Inflammations
Balanoposthitis
Inflammation of the prepuce is known as
posthitis; inflammation of the glans is balanitis. The opposing surfaces of the
two structures are often involved — hence the term balanoposthitis. Skin
conditions such as lichen planus and psoriasis affect the penis and may indeed
be localised there. Drug hypersensitivity reactions can affect the skin of the
penis.
In
mild cases, the only symptom is itching and some discharge. In more severe
inflammation, the glans and foreskin are red-raw and pus exudes. Balanoposthitis
is associated with penile cancer, diabetes and phimosis. Monilial infections
are quite common under the prepuce.
Treatment is by broad-spectrum antibiotics and local hygienic measures.
Genital herpes
Genital herpes is caused by sexual
transmission of the herpes virus hominis HPV (human papilloma virus type 2 —
occasionally type 1). Recurrent attacks occur in 50 per cent or more. Pain along
the distribution of the sensory nerve, usually genitofemoral, precedes the
eruption by 2 days and may be particularly severe around the anus. A group of
tiny vesicles rapidly erodes to form shallow yellow- or red-based ulcers. In
females the ulcers often spread on to the thighs during the attack. Involvement
of the urethra may cause retention of urine which may persist for up to 14 days
if there is radiculitis of the S2 and S3 nerve roots. Acyclovir has been shown
to be effective in treating genital herpes but it does not prevent recurrences.
A
child born to a mother with active infection is liable to a fatal generalised
herpes in the neonatal period. Caesarean section should be considered in these
circumstances. There is an increased risk of carcinoma of the cervix and annual
cytology for life is recommended.
Lymphogranuloma
venereum
Lymphogranuloma venereum is a sexually
transmitted tropical disease caused by Clamydia trachomatis (Chlamydia A) types L1—L3. The primary lesion is a
fleeting, painless, genital papule or ulcer often unnoticed by the patient.
The
inguinal glands become enlarged and painful in both sexes between 2 weeks and 4
months from infection. The masses of nodes mat together above and below the
inguinal ligament to give the ‘sign of the groove’. The overlying skin
reddens and there may be fluctuation. In women, there may be a proctitis which
can go on to produce a rectal stricture if untreated. Lymphatic obstruction
leads to lymphoedema in the perineum and occasionally the lower limbs.
Urethritis and urethral stricture occur in the male.
Confirmation is by isolating Chlamydia A from
the lesion and by immunological tests to detect antibodies against the organism.
Treatment is by a combination of antibiotics which may include sulphonamide,
oxytetracycline and erythromycin. The multilocular bubo should not be incised
— aspiration is permissible to reduce discomfort.
Granuloma
inguinale
This is a chronic and slowly progressive
ulcerative tropical disease -affecting the genitals and surrounding tissue but
occasionally occurring
Clinical course
A painless vesicle or indurated papule usually
on the external genitals but occasionally elsewhere on the skin gradually erodes
into a slowly extending ulcer with a beefy red, granulomatous base. More chronic
lesions may become greyish especially at the edges where, after months or years,
malignant change may develop. The ulcerated area may bleed, if touched, but is
surprisingly painless. Without treatment healing is only partial and keloid is
common.
Diagnosis is by microscopy of material from the edges of the ulcer which shows the
presence of short Gram-negative rods within the cytoplasm of the large
mononuclear cells — Donovan bodies.
Treatment is by oxytetracycline, streptomycin or cotrimoxazole.
Condylomata
acuminata (syn. genital warts)
Genital warts are caused by infection with
human papilloma virus and are sexually transmitted. Ordinary skin warts can
occur on the genitals by direct contact with a finger lesion but they are less
moist, soft and less often pedunculated than the genital variety. The lesions
most commonly occur under the prepuce in the coronal sulcus but may be found
elsewhere, including inside the urinary meatus (Fig.
67.22). In women, genital
warts are most commonly found on the vulva but they may line the vagina and
occur on the cervix. Perianal warts are common.
Other
associated sexually transmitted disease should be excluded — candidiasis and
trichomonas mainly in women, and in men, syphilis or gonorrhoea. Genital warts
may complicate human immunodeficiency virus (HIV) infection.
Treatment is by chemical or physical means. Podopyllin 25 per cent in spirit is
often effective as a topical application. It is applied to the wart with great
care to avoid the surrounding skin and washed off after 6 hours or so.
If
chemical methods fail, the warts can be excised or they can be ablated with
cryosurgery, electrosurgery or laser. Circumcision is sometimes advised if there
are florid lesions under the foreskin.
Other
abnormalities
Chordee. Chordee (French = corded) is a fixed
bowing of the penis due to hypospadias or, more rarely, chronic urethritis.
Erection is deformed and sexual intercourse may be impossible. Treatment is
usually surgical.
Peyronie’s
disease. Peyronie’s disease is a relatively common cause of deformity of the
erect penis. On examination, hard plaques of fibrosis can be palpated in the
tunica of one or both corpora cavernosa. The plaques may be calcified (Fig.
67.23). The presence of the unyielding plaque tissue within the normally elastic
wall of the corpus cavernosum causes the erect penis to bend, often
dramatically, towards the side of the plaque. The aetiology is uncertain, but it
may be a result of past trauma — there is an association with Dupuytren’s
contracture (see Chapter 30).
Treatment is difficult. Some cases continue to progress. Others seem to remit after 3—5 years. Various drug treatments have been suggested but their beneficial effect is hard to prove in such a chronic condition. When the deformity of the penis is causing distress, it may be possible to straighten it by placing nonabsorbable sutures in the corpus cavernosum opposite the plaque. This reduces the elasticity in this region to balance that caused by the plaque (Nesbitt’s operation).
Persistent
priapism. The penis remains erect and becomes painful. This is a pathological
erection and the glans penis and the corpus spongiosum are not involved. The
condition is usually seen as a complication of a blood disorder such as sickle
cell disease or leukaemia. However, it can sometimes follow therapeutic
injection of papaverine or even an abnormally prolonged bout of otherwise normal
sexual activity. A tiny proportion is due to malignant disease in the corpora
cavernosa or the pelvis. Priapism is rarely seen as a consequence of spinal cord
disease.
Treatment. An underlying cause should be excluded. The patient should be referred
for specialist urological care. If aspiration of the sludged blood in the
corpora cavernosa fails to cause detumescence, and injection of metaraminol or
1:100 000 adrenaline solution is ineffective, it may be necessary to decompress
the penis by an anastomosis between the corpus spongiosum and one of the corpora
cavernosa. The outlook for normal erectile function is poor.