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 elsewhere in the body. It is usually sexually transmitted and is most common among socially deprived people. The incubation period varies greatly but is frequently 7—30 days.

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.