Diseases of penis

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 Topic name
Sr.no. Pg.no.

1. Surgical anatomy 3

2. Phimosis 7

3. Paraphimosis 9

4. Balanoposthitis 15

5. Chordee 17

6. Priapism 19

7. Peyronie’s disease 21

8. Ram’s horn penis 23

9. Carcinoma penis 24

10. Congenital anamolies 37

11. Penile warts 42

12. Bibliography 44

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SURGICAL ANATOMY
The penis is composed mainly

 two corpora cavenosa

 Single corpus Spongiosum
which contains the urethra

It has an

 attached part (root)

 a free part (body)

Fig.Transvers section through body of penis

The root of penis

 consists of the two crura

 which are proximal parts of corpora cavernosa and re attched to the pubic arch & the bulb
of penis which is the proximal part of the corpus spongiosum; anchored to perineal
membrane.

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The body of penis

 is covered entirely by skin Urethra

 is formed by the tethering of the two proximal free parts of the corpora cavernosa and the
related free part of the corpus spongiosum

fig.Penis

Because the anatomic position of the penis is erect

 the paired corpora are defined as dorsal in the bodv of the penis
 the Single Spongiosum as ventral
 even though the positions are reversed in the nonerect (flaccid) penis.

 The corpus spongiosum expands to form the head of penis (glans penis), over the
distal ends of the corpora cavernosa.

The skin covering the penis

 very thin and dark in colour.

 It is loosely connected with the fascial sheath of the organ.
 At the neck it is folded to form the prepuce or foreskin which covers the glans
 and can be retracted backwards to expose the glans.

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Frenulum

 On the under surface of the glans there is a median fold of skin called the frenulum

Preputial sac

 The potential space between the glans and the prepuce is known as the preputial sac.
 Also called as Tyson’s gland

Smegma

 On the corona glandis and on the neck of the penis, there are numerous small preputial
(sebaceous) glands which secrete a sebaceous material called smegma, which collects in
the preputial sac

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Nerve supply of penis

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PHIMOSIS
 It is inability to retract the prepuce over the glans.

Causes

1. Congenital

- The child has pinhole meatus and

- Ballooning of prepuce occurs when the child urinates.

Fig.A and B: Pinhole meatus with phimosis.

ballooning of the prepuce during urination.

2. Balanitis (inflammation of glans) and

balanoposthitis (inflammation of glans, prepuce and sac).

- Common in Diabetics.

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Fig.A.Posthitis and balanoposthitis are common causes of phimosis in adult. It may be common
in diabetics. Carcinoma should also be ruled out. Specimen should be sent for histology after
circumcision; B. Phimosis. It is inability to retract prepuce over glans.

 Patients with phimosis are more prone for recurrent infection, smegma collection and
carcinoma penis.

Problems due to phimosis

 Recurrent balanoposthitis
 Paraphimosis
 Ballooning of prepuceal skin
 Retention of urine
 Prepuceal calculi formation due to smegma collection in prepuceal sac
 Carcinoma of penis later

Treatment

 Circumcision

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PAPARAPHIMOSIS
 Inability to place back (cover) the retracted prepucial skin over the glans is called as
paraphimosis.

 It causes ring like constriction proximal to the corona and prepuceal skin.
 As a result the glans will be swollen, oedematous with severe pain and tenderness.
 Often glans will undergo necrosis or becomes gangrenous.

 Paraphimosis is precipitated after sexual intercourse or iatrogenically after urethral

catheterisation.

FigA and B paraphimosis condition

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 Fig. Inability to retract prepuce

Fig.Paraphimosis developed after catheterisation due to failure of replacing back of

Prepuce

Treatment

 Manual reduction of prepuceal skin is to be tried.

 Sedation and hyaluronidase injection in 10 ml saline into the constriction ring or multiple
needle punctures over the oedematous part, reduces the oedema and makes the
paraphimosis to get reduced.

 If not possible,

initial dorsal slit is made to relieve the oedema and compression.

Antibiotics and analgesics are given.

 Circumcision is done after 3 weeks.

