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Penile Anomalies and Conditions

Penile Anomalies and Conditions

Penile anomalies and conditions may be congenital Congenital Chorioretinitis or acquired and can affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment the urethral opening, prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy, shaft, or glans or the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy. Examples include phimosis, paraphimosis, epispadias, hypospadias, balanitis, Peyronie disease, and priapism. The severity of clinical symptoms varies, but diagnosis of each of these conditions is usually based on the history and physical examination. Treatment varies from medical therapies to surgical intervention. These diagnoses are important to be aware of, since a few (such as phimosis and balanitis) are relatively common, while others (such as paraphimosis and priapism) can have severe complications if not treated in a timely fashion.

Last updated: 26 Aug, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Anatomy

The penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy is made up of:

  • Glans:
    • Also known as the head of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy
    • Covered by the prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy, also known as foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy
  • Penile shaft Penile Shaft Bowen Disease and Erythroplasia of Queyrat:
  • Urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy: 
    • Runs from the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess through the center of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy 
    • Terminates with an opening at the tip of the glans, called the urethral meatus

Classification

Penile conditions can be classified on the basis of the affected region of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy:

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Epispadias and Hypospadias

Epispadias

  • Definition: abnormal opening of the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy on the dorsal surface of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy 
  • Epidemiology:
    • Very rare
    • Reported incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: < 1 in 100,000 male newborns
  • Etiology:
    • Defective migration of the genital tubercle Genital Tubercle Development of the Urogenital System → incomplete urethral tubularization
    • Associated with abnormal abdominal wall Abdominal wall The outer margins of the abdomen, extending from the osteocartilaginous thoracic cage to the pelvis. Though its major part is muscular, the abdominal wall consists of at least seven layers: the skin, subcutaneous fat, deep fascia; abdominal muscles, transversalis fascia, extraperitoneal fat, and the parietal peritoneum. Surgical Anatomy of the Abdomen defects, such as exstrophy of the bladder Bladder A musculomembranous sac along the urinary tract. Urine flows from the kidneys into the bladder via the ureters, and is held there until urination. Pyelonephritis and Perinephric Abscess
  • Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor: 
    • Meatal opening on the dorsum of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy
    • Ventrally hooded prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy
    • Associated with curvature of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy (chordee)
  • Diagnosis: often made at the time of newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn genital examination
  • Management: surgical closure and reconstruction
  • Complications: 
    • ↑ Frequency of urinary tract infections Urinary tract infections Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary tract infections (UTIs) (UTIs)
    • Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
    • Urinary reflux
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
Male baby with epispadias

Male baby with epispadias

Image: “Male baby with epispadias” by Department of Pediatric Urology, University Medical Center Regensburg, Germany. License: CC BY 2.0

Hypospadias

  • Definition: abnormal opening of the urethra Urethra A tube that transports urine from the urinary bladder to the outside of the body in both the sexes. It also has a reproductive function in the male by providing a passage for sperm. Urinary Tract: Anatomy on the ventral surface of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy 
  • Epidemiology:
    • Most common congenital Congenital Chorioretinitis penile defect
    • Occurs in approximately 1 in 250 male newborns in the United States
  • Etiology: 
    • Due to failure of urethral folds to close
    • Cause is multifactorial 
    • May be associated with the following factors:
      • Environmental
      • Genetic
      • Endocrine
  • Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor:
    • Meatal opening on the ventral surface of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy
    • Deficient foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy on the ventral surface → incomplete foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy closure around the glans
    • Associated with chordee
  • Diagnosis: often made at the time of newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn genital examination
  • Management: 
    • Surgical correction
    • Not warranted for those with mild defects
  • Complications:
    • ↑ Risk of UTIs
    • Urinary incontinence Urinary incontinence Urinary incontinence (UI) is involuntary loss of bladder control or unintentional voiding, which represents a hygienic or social problem to the patient. Urinary incontinence is a symptom, a sign, and a disorder. The 5 types of UI include stress, urge, mixed, overflow, and functional. Urinary Incontinence
    • Urinary obstruction
    • Infertility Infertility Infertility is the inability to conceive in the context of regular intercourse. The most common causes of infertility in women are related to ovulatory dysfunction or tubal obstruction, whereas, in men, abnormal sperm is a common cause. Infertility
  • Difference between hypospadias and epispadias penile anomalies and conditions

    The difference between hypospadias and epispadias: Hypospadias results in an abnormal urethral opening on the ventral surface of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy, whereas epispadias results from an abnormal opening on the dorsal surface.

