Penis Problems

Phimosis

Definition: inability to replace retracted foreskin venous obstruction and oedema; urological emergencyManagement: analgesia; copious lubrication 2% lignocaine gel ice for 5-7mins, compression dressing manual reduction (1-2mins of sustained traction) Dundee-Perth technique (mulitple puncture holes under penile block, then compression to remove oedema fluid) dorsal slit with FU circumcision

Definition: prolonged painful erection not associated with sexual desireEpidemiology: 5-10yrs (Sickle Cell, cancer); 20-25yrs (idiopathic); >25yrs (impotence treatmetn); 50% become impotent as result of 1 episodeCauses: usually due to treat for impotence (eg. Sildenafil, tadalafil, intracavernosal papverine, PGE1) or Idiopathic; Sickle cell (occur in 30-65% of patients; 50% recurrent; treat with exchange transfusion), procoagulant states, haematological malignancies, spinal cord disease, vasculitis, trauma, idiopathic Drugs: chlorpromazine, Ca channel blockers, prazosin, antipsychotics, stimulants (eg. Cocaine), hydralazine, cannabis, Antidepressants, intracavernosal injectionsPathophysiology: destruction of sinusoidal epithelium and replacement with fibrous tissue; if lasts >4hrs, significant risk of impotence

Classification: Low flow = ischaemic = thrombotic: obstruction to outflow; most common; pH <7.25, pO2 <30, pCO2 >60, dark blood; painful; due to sludging of RBCHigh flow = non-ischaemic = non-thrombotic: uncommon; pH >7.25, pO2 >30, pCO2 <60, bright red blood; painless; usually due to AV fistula from trauma; impotence doesn’t occur therefore not true urological emergency; usually treated conservatively

Investigation: ESR, FBC, coags; USS differentiates high flow from low flow; Dorsal penile block 18G needle into one of corpora aspirate 20-30ml blood and do blood gas if pH etc…

Management: early urology consultation; terbutaline 500mcg subCIf low flow: PO terbutaline 5-10mg repeat 15mins later injection 60-120mg PO pseudoephedrine corporeal aspiration and irrigation (with N saline) injection with 2-3ml 1:100,000 adrenaline (can also use phenylephrine and metaraminol) intracorporeal (unlikely to be successful if >36hrs) repeat Q5minly if doesn’t work can inject methylene blue If SCD: IVF, O2, exchange blood transfusion and systemic alkalinisation; also treat as above surgical shunt if all else failsIf high flow: usually treated conservatively; if fails, surgical shunt (50% effectiveness) / angioembolism of lacerated artery

Definition: inability to retract foreskinEpidemiology: in nearly all infants; in 25% 3yrs; 10% 6yrs (most have resolved by 5yrs); 1% 16yrsManagement: refer urology

Paraphimosis

Priapism

Definition: inflammation of foreskin; bugs = Candida, Staph aureus, gardnerella, anaerobesEpidemiology: usually 2-6yrs; due to poor hygiene; more common in diabetesManagement: clean; antifungal cream; PO antibiotics; warm soaks; circumcision when inflammation goes down

Balanitis

Epidemiology: 3-6yrsManagement: cut median bar, cut closed teeth of zipper, soak entrapped area in old then gentle tractionPenile Zipper

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