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CIRCUMCISION

Indications

 Religious
 Phimosis
 Paraphimosis after doing initial dorsal slit
 Balanitis and balanoposthitis (common in diabetics)
 Early carcinoma of prepuce or glans penis—both diagnostic as well as therapeutic
purpose
 Certain sexually transmitted diseases, e.g.herpes infection

Procedure

 In children, it is done under G/A.

 In adults, it is done under local anaesthesia.

 Alter cleaning and draping,

- LA [1% lignocaine (plain) injected circumferentially near the root of the penis is
given (ring block)
- Dorsal skin is cut up to the corona and later circumferentially and ventrally
- Care is taken to see that optimum (less) skin is cut ventrally to prevent occurrence
of Chordee
- Frenular artery is transfixed and ligated ventrally using chromic catgut
(2-0 or 3-0)
- Small bleeders are also ligated.
- Skin is apposed to the cut edge of corona using interrupted chromic catgut
sutures.

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Operative steps of circumcision

Postoperatively

 antibiotics and analgesics are given.

Complications

 Reactionary haemorrhage due to slipping of ligature from frenular artery and dorsal vein
Infection
 Stricture urethra near the external meatus in children
 Chordee due to removal of excess skin on the ventral aspect
 Rarely priapism can occur

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Hollister Bell cap technique (Plastibel device):

 This specially devised plastic cap can be fitted over the glans penis and prepuce is rolled
Over it.
 A tight ligature is tied over it near base of the prepuce.
 In 7 days skin and prepuce sloughs off and sheds with the cap.
 Bleeding will not occur due to thrombosis of prepuceal vessels.

Technique can be used for

 religious circumcision
 balanoposthitis without phimosis.

Contraindicated in

 Phimosis
 Paraphimosis

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Circumcision by guillotine

 It is a method done by pulling and stretching the prepuceal skin beyond the glans and
cutting the prepuce.
 Should be condemned and not be done as injury to glans is common.

 It is practiced in religious circumcision.

 Monopolar cautery should not be used in circumcision,

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BALANOPOSTHITIS
 It is inflammation of glans and prepuce

 Inflammation of prepuce is posthitis

 Inflammation of the glans is balanitis

Causes

 Diabetes mellitus
 Candidiasis
 Veneral diseases like syphilis, herpes.

Fig.Balanoposthitis in diabetics

It can cause

 Phimosis
 carcinoma penis.

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Clinical features:

 Pain
 Swelling
 discharge.

Treatment:

 Antibiotics.
 Circumcision.
 The diabetes is controlled.

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CHORDEE (CORDEE)
 It is a fixed bending of glans penis, more obvious during erection.

Types

 Ventral.
 Dorsal.

Causes

 Hypospadias,
where urethra opens more proximally than normal
(ventral cordee).
 After circumcision,
if more skin Is cut over the ventral aspect
(ventral cordee).

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In epispadias dorsal cordee occurs.

Treatment

 Chordee due to hypospadias is corrected during staged procedure.

In chordee following circumcision,

 initially stilbestrol 6 mg daily is given.

 Later chordee is corrected surgically by excising fibrous tissue
 later doing skin grafting.

More often they require surgical Intervention.

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PRIAPISM
It is persistent, painful erection of penis.

 Corpora cavernosa are filled with blood due to defective venous drainage.
 Glans and corpus spongiosum are not involved.

Causes

 Idiopathic thrombosis of corpora cavernosa

 Idiopathic thrombosis of prostatic venous plexus
 Sickle cell disease
 Leukaemia
 Secondary deposits in corpora cavernosa
 Spinal injury or diseases

It can be

1. ischaemic (low flow)

2. non-ischaemic (high flow)
3. stuttering/intermittent.

Investigations

 Relevant for specific causes.

 Doppler duplex US scan is done.
 Arteriogram often with embolization is often done

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Treatment

 Doppler guided aspiration

 intracavernous injection of adrenergic agonists like phenylephrine are nonsurgical
methods.

 Anastomosis between corpora cavernosa and saphenous vein.

 Anastomosis between corpora cavernosa and corpus spongiosum.

