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.
a circumcision is required, most
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.
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.
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.
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.
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 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.