Disorders of the Penis

With age, the penile sinusoids lose compliance because of increased collagen deposition. Additionally, diseases frequently associated with aging (eg, atherosclerosis, diabetes) may predispose elderly men to erectile dysfunction; with age, men generally have less turgid erections, longer refractory periods, longer latency periods, and loss of forceful ejaculation.

Balanitis

Inflammation of the glans penis.

Balanitis usually occurs in uncircumcised men. Diabetes is a predisposing factor. Causes (see Table 117-4), especially candidiasis, should be investigated and the urine tested for glucose. Clinically, the glans is red, often with an exudate on the surface. Balanitis is usually treated with antibiotic creams. Resistant or recurrent balanitis requires circumcision.

Balanitis xerotica obliterans, a genital variation of lichen sclerosus, is due to chronic inflammation. It is characterized by a white discoloration of the tip of the glans penis with associated scarring. In uncircumcised men, the foreskin may become "fused" with the glans penis, making circumcision extremely difficult. The most common complication is meatal stenosis. When this complication occurs, recurrent urethral strictures are common and may require urethral plastic surgery.

Condylomata Acuminata

(Genital Warts; Venereal Warts)

Hyperplastic lesions of the skin or mucous membranes of the genitalia caused by human papillomaviruses.

Condylomata are soft, moist, tiny pink or gray polyps that enlarge, may become pedunculated, and are usually found in clusters, their surface resembling a cauliflower. About 5% of men with condylomata localized at the urinary meatus have urethral involvement. In these patients, the urethra should be evaluated. However, patients with lesions that do not resemble condylomata or balanitis should be referred to a dermatologist. Condylomata can be treated with drugs (eg, topical podophyllin) or laser therapy.

Priapism

A sustained erection that is not associated with sexual arousal and does not subside after orgasm.

Priapism may be primary or secondary to sickle cell disease, neurogenic disorders (eg, spinal cord lesions), metastatic cancer, or drugs (eg, antihistamines; certain antidepressants, especially trazodone). Intracavernosal use of vasoactive drugs (eg, papaverine, prostaglandin) can cause priapism.

Treatment of drug-induced priapism involves aspiration of the corpora and injection of an -adrenergic agonist (eg, phenylephrine 250 to 500 µg). If this approach fails or if the priapism is not drug-induced, treatment involves aspiration or irrigation of the corpora or use of cavernosal-spongiosal shunts. Any underlying cause should also be treated, if possible.

Penile Cancer

Penile cancer is rare (0.5% of all malignancies among males) in the USA. It almost exclusively affects men who are not circumcised. Squamous cell carcinoma of the penis is more common (up to 10% of malignancies among males) in countries that do not practice neonatal circumcision. It primarily affects elderly men, although some cases have occurred in men < 50.

Because of the epidemiologic association with neonatal circumcision, one hypothesis suggests that penile cancer is caused by irritation from smegma. Other etiologic possibilities include viral infections (eg, herpes, human papillomavirus).

Squamous cell carcinoma of the penis usually starts as a small erythematous lesion on the foreskin or glans penis, which, if untreated, gradually erodes the penis itself. The lesion spreads to the inguinal lymph nodes, where it may erode the femoral vessels.

Small lesions of the foreskin may be treated with circumcision alone. Small lesions of the glans penis may be treated locally with Mohs' surgery, whereas larger lesions require partial or total penectomy (a margin is left 2 cm proximal to the overt tumor) depending on whether sufficient penis may be retained for voiding. For high-grade tumors or those invading the corpora cavernosa, an inguinal node dissection is performed. Treatment options for metastatic tumors are limited; no chemotherapy regimen has proved effective.