Penile Emergencies

Penile Emergencies

Phimosis

  • Condition in which the foreskin cannot be retracted behind the glans penis
  • By 3 yr of age, 90% of foreskins can be retracted
  • Fewer than 1% of males have phimosis by age 17
  • Usually not painful, but may produce urinary obstruction with ballooning of foreskin
  • May occur as a result of recurrent balanitis
  • May lead to chronic inflammation and carcinoma
  • Treatment in boys older than 4 or 5 yr of age and in those who develop balanitis or balanoposthitis is topical corticosteroids (0.1% dexamethasone) to the foreskin three to four times daily for 6 wk. This loosens the phimotic ring in two-thirds of cases and usually allows the foreskin to be retracted manually.
  • In uncircumcised boys older than 7 or 8 yr old with corticosteroid-resistant phimosis or in boys with ballooning of the foreskin or recurrent balanitis, circumcision or dorsal slit is recommended.

Paraphimosis

  • Condition in which the foreskin has been retracted and left behind the glans penis, constricting the glans and causing painful vascular engorgement and edema of the foreskin distal to the phimotic ring.
  • Can occur iatrogenically and frequently occurs after penis has been examined or urethral catheter has been inserted
  • Can result in marked swelling of the glans penis such that the foreskin can no longer be drawn forward, which may lead to arterial compromise and fournier’s gangrene
  • Reduction of paraphimosis can be initiated with gentle, steady pressure to the foreskin to decrease the swelling. Elastic bandage wrap (2 x 2 in) used for 5 min may be helpful in some cases. Short-term ice-packing may help as an analgesic or a local anesthetic block of the penis may be indicated in marked discomfort.
  • Marked or irreducible cases may necessitate an emergency dorsal slit or circumcision by a urologist. Reduced paraphimosis should be scheduled for a dorsal slit or circumcision at a later date, as paraphimosis tends to recur.

Balanitis

  • Inflammation of the glans, which occurs usually as a result of poor hygiene, from failure to retract and clean under the foreskin.
  • Usually responds to local care and antibiotic ointment. Occasionally oral antibiotic therapy may be necessary.
  • Recurrent balanitis may result in phimosis.
  • Balanitis in older patients may be a presenting sign of diabetes, in which cases, circumcision may be necessary.

Balanoposthitis


  • Severe balanitis, in which the phimotic band is tight enough to retain inflammatory secretions, creating a preputial cavity abscess.
  • Treatment includes cleansing and application of antifungal creams (clotrimazole bid)
  • Urologic follow-up and possible circumcision may be indicated.
  • In the presence of secondary bacterial infection, an oral cephalosporin should be prescribed.
  • On occasion, an emergent dorsal slit is required.

Penile Fracture

  • Acute tear of the tunica albuginea, presenting with acute swelling, discoloration, and tenderness.
  • Usually caused by trauma during intercourse accompanied by a snapping sound.
  • Urologic consultation is indicated.

Peyronie’s Disease

  • Condition that results in fibrosis of the tunica albuginea, the elastic membrane that surrounds each corpus cavernosum, producing curvature of the penis during erection.
  • Difficult to diagnose in flaccid state; however patient’s prior history of buckling trauma may establish the diagnosis.
  • Physical exam reveals fibrous plaques or ridges along the dorsal shaft of the penis.
  • Benign condition that may resolve or stabilize spontaneously without treatment.
  • Complication may include erectile dysfunction.
  • Reassurance and urologic follow-up are indicated.

Priapism

  • Prolonged painful and tender erection that persists beyond or is not related to sexual activity
  • Occurs most commonly in patients with sickle cell disease but can also occur in those with advanced malignancy or coagulation disorders, those on total parenteral nutrition, certain drug therapy, and after trauma or idiopathically.
  • Classified as primary/idiopathic and secondary, or ischemic/veno-occlusive and nonischemic/arterial.
  • Ischemic priapism beyond 4 h is a compartment syndrome requiring emergent medical intervention
  • Nonischemic priapism is less common and is caused by unregulated cavernous inflow, which usually presents with an erection that is not fully rigid and is painless
  • Drugs reported to cause priapism include but are not restricted to:
  • Antidepressants-bupropion, trazadone, fluoxetine, setraline, lithium
  • Antipsychotics-clozapine
  • Tranquilizers-mesoridazine, perphenazine
  • Anxiolytics-hydroxyzine
  • Psychotropics-chlorpromazine
  • Alpha-adrenergic blockers-prazosin
  • Hormones-GnRH
  • Anticoagulants-heparin, warfarin
  • Recreational drugs-cocaine, alcohol
  • Complications include urinary retention, infection, and impotence
  • Initial therapy includes terbutaline 0.25-0.5 mg subcutaneously in the deltoid area
  • Corporal aspiration (corpus cavernosum) and irrigation with normal saline or a-adrenergic blocker is the next step by a urologist.
       
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