Penile Abnormalities

Emmanuel Konadu
Bsc. Physician Assistantship
Studies
Sunday 23 March 2025
 OUTLINE
• Definition
• Embryology and Anatomy
• Epidemiology
• Aetiology
• Pathophysiology
• Clinical Presentation
• Investigations
• Complications
• Differential Diagnosis
• Management
 DEFINITION

Penile abnormalities encompass a variety of disorders of

the soft tissues of the male genitalia
EMBRYOLOGY OF MALE UROGENITAL
TRACT
• All the components of the urogenital tract undergoes:
• Indifferentiation stage:
• mesenchyme migrates to cloacal membrane to form
genital tubercle
• caudal portion of the cloacal membrane develops into
urogenital folds
• genital swellings become visible on each side of
urethral folds
 EMBRYOLOGY OF THE MALE
UROGENITAL TRACT
• Differentiation into external genitalia in male:
• It is under influence of androgens(testosterone)
• Rapid elongation of the genital tubercle called the
phallus
• Phallus pulls the urethral folds to form the lateral
walls of the urethral groove
• At end of the third month, the two urethral folds close
over the urethral plate, forming the penile urethra
ANATOMY OF THE MALE PENIS
• Penis is divided into three
parts:
• Root of the penis:
• lies under the pubic
bone
• provides stability when
the penis is erect
• 2 cavernosal bodies and
corpus spongiosum
• Glans:
• Distal expansion of
corpus spongiosum
Phimosis
 DEFINITION

Inability to retract the prepuce over the glan of the penis

 TYPES OF PHIMOSIS
• Phimosis is divided into two form:
• Physiological Phimosis
• Occurs naturally in newborn males
• Pathological Phimosis
• Inability to retract the foreskin after it was
previously retractible or after puberty
 EPIDEMIOLOGY
• 4% of new-borns will have retractable foreskin
• By the age of 3, 90% of the prepuces are retractable
• Remaining 10%, will have physiologic phimosis
• 1% of 16-year-old will have non-retractile foreskins
• 46.5% of adult circumcision was attributed to phimosis
 AETIOLOGY
• Congenital
• Acquired
• Inflammatory
• Balanitis
• Posthitis
• Balanoposthitis
• Traumatic
• Fibrosis of prepuce
• Neoplastic
• Underling Ca
 PHYSIOLOGIC PHIMOSIS

• Formation of the prepuce is completed by 16 weeks’

gestation
• Inner prepuce and glans penis share a common, fused
mucosal epithelium
• Epithelium separates via desquamation
• Desquamation is due to hormonal and growth factors
are produced
 PATHOLOGIC PHIMOSIS
• Usually the result of poor hygiene or chronic
balanoposthitis
• Eventually leads formation of fibrotic ring of tissue close
to opening of the prepuce
• When foreskin is forcefully retracted, it results in
significant bleeding
• This leads to dense fibrous adhesions formation during
healing process leading to pathologic phimosis
 CLINICAL PRESENTATION
• HISTORY • PHYSICAL EXAMINATION
• Age • Inspection
• Symptoms • Redness, purulent foreskin
• Ballooning of foreskin • Scarring of the foreskin
during voiding (white)
• Pain
• Dysuria • Palpation
• Urinary infections • Tenderness
• Retraction of the foreskin
not possible
 MANAGEMENT
• Management depends on:
• age of child
• type of non retraction
• severity of phimosis
• the cause
• associated morbid conditions
 TREATMENT
• Reassurance and Vigilance
• Proper preputial care and hygiene
• Topical Steroids
• 0.05% Betamethasone twice daily for 4-6 weeks
• Dilation and Stretching

