis at some point
in the course of their lives. While erectile dysfunction (ED) is extremely
common, particularly as men get older, this article will not address ED except
as part of the treatment of Peyronie’s disease.
Perhaps the commonest problem affecting men is with the
foreskin, and this poor little piece of skin can be afflicted with all the
dermatologic problems affecting the rest of the cuticle plus several extra
ones. Before starting to consider the diseases affecting the foreskin it is
worth addressing its purpose and dispelling some of the myths surrounding it.
The foreskin exists to cover and protect the sensitive skin
on the glans penis. In some mammals the glans is surfaced with a moist epithelium, although in man
this is not the case. The foreskin is frequently attached to the glans at birth and, presumably by a process of apoptosis,
becomes free by the age of three or four years. It is important to reassure
parents that a non-retractile foreskin in a baby is not a problem, and that
forceful retraction to attempt to clean the penis may cause damage.
Men who are circumcised develop a thicker epithelium on the
head of the penis with a corresponding loss of sensation, and although this has
been proposed as a potential treatment for premature ejaculation there is no
proof this works.
While a substantial minority of the world’s population are
circumcised in infancy, it is impossible to make a scientific argument for this
practice. Proponents of circumcision point to the lower rate of penile cancer
in circumcised men (there are alternative epidemiological explanations for
this) and also to the lower risk of urinary infections in uncircumcised male
children. However boys are not at high risk of urinary tract infection in the
first place and the studies which have addressed this issue have failed to
correct for uncircumcised boys with normal as opposed to phimotic
foreskins.
From a religious point of view, doctors have traditionally
taken the view that it is better for a child to be circumcised by an expert
than by a non-medical practitioner. It is interesting that this view is not
applauded for female circumcision!
My view on the matter is perhaps coloured by having seen a
number of patients who have suffered partial or complete loss of the glans penis as a complication of infant religious
circumcision, and I no longer carry out this procedure on religious grounds
until the patient has attained the age of consent.
Phimosis probably affects about one in
twenty uncircumcised men. It is characterised by a tight band of inelastic skin
at the tip of the foreskin. This may vary from slight difficulty in moving the
foreskin over the erect glans penis to a pinhole
opening which will not allow free urine passage. Balanitis
Xerotica Obliterans (BXO)
or Lichen Sclerosus et Atrophicus
(LSA) are progressively more common causes of phimosis
as a man gets older, but in children and young adults there is frequently no
major scarring of the prepuce.
In men and boys with a tight foreskin, either a course of
treatment with a mild topical steroid (combined with gentle gradual
stretching at home), or a stretch under general anaesthetic (with division of
the preputial adhesions) will usually suffice. In
refractory cases a preputial plasty
may be needed, or a circumcision if preferred. In adults, while preputial plasty will give
satisfactory results in most cases with no scarring there seems to be a high
recurrence rate if this is done in the presence of BXO, so circumcision is
usually preferred.
For the infirm, a more radical version of the same procedure
is a dorsal slit which, while simple and effective, does not give a very good
cosmetic appearance.
When
a circumcision is required, most
Short
Frenulum
Another
common reason for men being circumcised is due to tightness or scarring of the frenulum (the short bridge of skin under the urethral meatus. This may be torn or stretched during sex and may
bleed profusely from the small frenular artery. It is
simply fixed by a small plastic surgical procedure (a frenuloplasty)
under local anaesthesia with excellent results.
Paraphimosis
This
occurs when a tight foreskin is stuck in retraction behind the glans and acts as a tourniquet. Early reduction,
either manually or by a dorsal slit procedure, is essential to avoid venous
gangrene. Most men will require circumcision after the swelling has settled, as
the foreskin is often left scarred.
Skin conditions affecting the penis
The accompanying section gives a summary of benign and
pre-malignant skin conditions affecting the penis: in many cases circumcision
will be helpful if medical management fails although in some cases laser
ablation of the affected area will be necessary.
Meatal strictures
Most strictures of the external urethral meatus
are associated with BXO or LSA, although in children they may be caused by
inexpert circumcision (possibly due to damage to the frenular
artery). In adults urethral instrumentation or catheter trauma may be the
cause. Patients will present with classical symptoms of bladder outflow
obstruction and possible penile pain if there is infection.
Simple dilatation, while widely practised, has a high
recurrence rate unless the patient is prepared to take up regular self dilatation. Where BXO is
present the recurrence rate with standard reconstruction is very high and
insertion of a patch of buccal mucosa will give the
best long term results, although often at the cost of a relatively complex two
stage procedure.
Small penis
It is relatively common to see men who are unhappy with
their penile length: sadly many of these men only come to see specialists after
having been though unscrupulous clinics who charge
much but deliver only scarring. IN fact the majority of patients requesting
penile enhancement surgery, as show in research by our group, have penile dimensions
within the normal range.
Penile enhancement surgery should still be viewed as
experimental and while it is possible to give the impression of a slightly
longer or thicker flaccid penis, the surgery may well leave the penis looking
severely misshapen if done badly. There is no proven technique to increase the
size of the erect organ, and those techniques which are available have
significant risks of post operative erectile failure.
The desire to have a longer penis appears to be a variant of
dysmorphophobia and patients should not be invited to
undergo surgery without being seen by an experienced psychosexual expert first.
Peyronie’s disease
Since
the erection bodies of the penis stretch to a pre-defined length during
erection, a shortening of one side will result in a bend to that side (This can
be demonstrated by taping a piece of sellotape onto
the side of a long balloon then blowing it up). Peyronie’s
disease is a condition where a fibrous plaque affects the fibrous covering of
the penis in such a way; congenital curvature can cause the penis to bend.
Generally speaking, a gentle bend of up to 25 degrees will often not cause too
many problems, and indeed most men do have a penis which bends a little bit.
In
the early stages of Peyronie’s disease pain is often
a problem, due to an active inflammation in the affected area.
Initial
treatment in the painful phase of the disease is controversial, with few
properly conducted studies showing a benefit of any treatment over simple rest.
There appears to be a place for anti-oxidant vitamin therapy and I usually
advise a three month initial course of high dose anti-oxidants which may help
by reducing free radicals in the developing scar tissue. Intercourse should be
avoided if pain is a major feature, and if a man continues to have sex then
extra lubrication is helpful to reduce the risk of further stressing the
erection. Tamoxifen in conjunction with a course of
anti-inflammatory medicine may help more persistent cases.
The
commonest and simplest operation is a procedure called the Nesbit’s
operation. This involves reducing the length of the normal side of the penis to
straighten it. While this procedure causes a small amount of penile shortening
and leaves the affected area in place, few men find they are bothered by the
residual scar tissue if the penis is straight in erection.
If
there is a major bend, a persistent painful plaque, or the penis is short, a Nesbit’s procedure may not give a good result. It may then
be necessary to consider removing the plaque and putting in a replacement
tissue such as vein or dermis. Although this option preserves penile length it
is considerably more complex than the simple Nesbit’s
procedure.
Penile carcinoma
Penile cancers are rare and associated with poor hygiene,
uncircumcised men and some pre-malignant skin conditions.
Nearly always the lesion starts as an ulcer on the glans or foreskin, and spreads to the penile bodies and
then the inguinal lymph nodes. If the disease is caught at an early stage
surgery is curative and it may be possible to practice conservative techniques
to allow continued potency. If the disease is advanced however partial or total
penectomy is required, although radiotherapy may be
an option. Early regional
lymphadenectomy, while associated with
significant morbidity, appears to offer a survival benefit in patients with
poor prognosis tumours or low volume lymph node disease.