    Image by Lecturio.
  • Glanular hypospadias

    Glanular hypospadias

    Image: “Glanular hypospadias is detected with the retraction of the foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy” by Yesildag E et al AL Amyloidosis. License: CC BY 3.0
  • Hypospadias penile anomalies and diseases

    Abnormal opening on the ventral surface of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy consistent with hypospadias

    Image: “Depiction of a human penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy with hypospadias” by Buddy. License: Public Domain

Phimosis and Paraphimosis

Phimosis

  • Definition: inability to retract the prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy over the glans
  • Epidemiology: 1 of the most common penile abnormalities
  • Etiology:
    • Physiologic:
      • Occurs in almost all male newborns
      • Due to normal development of congenital Congenital Chorioretinitis adhesions between the prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy and glans
    • Pathologic: 
      • Nonretractable prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy secondary to scarring Scarring Inflammation
      • Usually a result of infection and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor:
  • Diagnosis: physical examination
  • Management:
  • Complications: 
    • Paraphimosis
    • Balanitis
    • ↑ Risk of penile cancer Penile cancer Malignant lesions of the penis arise from the squamous epithelium of the glans, prepuce, or penile shaft. Penile cancer is rare in the United States, but there is a higher prevalence in lower socioeconomic regions. The most common histologic subtype is squamous cell carcinoma. Penile Cancer
Phimosis

An erect penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy with phimosis

Image: “Example of an erect penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy with Phimosis. The foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy will not retract.” by Andrew1985. License: Public Domain

Paraphimosis

  • Definition: condition in which the prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy of an uncircumcised penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy gets trapped behind the glans and cannot be reduced:
  • Etiology: several potential predisposing factors:
    • Phimosis 
    • Trauma
    • Sexual activity
    • Procedures (usually due to not replacing the prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy over the glans after the procedure): 
      • Cystoscopy 
      • Catheterization
  • Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor:
    • Swelling Swelling Inflammation
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and tenderness
    • Constricting band of tissue proximal to the glans
    • Retracted prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy does not easily reduce manually
    • If not corrected: ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage or necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage → blue or black discoloration 
  • Diagnosis: physical examination
  • Management:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control
    • Manual reduction
    • Surgical intervention:
      • Dorsal slit reduction (incision of the constricting band) 
      • Emergent circumcision Circumcision Excision of the prepuce of the penis (foreskin) or part of it. HIV Infection and AIDS
  • Complications: necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage of the glans
Paraphimosis complicated by glans gangrene

Paraphimosis complicated by glans gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction:
This condition is caused by impairment of lymphatic and venous blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure, leading to swelling Swelling Inflammation and compromise of arterial blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure.

Image: “Demonstrating penile glans gangrene Gangrene Death and putrefaction of tissue usually due to a loss of blood supply. Small Bowel Obstruction with paraphimotic constriction ring with purulent urethral discharge” by Balkan Medical Journal. License: CC BY 2.5

Balanitis

Definition and epidemiology

  • Balanitis is inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the glans penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy.
  • Affects approximately 3% of uncircumcised males globally