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PEYRONIE’S DISEASE
(Induratio-penis Plastica)

 It is development of fibrous tissue plaque on the covering of corpus cavernosum and later
involving its full extent resulting in induration of corpus.
 It is a slowly progressive disease

 uncertain aetiology
may be
- Due to old trauma
- often associated with Dupuytren’s contracture
Retroperitoneal fibrosis
plantar fascitis.

 Initial active phase has

- painful erection
- with changing deformity of penis.

 Later quiescent phase has

- disappearance of painful erection
- with development of deformity which is painless.

 Later erectile dysfunction

 penile shortening occurs.
 Indurated plaque is noticed in the penis.

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Treatment

 Some cases resolve spontaneously.

Drugs

 Steroids.
 Vitamin E.
 Potassium amino benzoate 12 mg/day.
 Tamoxifen 20 mg daily.
 Terfenadine and fexafenadine
 Colchicine therapy.
 Intralesional injection of verapamil 10 mg once in weeks-12 injections.

Surgery is needed in many cases

1. Excision and plication to opposite side- Fitzpatric operation.

2. Multiple incisions over the fibrous plaque and temporal fascia bridging—Gelhard’s
operation.
3. Excision of fibrous plaque and corporotomy is covered with overlay flap like tunica
vaginalis flap (Lockhart’s)/dermal flap (Devine and Horton’s).
4. Intracorporeal penile prosthesis placement.

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RAM’S HORN PENIS
 Filarial involvement of penis
 where it becomes
thick
distorted
resembles horn of a ram.

CARCINOMA PENIS
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  It is commonly squamous cell carcinoma
 But - melanoma
- adenocarcinoma from Tyson’s gland
- basal cell carcinoma
- secondaries may also occur.

Aetiology

 Chronic balanoposthitis
 phimosis
 Sexually transmitted diseases.
 Leukoplakia of glans.
 Long-standing genital warts.
 Paget’s disease of penis.
 Erythroplasia of Querat is persistent rawness of glans penis
 Condyloma acuminata (by human papilloma virus)
 Balanitis xerotica obliterans.
 HIV infection—HPV-16.

‣ Circumcision during infancy confers total immunity against carcinoma penis.

‣ It is common in Asia and Africa.

Fig.Carcinoma penis earlier operated by total amputation of penis has now developed
secondaries in inguinal lymph nodes which has already fungated. Note the perineal urethrostomy
done.

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Fig.A and B Carcinoma of penis in two different patients

Pathology

 Infiltrating type occurs in a pre-existing leukoplakia.

 It often presents as indurated area.

 Papillferous type eventually attains

- a large size
- fungating foul smelling lesion
- which often gets infected.

 Ulcerative type

- glans penis is the most common site

- 80% are of low grade tumours.

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Fig circumferentially proliferated lesion

Fig.small ulcerated lesion

Fig.genital warts premalignant condition

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Fig. Erythroplasia premalignant condition

Spread

1. Through lymphatics,
 it spreads to the horizontal group of inguinal lymph nodes
 which become nodular and hard.
 Lymph nodes on both sides can get involved.

 Later, externas iliae group are involved (above and on medial aspect of the inguinal
ligament).
 Once inguinal lymph nodes are fixed,

- it causes severe excruciating pain

- lymphoedema.

 Fixed lymph node status indicates the advancement of the disease.

 It may erode into the femoral vessels causing torrential haemorrhage and death.
 Fungation can occur.
2. From glans,it also spreads to Cloquet lymph node which is located in femoral canal

3. Carcinoma from shaft of penis

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  can spread directly to the externa iliac lymph nodes.
 It spreads proximally to the body of penis causing induration.
 Urethral meatus may get involved causing alteration in urinary stream.
 It is a locoregional malignant disease.

4. Blood spread is rare.

Clinical Features

 In an adult, recent onset of phimosis should raise the suspicion of carcinoma penis.