• Surgical
• Conservative Surgical Alternatives
• Conventional Male Circumcision
 CIRCUMCISION
INDICATIONS CONTRAINDICATIONS
• Religious, cultural, • Prematurity
hygienic • Anomalies of the penis
• Phimosis
• Bleeding diatheses are
• Paraphimosis
not absolute
• Balanitis contraindications
• Posthitis
 TYPES OF CIRCUMCISION
• Using surgical devices
• Gomco Clamp
• Mogen Clamp
• Plastibell
• Dorsal Slit
• Excision
• Sleeve Resection
 TYPES OF CIRCUMCISION
• Gomco Clamp:
• Bell is placed over glans
and foreskin is replaced
into the anatomic position
• Yoke is then placed over
the bell and clamp is
tightened, crushing the
foreskin
• Scalpel is run around the
upper surface of the plate
to remove the prepuce
 Mogen Clamp
• Foreskin is extended using straight hemostats
• Mogen clamp is then slid over the foreskin
• Clamp is then locked
• Scalpel is used to skin from the upper side of the
clamp
 Plastibell

• Plastibell is placed under

foreskin and secured with
circumferential ligature
• Ring falls off after 4-7 days
leaving a circumferential
wound
 Dorsal Slit Procedure
• Identification of plane b/n
dorsal foreskin and corona
• Haemostat is used to
crush foreskin at 12 o’clock
position for 30-60 seconds
• Crushed area is sharply
incised with scissors
• Edges are often over sewn
with an interrupted or
running dissolvable suture
 Sleeve Resection

• Prepuce is retracted over the glans

• Circumferential incision is made around the shaft
• Prepuce is returned to cover the glans and another incision is
made round the shaft
• Longitudinal cut is made between the two circumferential
• Free raw edges are then sutured with absorbable suture
Sleeve Resection
 Complications of Circumcision
• Early Complications
• Bleeding
• Infection
• Late Complications
• Meatitis and Meatal Stenosis
• Urethocutaneous Fistula
• Necrosis
• Phimosis
• Glans Injury
Complications of Circumcision
Complications of Circumcision
 FOLLOW-UP

• Routine follow-up after adult circumcision is advisable

• Patient may be seen 2-3 weeks after operation
 COMPLICATIONS
Associated with Phimosis:
• Balanitis
• Posthitis
• Paraphimosis
• Voiding Dysfunction
• Penile Carcinoma
 PROGNOSIS
• Physiologic phimosis has an excellent prognosis with or
without appropriate treatment
• Pathologic phimosis usually require treatment and the
prognosis is good, if the underlying condition is treated
successfully
Paraphimosi
s
 Definition

Urological emergency in which the retracted foreskin of

an uncircumcised male cannot be returned to its
anatomical position
 Epidemiology
• Relative uncommon condition
• The incidence in unknown
• Few cases have been reported in literature
• Almost always an iatrogenically or inadvertently induced
condition
 Aetiology
IATROGENIC CAUSES:
• Penile examination
• Urethral catherization
• Cystoscopy

OTHER CAUSES:
• Self-inflicted injury to the penis
• Secondary to penile erection
 PATHOPHYSIOLOGY
• Retraction of the foreskin behind the glans penis leads
to phimotic ring
• Ring causes constriction of the distal glans
• Leads to vascular engorgement as the lymphatic and
venous are impaired
• Causes impediment of the arterial flow and potential
ischemia of the penis distal to ring
• Eventual necrosis of the glan penis may be observed
• HISTORY Clinical Presentation
• Age
• Occurs in young men
• Symptoms • PHYSICAL
• Swelling EXAMINATION
• Penile pain • Presence of the foreskin
• Obstructive voiding • Colour of the glans
symptom
• Past Medical History • Degree of constriction
• No history of • Palpation of the glans
circumcision
• History of endoscopic
surgery of the bladder or
urethra
 Management
• Treatment modalities include
• Medical Therapy
• Surgical Therapy
• The goals of management involves:
• Reassuring the patient
• Reducing the preputial oedema
• Restoring the prepuce to its original position and
condition
 MEDICAL THERAPY
• Non-pharmacological
• Ice packs
• Manual Reduction
• Pharmacological
• Injection of hyaluronidase into oedematous prepuce
• Osmotic agents (Mannitol soaked-guaze)
MANUAL REDUCTION