Etiology

  • Predisposing factors:
    • Inadequate cleaning of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy and foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy
    • Phimosis
    • Exposure Exposure ABCDE Assessment to irritants:
      • Soaps
      • Lubricants
      • Latex
    • Dermatologic conditions:
      • Allergic reaction
      • Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema)
      • Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis
      • Lichen planus Lichen planus Lichen planus (LP) is an idiopathic, cell-mediated inflammatory skin disease. It is characterized by pruritic, flat-topped, papular, purple skin lesions commonly found on the flexural surfaces of the extremities. Other areas affected include genitalia, nails, scalp, and mucous membranes. Lichen Planus
    • Trauma
    • Chronic medical conditions, such as: 
      • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
      • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
      • Congestive heart failure Heart Failure A heterogeneous condition in which the heart is unable to pump out sufficient blood to meet the metabolic need of the body. Heart failure can be caused by structural defects, functional abnormalities (ventricular dysfunction), or a sudden overload beyond its capacity. Chronic heart failure is more common than acute heart failure which results from sudden insult to cardiac function, such as myocardial infarction. Total Anomalous Pulmonary Venous Return (TAPVR) or other edematous conditions
  • Common infectious Infectious Febrile Infant causes:
    • Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis 
    • Bacteria Bacteria Bacteria are prokaryotic single-celled microorganisms that are metabolically active and divide by binary fission. Some of these organisms play a significant role in the pathogenesis of diseases. Bacteriology 
      • Neisseria Neisseria Neisseria is a genus of bacteria commonly present on mucosal surfaces. Several species exist, but only 2 are pathogenic to humans: N. gonorrhoeae and N. meningitidis. Neisseria species are non-motile, gram-negative diplococci most commonly isolated on modified Thayer-Martin (MTM) agar. Neisseria gonorrhoeae
      • Group B streptococci
      • Chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia
      • Anaerobes Anaerobes Lincosamides
      • Treponema pallidum Treponema pallidum The causative agent of venereal and non-venereal syphilis as well as yaws. Treponema
      • Trichomonas Trichomonas A genus of parasitic flagellate eukaryotes distinguished by the presence of four anterior flagella, an undulating membrane, and a trailing flagellum. Nitroimidazoles
      • Herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections
      • Scabies Scabies Scabies is an infestation of the skin by the Sarcoptes scabiei mite, which presents most commonly with intense pruritus, characteristic linear burrows, and erythematous papules, particularly in the interdigital folds and the flexor aspects of the wrists. Scabies

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
  • Edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema of the glans
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and tenderness
  • Pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema)
  • Tight foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy
  • Purulent exudate Exudate Exudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues. Pleural Effusion
  • Ulcerated lesions of the glans and prepuce Prepuce The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy 
  • Urinary obstruction
  • Lymphadenopathy Lymphadenopathy Lymphadenopathy is lymph node enlargement (> 1 cm) and is benign and self-limited in most patients. Etiologies include malignancy, infection, and autoimmune disorders, as well as iatrogenic causes such as the use of certain medications. Generalized lymphadenopathy often indicates underlying systemic disease. Lymphadenopathy
Balanitis_caused_by_smegma

Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema of the glans penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy consistent with balanitis

Image: “Balanitis caused by smegma” by MFN24. License: CC0 1.0

Diagnosis

  • Physical examination
  • Further workup is determined based on the history, but may include:
    • Bacterial cultures Cultures Klebsiella
    • Herpes simplex Herpes Simplex A group of acute infections caused by herpes simplex virus type 1 or type 2 that is characterized by the development of one or more small fluid-filled vesicles with a raised erythematous base on the skin or mucous membrane. It occurs as a primary infection or recurs due to a reactivation of a latent infection. Congenital TORCH Infections virus Virus Viruses are infectious, obligate intracellular parasites composed of a nucleic acid core surrounded by a protein capsid. Viruses can be either naked (non-enveloped) or enveloped. The classification of viruses is complex and based on many factors, including type and structure of the nucleoid and capsid, the presence of an envelope, the replication cycle, and the host range. Virology testing
    • Potassium Potassium An element in the alkali group of metals with an atomic symbol k, atomic number 19, and atomic weight 39. 10. It is the chief cation in the intracellular fluid of muscle and other cells. Potassium ion is a strong electrolyte that plays a significant role in the regulation of fluid volume and maintenance of the water-electrolyte balance. Hyperkalemia hydroxide preparation → assess for Candida Candida Candida is a genus of dimorphic, opportunistic fungi. Candida albicans is part of the normal human flora and is the most common cause of candidiasis. The clinical presentation varies and can include localized mucocutaneous infections (e.g., oropharyngeal, esophageal, intertriginous, and vulvovaginal candidiasis) and invasive disease (e.g., candidemia, intraabdominal abscess, pericarditis, and meningitis). Candida/Candidiasis
    • Gonorrhea Gonorrhea Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative bacteria Neisseria gonorrhoeae (N. gonorrhoeae). Gonorrhea may be asymptomatic but commonly manifests as cervicitis or urethritis with less common presentations such as proctitis, conjunctivitis, or pharyngitis. Gonorrhea and chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia testing