 Lesion is painless initially

 but later becomes painful due to secondary infection
 often accompanied by discharge which is foul smelling, purulent and irritating.
 Altered urinary stream.
 Fungation and induration everted edge, often extending into the body of penis.
 Palpable hard nodular inguinal Jymph nodes on both sides may be present.
 External iliac lymph nodes may be palpable.
 After infection

- Pain
- Oedema
- Tenderness
- Redness

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Fig.A and B verrucous carcinoma

Investigations

 Wedge biopsy from the lesion shows squamous cell carcinoma with epithelial pearls.

 FNAC of lymph nodes (No open biopsy for lymph nodes).

 Ultrasound abdomen, to look for involvement of external iliac lymph nodes.

 SLNB-Cabana sentinel node is located above and medial to the junction of saphenous
and femoral vein.
- It is the first node to get involved in carcinoma penis.
- So this Sentinel Lymph Node Biopsy (SLNB) after isosulphan blue dye injection
in to the primary is done to decide for the necessity for ilioinguinal block issection

Fig. Insitu carcinoma over glans

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Broder’s grading

1. Very well differentiated (75% epithelial pearls)

2. Well differentiated (50-75%)
3. Moderately differentiated (25-50%)
4. Undifferentiated (<25%)

Staging of Carcinoma of Penis

Jackson’s staging of carcinoma penis

Stage 1 - Tumour involving only 90% five-year glans/prepuce/both survival
Stage 2 - Tumour extending into 709% body of penis
Stage 3 - Tumour having mobile 50% inguinal nodes
Stage 4 - Tumour spreading to 5% adjacentstructures/fixed node

TNM Staging of carcinoma penis (AJCC, 2013, 7th edition)

TX: Primary tumour cannot be assessed

T0: No evidence of primary tumour
Tis: Carcinoma in situ (cancer that is only in the top layers of skin). This is called as
erythroplasia of Queyrat when it occurs on the glans of the penis;it can be called Bowen disease
when it occurs on the shaft of the penis.
Ta: Verrucous (wart-like) carcinoma that is only in the top layers of skin (non-invasive)
T1: Tumour has grown into the tissue below the top layers of skin (called the subepithelial
connective tissue)
 T1a: The cancer has grown into the subepithelial connective tissue, but it has not grown
into blood or lymph vessels. The cancer is grade 1 or 2.
 T1b: The cancer has grown into the subepithelial connective tissue and either it has
grown into blood and lymph vessels OR it is high-grade (grade 3 or 4).

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T2: Tumour has grown into one of the internal chambers of the penis (the corpus spongiosum or
corpora cavernosum)
T3: Tumour has grown into the urethra
T4: Tumour has grown into the prostate or other nearby structures
NX: Nearby lymph nodes cannot be assessed
N0: No spread to nearby lymph nodes
N1: The cancer has spread to a single lymph node in the groin (inguinal lymph node)
N2: The cancer has spread to more than 1 inguinal lymph node
N3: The cancer has spread to lymph nodes in the pelvis and/or the cancer in the lymph node has
grown through the outer covering of the lymph node and into the surrounding tissue (fixed unit-
or bilateral lymph nodes).
M0: The cancer has not spread to distant organs or tissues
M1: The cancer has spread to distant organs or tissues (such as lymph nodes outside of the
pelvis, lungs, or liver)

Staging:

Stage 0: Tis or Ta, N0, M0

Stage I:T1a, N0,M0
Stage II:Any of the following: T1b,th0, M0: T2, N0, M0: T3, N0, M0
Stage IIIa:T1 to T3, N1, M0
Stage IIIb: T1 to T3, N2,M0
Stage IV: Any of the following: T4, any N, M0: Any T, N3, M0: Any T, any N,M1

Treatment

 If growth involves the glans without extending into the proximal part of shaft of the penis

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 - partial amputation of the penis is done.
- A length of 25 cm stump is retained.
- Clearance of 2 cm from the proximal extended part of the tumour is needed.
- Advantage is proper streaming of the urine is possible.

 Partial amputation of penis with bilateral ilioinguinal lymph node block dissection is
called as Young ‘s operation.

