The penis
Phimosis
Phimosis is sometimes congenital but is much
over-diagnosed. The physiological adhesions between the foreskin and the glans
penis may persist until the boy is 6 years of age or more, giving the false
impression that the prepuce will not retract. Rolling back the prepuce causes
its inner lining to pout and the meatus comes into view. This condition should
not be confused with true phimosis in small boys where there is scarring of the
prepuce which will not retract without fissuring. In these cases, the aperture
in the prepuce may be so tight as to cause urinary obstruction. Urinary
difficulty with residual urine and back-pressure effects on the ureters and
kidney is more commonly due to meatal atresia which may be masked by the
prepuce. Phimosis also occurs later in life as a result of balanitis xerotica obliterans, a curious condition in which the
normally pliant foreskin becomes thickened and will not retract. It is difficult
to keep the penis clean, and there is both a problem with hygiene and an
increased susceptibility to carcinoma.
Treatment is by circumcision.
Circumcision
Apparently, circumcision did not originate
among the Jews:
they took the practice from either the
Babylonians or the
Negroes, probably the latter. It had been
practised in West
Africa for over 5000 years.
Indications.
In infants and young boys, circumcision
is most usually performed at the request of the parents for social or religious
reasons. Occasionally, there is true phimosis with recurrent attacks of
balanitis. As stated above, it is normal for the prepuce to be long and adherent
to the glands during the first few years of life. Recurrent balanoprosthitis and
phimosis may result from misguided attempts by parents to expose the glans
forcibly.
In adults, circumcision is indicated because of inability to retract for
intercourse, for splitting of an abnormally tight frenulum, balanitis and
sometimes prior to radiotherapy for carcinoma of the penis.
Technique in an infant. The much advocated
method of applying a clamp or bone forceps across the prepuce distal to the
glans with blind division of the foreskin can no longer be condoned. To see one
little boy with partial or total amputation of the glans is enough to realise
the folly of this technique. It is far better to perform a proper circumcision
under direct vision as in an adult.
The
Plastibel (Hollister) is used as shown in Fig.
67.18: the ring separates between
5 and 8 days postoperatively.
Technique
in adolescents and adults. In adolescents and adults the following method is
preferable. The prepuce is held in haemostats and put on a gentle stretch. A
circumferential incision in the penile skin is made at the level of the corona
using a knife. The prepuce is then slit up the midline dorsally to within 1 cm
of the corona. This converts the foreskin into two flaps connected at the
midline anteriorly. When the undersurface of the prepuce has been separated from
the glans, the inner layer of each flap is incised with a second circumferential
incision leaving about 5 mm of the
inner layer of the prepuce distal to the corona. Cutting the remaining
connective tissue completes the excision (Fig. 67.19). Monopolar diathermy
should be avoided in operations on the penis in small boys because there is a
danger that the small current path will cause coagulation at the base of the
penis. Haemostasis is important in circumcision, however, and should be secured
by bipolar diathermy or ligated with catgut. The cut edges are approximated
using catgut sutures and the layers in the immediate region of the frenulum are
brought neatly together using a mattress suture (Fig.
67.20).
Preputial
calculi
Late in life, chronic posthitis may lead to adhesions between the prepuce and the glans and closure of the orifice of the preputial sac. Preputial calculi result from inspissated smegma, urinary salts or both.
Injuries
Avulsion of the
skin of the penis
Entanglement of clothing in rotating machinery
is the usual cause. Repair is effected by burying the shaft of the penis in the
scrotum (Fig. 67.21) with subsequent release at the time of a definitive plastic
surgical repair. The prepuce is also at risk in the zip fastening of the trouser
fly.
Fracture of the
penis
Fracture of the penis is an uncommon accident
usually occurring when the erect penis is bent violently downwards during
over-enthusiastic intercourse. The extravasation of blood causes great pain and
swelling. In early cases, incision and drainage of the clot with suture of the
defect in the tunica of the ruptured corpus cavernosum give acceptable results.
Strangulation
of the penis
Strangulation of the penis by rings placed on the penis, usually for sexual reasons, can cause venous engorgement which prevents their removal. It may help to aspirate the corpora cavernosa but often the ring must be cut off with a ring cutter or hacksaw.