Management

  • Good hygiene, with adequate cleaning of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy and foreskin foreskin The double-layered skin fold that covers the glans penis, the head of the penis. Penis: Anatomy 
  • Avoid irritants
  • Treatment of underlying infection, if present 
  • Management of chronic, predisposing conditions

Complications

  • Phimosis
  • Paraphimosis
  • ↑ Risk of penile cancer Penile cancer Malignant lesions of the penis arise from the squamous epithelium of the glans, prepuce, or penile shaft. Penile cancer is rare in the United States, but there is a higher prevalence in lower socioeconomic regions. The most common histologic subtype is squamous cell carcinoma. Penile Cancer
  • Urethral stricture Urethral stricture Narrowing of any part of the urethra. It is characterized by decreased urinary stream and often other obstructive voiding symptoms. Urinary Tract Obstruction

Peyronie Disease

Definition

Peyronie disease is a penile deformity Deformity Examination of the Upper Limbs caused by fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans/ scarring Scarring Inflammation of the tunica albuginea Tunica albuginea Penis: Anatomy.

Epidemiology

  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: approximately 5% of men (likely underreported)
  • Mean Mean Mean is the sum of all measurements in a data set divided by the number of measurements in that data set. Measures of Central Tendency and Dispersion age: approximately 68 years

Etiology

  • Fibrous Fibrous Fibrocystic Change plaques may occur because of:
    • Trauma
    • Tissue ischemia Ischemia A hypoperfusion of the blood through an organ or tissue caused by a pathologic constriction or obstruction of its blood vessels, or an absence of blood circulation. Ischemic Cell Damage
  • Risk factors:
    • Urologic procedures:
    • Connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue: Histology disorders
    • Genetics Genetics Genetics is the study of genes and their functions and behaviors. Basic Terms of Genetics
    • Hypogonadism Hypogonadism Hypogonadism is a condition characterized by reduced or no sex hormone production by the testes or ovaries. Hypogonadism can result from primary (hypergonadotropic) or secondary (hypogonadotropic) failure. Symptoms include infertility, increased risk of osteoporosis, erectile dysfunction, decreased libido, and regression (or absence) of secondary sexual characteristics. Hypogonadism
    • Diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
    • Tobacco use
    • Alcohol use
    • Older age

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • More often evident with an erection Erection The state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions. Penis: Anatomy
  • Deviation of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy to the affected side
  • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
  • Palpable nodules or plaques
Abnormal curvature of penis peyronie disease

Abnormal curvature of the penis Penis The penis is the male organ of copulation and micturition. The organ is composed of a root, body, and glans. The root is attached to the pubic bone by the crura penis. The body consists of the 2 parallel corpora cavernosa and the corpus spongiosum. The glans is ensheathed by the prepuce or foreskin. Penis: Anatomy secondary to Peyronie disease

Image: “Penile deformity Deformity Examination of the Upper Limbs secondary to Peyronie’s disease” by Tran VQ et al AL Amyloidosis. License: CC BY 3.0

Diagnosis

The diagnosis is clinical.

Management

  • Observation (for those with mild, stable disease)
  • Medical therapy:
    • Pentoxifylline Pentoxifylline A methylxanthine derivative that inhibits phosphodiesterase and affects blood rheology. It improves blood flow by increasing erythrocyte and leukocyte flexibility. It also inhibits platelet aggregation. Pentoxifylline modulates immunologic activity by stimulating cytokine production. Phosphodiesterase Inhibitors → prevents collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology deposition and fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans
    • Intralesional injections: 
      • Collagenase
      • Verapamil Verapamil A calcium channel blocker that is a class IV anti-arrhythmia agent. Pulmonary Hypertension Drugs → ↑ collagenase activity, ↓ collagen Collagen A polypeptide substance comprising about one third of the total protein in mammalian organisms. It is the main constituent of skin; connective tissue; and the organic substance of bones (bone and bones) and teeth (tooth). Connective Tissue: Histology production
  • Surgical repair for severe cases

Complications

  • Erectile dysfunction Erectile Dysfunction Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction
  • Psychologic effects:

Priapism

Definition

Priapism is an abnormal, persistent erection Erection The state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions. Penis: Anatomy (usually > 4 hours) that is not associated with sexual stimulation.