 If tumour involves the proximal part of the body of penis or if it is anaplastic/poorly

differentiated tumour
- total amputation of penis is done with perineal urethrostomy.
- Problems with perineal urethrostomy are scrotal ammoniacal dermatitis
- stricture at urethrostomy site.

 Dermatitis is prevented by asking the patient to urinate in sitting position lifting the
scrotum upwards.
 Stricture needs dilatation.
 Total scrotectomy with orchidectomy is done along with total amputation of the penis---
Sir Piersey Gold operation.
- It prevents frequent dermatitis of the scrotal skin because of the perineal
urethrostomy and also reduces the sexual desire.

 In case of carcinoma in situ,

- T lesion of glans penis or well differentiated tumour in young individual,
circumcision and curative radiotherapy to the penis can be given using radio-
active tantalum wire implantation (6000 cGy in 7 days) or by wearing radium
penile mould continuously or intermittently (6000 cGy in 7 days) or by linear
accelerator external beam radiotherapy (6000 cGy in 5 weeks).
- Involvement of nodes in these patients is less than 10%.

 When lymph nodes are involved and are mobile

- bilateral ilioinguinal nodal dissection is done.

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  Primary inguinal block is doing block dissection within 4 weeks of surgery for primary
tumour.
 Secondary inguinal block is doing block dissection after 4 weeks of surgery for primary
disease.
 Only 50% of palpable inguinal nodes are involved by metastatic spread. So often a course

of antibiotic is given and waited for 4-6 weeks.

Fig. partial amputation of penis

Fig. Partial amputation with catheter insitu

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Fig. Amputated penis

Complications of ilioinguinal block dissection are

 flap necrosis
 lymphoedema of lower limb
 femoral blow out
 infection
 lymphorrhoea
 haemorrhage.
•If primary tumour is poorly differentiated, and if tumour of T2 or above, chances of inguinal
nodal spread is more than 50% and so a prophylactic inguinal nodal dissection is done.
•Often,involvement of inguinal nodes may be due to infection.
 So a trial of antibiotic therapy is given for 4-6 weeks to reduce the size of the inguinal
node
 Removal of iliac nodes does not alter the outcome.
 It is done to confirm the spread, so that further therapy can be planned and prognosis can
be predicted.

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Postoperative

Radiotherapy
 radiotherapy to inguinal region is often given.
 In advanced fixed inguinal nodes palliative external radio- therapy is given.
 It is to palliate pain, fungation and anticipated erosion in femoral Vessels.
 Topical 5 FU cream or imiquimab or Mohs surgery or llimited wide excision or Nd:YAG
laser photoirradiation is useful in carcinoma in situ.

Chemotherapy:
 5 FU; methotrexate
 Bleomucin
 cisplatin
 vincristine MBP/VBM combinations are used.
Bleomycin is a radiosensitiser and so beneficial if RT is planned later.

Role of radiotherapy

 Carcinoma in situ
 Small lesion less than 2 cm
 Lesion confined to glans
 small lesion in young individual
 Advanced inoperable disease
 Palliation to inoperable inguinal nodes in groin
 Postoperative RT

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CONGENITAL ANOMALIES

HYPOSPADIAS

 Hypospadias is defined as an anomaly (hypo- or dysplasia) involving the ventral aspect

of the penis.
 In this condition the external urethral meatus of urethra is situated on the undersurface of
penis (instead of at the tip).
 This is the most common congenital malformation of the male urethra.

Incidence : It is common condition and occurs once in 350 male newborns.

ETIOLOGY

 In most cases, the cause of this congenital defect is not fully understood.
 Treatment with hormones such as progesterone during pregnancy may increase the risk of
hypospadias.
 Certain hormonal fluctuations, such as failure to produce enough testosterone or the
failure of the body to respond to testosterone, increase the risk of hypospadias and other
genetic problems.
 Genetic factors : Gene mutations.
 Environmental factors :
- Increasing maternal age
- Fertility drugs
- Antiepileptic drugs
- Low birth weight
- Pre-eclampsia.

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TYPES

The hypospadias is classified into 5 varieties -

1. Glandular
 This is the most common type when the urethral opening is found under surface of glans.

2. Coronal
 In this type the external urethral meatus is situated at the corona glandis (junction of
under surface of glans with the body of penis).