• A gloved hand is circled

around the distal penis
• A circumferential pressure
is applied to disperse the
oedema
 SURGICAL THERAPY
• Minimally invasive
• Puncture technique
• Blood aspiration
• Dorsal slit
• Circumcision
 PUNCTURE TECHNIQUE
• Hypodermic needle (21-26
gauge) is used to puncture
the oedematous prepuce
at multiple sites to release
the trapped fluid
• External drainage results in
rapid resolution of oedema
• It is then followed by
manual reduction of the
prepuce
 DORSAL SLIT PROCEDURE
• Skin preparation, draping and anaesthesia
• Identification of the plane between the dorsal foreskin
and corona
• A haemostat is then used to crush the foreskin at 12
o’clock position for 30-60 seconds
• The crushed area is then sharply incised with scissors
• The edges are often over sewn with an interrupted or
running dissolvable suture
 FOLLOW-UP
• Follow-up examination in 2-3 weeks
 COMPLICATIONS
Associated with Paraphimosis:
• Infection
• Swelling of the glans
• Ischemia and necrosis
Associated with Dorsal Slit:
• Infection
• Bleeding
• Urethral Injury
• Shortening of penile skin
 OUTCOME AND PROGNOSIS
• Does not occur after a proper circumcision
• Outcome of dorsal slit is excellent
Hypospadia
s
 DEFINITION

An abnormal ventral opening of urethral meatus located

anywhere from the ventral aspect of glans penis to
perineum
 CLASSIFICATION OF HYPOSPADIAS
• Is based on the position of meatus
• Anterior
• Glanular
• Subcoronal
• Middle
• Distal penile
• Midshaft
• Proxiaml penile
• Posterior
• Penoscrotal
• Scrotal
• Perineal
 EPIDEMIOLOGY

• Most common congenital malformation

• Occurs in one of 350 male births
• Incidence is higher in whites than in blacks
• Increased rate in premature babies
 AETIOLOGY
• The aetiologies for hypospadias include:
• Genetic factors
• Higher incidence in monozygotic twins
• Endocrine factors
• Dysfunction in androgen production and utilization.
• Mutations in 5-alpha reductase
• Maternal exposure to progesterone
• Environmental factors
 PATHOPHYSIOLOGY
• Occurs embryologically during urethral development
• As phallus grows, the open groove extends from its base
to the level of the corona
• 2 theories proposed to explain pathophysiology
• Urethral folds coalesce in midline from base to tip,
forming a tubularized penile urethra and median scrotal
raphe.
• Ectodermal core forming at tip of the glans penis, which
canalizes to join with the more proximal urethra at the
level of the corona
 DIAGNOSIS
• Diagnosis is usually made at birth
• History
• Familial pattern of hypospadias
• History of Infertility

• Physical Examination
• Position, shape and width of the meatal orifice
• Appearance of the preputial hood and scrotum
• Size of the penis
• Curvature of the penis on erection (chordee)
• Deficiency of ventral foreskin
 MANAGEMENT
• Treatment is surgical repair
• The goals of surgical treatment is to:
• To create a straight penis by repairing curvature (chordee)
• To create a urethra with its meatus at the tip of penis
• To reform the glans into a more natural conical
configuration
• To achieve cosmetically acceptable penile skin coverage
• To create a normal-appearing scrotum
 SURGICAL
• Timing of Surgery
• Before 1980, repair was performed in children older
than 3years
• Currently, repair is between 4 and 18 months
• Preoperative Hormonal Simulation
• HCG 250-500U sc twice a week for 3weeks
• Testosterone propionate cream 2% three times daily
for 3 weeks
 SURGICAL PRINCIPLES
• Use optical magnification
• Artificial erection (when appropriate)
• Chordee repair (orthoplasty)
• Urethral plate preservation if possible
• Use well-vascularized non hair-bearing local tissue for
urethral construction
• Neourethral coverage (1-2 layers)
• Catheter (urethral)
• Use an appropriate dressing
 COMPLICATIONS OF REPAIR
Immediate complications
• Postoperative bleeding
• Infection
Long-term complications
• Urethrocutaneous fistula
• Meatal/Urethral stenosis
• Diverticulum
• Hair in the urethra
THANK YOU