Illustrated: Penile problems

Contributed by Mr Paul Anderson, consultant urological surgeon with a special interest in penile and urethral reconstruction, Russells Hall Hospital, Dudley, West Midlands.

Peyronie's disease


Peyronie's disease affects around 3 per cent of men, usually causing a dorsal deviation. Patients will often present with pain on erection during the inflammatory phase. It can last about six months prior to the advent of the curvature.

A plaque is usually palpable and in the worst cases this can cause an hourglass deformity with distal flaccidity.

There is no good medical treatment, but there is good evidence to support use of penile stretching devices. Surgical candidates are those with stable curvature that precludes intercourse.

Penile metastasis

This patient had not long undergone an abdominoperineal resection for an advanced rectal cancer when he was referred by his GP with a lump on his glans penis. A biopsy confirmed the diagnosis of metastatic adenocarcinoma.

Metastases to the penis are very uncommon, but by the time they arrive, the penis (corpora cavernosa and corpus spongiosum) is so vascular that widespread systemic dissemination has virtually always occurred.

The patient was referred to the oncologists for second-line chemotherapy.

Fournier's gangrene


A fortunately rare but devastating disease that normally affects debilitated patients - elderly, diabetic, catheterised. This man had a spinal cord injury and was unaware that at his last catheter change the balloon was blown up in the bulbar urethra leading to urethral pressure necrosis with a pyocystis and subsequent Fournier's.

Management usually necessitates ITU, inotropes, antibiotics and aggressive surgical debridement with multiple operations to control the sepsis. Mortality is up to 45 per cent. Reconstruction is only contemplated when the patient is entirely stable and all infection eradicated.

Hypospadias

This man has a coronal hypospadiac meatus, a dorsal hooded foreskin and chordee (ventral curvature). One in 300 male births will have hypospadias, which can vary from mild to perineal with a bifid scrotum with or without undescended testicles. It is unusual for adults to present with untouched hypospadias unless they are from countries with poor healthcare.

These days we strive for a normal slit-like meatus correctly positioned in the glans. This man's hypospadias was easily repaired with a one-stage operation.

Penile cancer

This rare cancer affects around 360 men a year in the UK. Smoking and chronic irritation (for example, poor hygiene behind a phimosis) are risk factors.

Around 80 per cent of cancers will be suitable for glansectomy and reconstruction of a neoglans with a split skin graft, giving good cosmesis and preserving sexual function. Prognosis is dependent on (inguinal) nodal spread as opposed to the primary. Five-year survival for node negative cancer is 66 per cent but only 27 per cent for patients with palpable malignant nodes at presentation.

Excessive circumcision

This man attended hospital for a day-case circumcision, but is now unable to have satisfactory sexual intercourse. Clearly, far too much shaft skin has been taken and the penis is 'trapped'. There are a number of options here, but none of them are as good as natural shaft skin.

Ventral length deficit can be managed with redefinition of the penoscrotal angle with a Z-plasty and is straightforward.

Lack of dorsal skin may require a V-Y plasty at the peno-pubic angle, or formation of a scrotal flap for shaft cover or the use of skin grafts.

Balanitis xerotica obliterans

One in 200 boys under the age of 15 are affected by balanitis xerotica obliterans (BXO). This patient's disease was severe with the typical white scarring and telangiectases covering the whole of the glans and retracted prepuce. The diseased skin cracks and bleeds leading to further scarring. Steroid creams are ineffective. More worrying is the meatal stenosis, which indicates urethral involvement/stricturing secondary to BXO.

This man needed a difficult unburying circumcision combined with a two-stage buccal mucosal graft urethroplasty and a glans resurfacing.

Genital warts


Over 90 per cent of genital warts are caused by human papillomavirus types 6 and 11 (unfortunately the national HPV vaccination programme uses the vaccine active against only types 16 and 18 as opposed to that which acts against 16, 18, 6 and 11). When the conventional treatments of podophyllotoxin and imiquimod fail then destructive techniques such as cryotherapy or surgical debulking are needed.

This man's wart burden was removed by a circumcision combined with a glans resurfacing.

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