Epidemiology

  • Incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency: 0.73 case per 100,000 men per year
  • Ischemic priapism is more common (approximately â…” of cases are associated with erectile dysfunction Erectile Dysfunction Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction treatment).
  • Bimodal age distribution:
    • 5–10 years
    • 20–50 years

Etiology and pathophysiology

  • Ischemic:
    • Caused by failure of venous outflow, which can be due to: 
      • Excessive neurotransmitters
      • Blocked venules Venules The minute vessels that collect blood from the capillary plexuses and join together to form veins. Veins: Histology → prevent venous drainage
      • Prolonged smooth muscle relaxation
    • Can lead to compartment syndrome Compartment Syndrome Compartment syndrome is a surgical emergency usually occurring secondary to trauma. The condition is marked by increased pressure within a compartment that compromises the circulation and function of the tissues within that space. Compartment Syndrome → tissue damage
    • Causes:
      • Drugs (e.g., sildenafil Sildenafil A phosphodiesterase type-5 inhibitor; vasodilator agent and urological agent that is used in the treatment of erectile dysfunction and primary pulmonary hypertension. Phosphodiesterase Inhibitors, amphetamines Amphetamines Analogs or derivatives of amphetamine. Many are sympathomimetics and central nervous system stimulators causing excitation, vasopressin, bronchodilation, and to varying degrees, anorexia, analepsis, nasal decongestion, and some smooth muscle relaxation. Stimulants, hydralazine Hydralazine A direct-acting vasodilator that is used as an antihypertensive agent. Heart Failure and Angina Medication, prazosin Prazosin A selective adrenergic alpha-1 antagonist used in the treatment of heart failure; hypertension; pheochromocytoma; raynaud disease; prostatic hypertrophy; and urinary retention. Antiadrenergic Drugs)
      • Sickle cell disease Sickle cell disease Sickle cell disease (SCD) is a group of genetic disorders in which an abnormal Hb molecule (HbS) transforms RBCs into sickle-shaped cells, resulting in chronic anemia, vasoocclusive episodes, pain, and organ damage. Sickle Cell Disease
      • Leukemia
      • Vasculitis Vasculitis Inflammation of any one of the blood vessels, including the arteries; veins; and rest of the vasculature system in the body. Systemic Lupus Erythematosus
      • Hypercoagulable Hypercoagulable Hypercoagulable states (also referred to as thrombophilias) are a group of hematologic diseases defined by an increased risk of clot formation (i.e., thrombosis) due to either an increase in procoagulants, a decrease in anticoagulants, or a decrease in fibrinolysis. Hypercoagulable States state
  • Nonischemic:
    • Arterial fistula Fistula Abnormal communication most commonly seen between two internal organs, or between an internal organ and the surface of the body. Anal Fistula formation → abnormal arterial flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure into the corpora cavernosa Corpora cavernosa Penis: Anatomy 
    • No venous outflow obstruction
    • Usually from a direct injury

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Ischemic:
    • Painful erection Erection The state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions. Penis: Anatomy
    • Rigid
    • If not treated → necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage
  • Nonischemic:
    • No pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with erection Erection The state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions. Penis: Anatomy
    • Less rigid
    • Not associated with necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage

Diagnosis

The diagnosis is suspected on the basis of the history and physical exam. The following can help differentiate ischemic from nonischemic priapism:

  • Cavernosal blood gas:
    • Ischemic:
      • Blood sample will appear black
      • Hypoxia Hypoxia Sub-optimal oxygen levels in the ambient air of living organisms. Ischemic Cell Damage
      • Hypercarbia
      • Acidosis Acidosis A pathologic condition of acid accumulation or depletion of base in the body. The two main types are respiratory acidosis and metabolic acidosis, due to metabolic acid build up. Respiratory Acidosis
    • Nonischemic:
      • Blood sample will be red
      • Normal oxygen
      • Normal carbon dioxide
      • Normal pH pH The quantitative measurement of the acidity or basicity of a solution. Acid-Base Balance
  • Doppler ultrasound Doppler ultrasound Ultrasonography applying the doppler effect, with frequency-shifted ultrasound reflections produced by moving targets (usually red blood cells) in the bloodstream along the ultrasound axis in direct proportion to the velocity of movement of the targets, to determine both direction and velocity of blood flow. Ultrasound (Sonography):
    • Ischemic: minimal or absent blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure in the cavernosal arteries Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries: Histology
    • Nonischemic: normal or high arterial blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure

Management

  • Ischemic:
    • Urologic consultation
    • Cavernosal aspiration
    • Intracavernosal phenylephrine Phenylephrine An alpha-1 adrenergic agonist used as a mydriatic, nasal decongestant, and cardiotonic agent. Sympathomimetic Drugs injection → induce smooth muscle contraction Smooth muscle contraction Smooth muscle is primarily found in the walls of hollow structures and some visceral organs, including the walls of the vasculature, GI, respiratory, and genitourinary tracts. Smooth muscle contracts more slowly and is regulated differently than skeletal muscle. Smooth muscle can be stimulated by nerve impulses, hormones, metabolic factors (like pH, CO2 or O2 levels), its own intrinsic pacemaker ability, or even mechanical stretch. Smooth Muscle Contraction → ↑ venous outflow
    • Surgery 
  • Nonischemic:
    • May resolve spontaneously
    • Arteriography with embolization Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding

Complications

Complications of ischemic priapism include:

  • Erectile dysfunction Erectile Dysfunction Erectile dysfunction (ED) is defined as the inability to achieve or maintain a penile erection, resulting in difficulty to perform penetrative sexual intercourse. Local penile factors and systemic diseases, including diabetes, cardiac disease, and neurological disorders, can cause ED. Erectile Dysfunction
  • Penile necrosis Necrosis The death of cells in an organ or tissue due to disease, injury or failure of the blood supply. Ischemic Cell Damage

References

  1. Fahmy, M. (2018). Congenital Anomalies of the Penis. Springer.
  2. Baskin, L.S. (2020). Hypospadias: pathogenesis, diagnosis, and evaluation. UpToDate. Retrieved August 10, 2021, from https://www.uptodate.com/contents/hypospadias-pathogenesis-diagnosis-and-evaluation
  3. Baskin, L.S. (2020). Hypospadias: management and outcome. UpToDate. Retrieved August 10, 2021, from https://www.uptodate.com/contents/hypospadias-management-and-outcome
  4. Wilcox, D. (2021). Care of the uncircumcised penis in infants and children. UpToDate. Retrieved August 13, 2021, from https://www.uptodate.com/contents/care-of-the-uncircumcised-penis-in-infants-and-children
  5. Tews, M. (2020). Paraphimosis: clinical manifestations, diagnosis and treatment. UpToDate. Retrieved August 13, 2021, from https://www.uptodate.com/contents/paraphimosis-clinical-manifestations-diagnosis-and-treatment
  6. Tews, M., Singer, J.I. (2020). Balanitis and balanoposthitis in children and adolescents: clinical manifestations, evaluation, and diagnosis. UpToDate. Retrieved August 19, 2021, from https://www.uptodate.com/contents/balanitis-and-balanoposthitis-in-children-and-adolescents-clinical-manifestations-evaluation-and-diagnosis
  7. Barrisford, G.W. (2021). Balanitis in adults. UpTodate. Retrieved August 19, 2021, from https://www.uptodate.com/contents/balanitis-in-adults
  8. Deveci, S. (2021). Priapism. UpToDate. Retrieved August 19, 2021, from https://www.uptodate.com/contents/priapism
  9. Brant, W.O., Bella, A.J., Lue, T.F. (2021). Peyronie’s disease: diagnosis and medical management. UpToDate. Retrieved August 19, 2021, from https://www.uptodate.com/contents/peyronies-disease-diagnosis-and-medical-management
  10. Rabinowitz, R., Cubillos, J. (2020). Penile and urethral anomalies. MSD Manual Professional Version. Retrieved August 19, 2021, from https://www.msdmanuals.com/professional/pediatrics/congenital-renal-and-genitourinary-anomalies/penile-and-urethral-anomalies
  11. Anand, S., Lotfollahzadaeh, S. (2021). Epispadias. StatPearls. Retrieved August 19, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK563180/
  12. McPhee, A.S., Stormont, G., McKay, A.C. (2020). Phimosis. StatPearls. Retrieved August 19, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK525972/
  13. Bragg, B.N., Kong, E.L., Leslie, S.W. (2021). Paraphimosis. StatPearls. Retrieved August 19, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK459233/
  14. Ghory, H.Z., Sharma, R. (2017). Phimosis and paraphimosis. Medscape. Retrieved August 19, 2021, from https://emedicine.medscape.com/article/777539-overview

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