3. Penile
 In this type the external urethral meatus is situated at any part of under surface of shaft of
the penis.

4. Penoscrotal
 In this type the urethral opening is found at the junction of penis with scrotum.

5. Perineal
 In this type the urethral opening is found behind the scrotal sac.
 This is the most severe form of hypospadias and less frequently found
 In this condition the sex determination of child becomes difficult.

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CLINICAL FEATURES

 Abnormal meatal opening along ventral aspect of penoscrotal tissue or even on perineum
 Chordee
- This is an abnormal ventral curvature of the penis.
- This is due to the difference in length between the ventral and the dorsal side of
the penis (corporocavernosal dysproportion).
 Hooded prepuce
- The prepuce is poorly developed
- The superior aspect of the prepuce is almost normally developed whereas inferior
aspect is poorly developed, it causes hooded appearance of prepuce
 The urine stream may be hard to direct and control
 In all types the urethral meatus is narrow, so it may cause urinary obstruction in varying
extent
 It is usually not associated with urinary incontinence
 Associated conditions

- Cryptorchidism
- Bifid scrotum
- Inguinal hernia
- Renal tract malformations

COMPLICATIONS

 Spraying of urine stream

 Urine soakage over the scrotum with dermatitis and infection
 Due to chordee, intercourse may be difficult or impossible
 Infertility in case of penoscrotal and perineal types
 Sex determination may be difficult in case of perineal type.

MANAGEMENT
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  The glandular hypospadias usually doesn’t require any treatment, but when there is
urethral meatus is very small, simple dilatation is required.
 In other types a plastic operation is performed to bring the external urethral meatus to its
normal position

ONE-STAGE URETHROPLASTY

 Chordee correction : At the age of one and half years, surgical correction of the chordee is
done
 Urethral tube formation by tabularizing urethra.

TWO-STAGE URETHROPLASTY

 When the child is 6-12 months old, chordee is corrected by straightening the penis.
 At the age of 5-7 years, reconstruction of urethra is done using prepucial skin (ideal) or
scrotal skin if the patient has been circumcised

Urethroplasty :
 It is Dennis Browne's operation and this is the simplest and commonly performed
technique.

 In hypospadias, circumcision is contraindicated because the prepucial skin is required for

future Urethroplasty.

EPISPADIAS
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  An epispadia, is a rare type of malformation of the penis in which the urethral orifice is
situatec on the upper aspect of the penis.

 Incidence; It is extremely rare condition. It is seen once in 30,000 male births.

 In epispadias the penis is curved upwards.

Treatment

 The Dennis Browne’s operation ST usually performed

PENILE WARTS
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  Ponile warts are one of the most common types of sexually transmitted infections.
 These are small, gray or skin-colored growths that grow in or near the genitals.
 These may occur on the tip or shaft of the penis, the scrotum, or the anus.
 Sometimes, they’re so small and flat that might not be noticed.
 They may clump together or look like cauliflower

ETIOLOGY

 The human papilloma virus (HPV) causes warts.

 There are more than 40 different strains of HPV that specifically affect the genital area.
 Genital HPV is spread through sexual contact.
 In most cases, the immune system kills genital HPV and patient never develop signs of
symptoms of the infection.

RISK FACTORS

 It is believed that nearly all sexually active people become infected with at least one type
of HPV at some point during their lives.
 Factors that can increase the risk of becoming infected include:
- Having unprotected intercourse with multiple partners,
- Having had another sexually transmitted infection,
- Smoking,
- Decreased immunity.

CLINICAL FEATURES

 Small, flesh-colored or gray swellings

 Several warts close together to form cauli-flower like shape
 Itching or discomfort in the genital area
 Bleeding with intercourse

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Fig. Penile warts

MANAGEMENT

 Avoid unprotected sexual intercourse

 Surgical or laser ablation
 Chemical cauterization.

Bibliography
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Manual of surgery . Sriram Bhatt M

Consice textbook of surgery . Dr Areef Nasim

Photos from google

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