Common penile abnormalities such as paraphimosis, phimosis, and hypospadias, risk factors, presentation, pathophysiology, investigations, and treatment.

1. Penile Abnormalities
Emmanuel Konadu
Bsc. Physician Assistantship
Studies
Sunday, 04 August 2019

2. OUTLINE
• Definition
• Embryology and Anatomy
• Epidemiology
• Aetiology
• Pathophysiology
• Clinical Presentation
• Investigations
• Complications
• Differential Diagnosis
• Management

3. DEFINITION
Penile abnormalities encompass a variety of disorders of
the soft tissues of the male genitalia

4. 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

5. 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

7. 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

8. Phimosis

9. DEFINITION
Inability to retract the prepuce over the glan of the penis

11. 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

12. 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

13. AETIOLOGY
• Congenital
• Acquired
• Inflammatory
• Balanitis
• Posthitis
• Balanoposthitis
• Traumatic
• Fibrosis of prepuce
• Neoplastic
• Underling Ca

14. 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

15. 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

16. CLINICAL PRESENTATION
• HISTORY
• Age
• Symptoms
• Ballooning of foreskin
during voiding
• Pain
• Dysuria
• Urinary infections
• PHYSICAL EXAMINATION
• Inspection
• Redness, purulent foreskin
• Scarring of the foreskin
(white)
• Palpation
• Tenderness
• Retraction of the foreskin
not possible

17. MANAGEMENT
• Management depends on:
• age of child
• type of non retraction
• severity of phimosis
• the cause
• associated morbid conditions

18. 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

19. CIRCUMCISION
INDICATIONS
• Religious, cultural,
hygienic
• Phimosis
• Paraphimosis
• Balanitis
• Posthitis
CONTRAINDICATIONS
• Prematurity
• Anomalies of the penis
• Bleeding diatheses are
not absolute
contraindications

20. TYPES OF CIRCUMCISION
• Using surgical devices
• Gomco Clamp
• Mogen Clamp
• Plastibell
• Dorsal Slit
• Excision
• Sleeve Resection

21. 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

23. 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

25. Plastibell
• Plastibell is placed under
foreskin and secured with
circumferential ligature
• Ring falls off after 4-7 days
leaving a circumferential
wound

26. 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

27. 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

28. Sleeve Resection

29. Complications of Circumcision
• Early Complications
• Bleeding
• Infection
• Late Complications
• Meatitis and Meatal Stenosis
• Urethocutaneous Fistula
• Necrosis
• Phimosis
• Glans Injury

30. Complications of Circumcision

31. Complications of Circumcision

32. FOLLOW-UP
• Routine follow-up after adult circumcision is advisable
• Patient may be seen 2-3 weeks after operation

33. COMPLICATIONS
Associated with Phimosis:
• Balanitis
• Posthitis
• Paraphimosis
• Voiding Dysfunction
• Penile Carcinoma

34. 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

35. Paraphimosis

36. Definition
Urological emergency in which the retracted foreskin of
an uncircumcised male cannot be returned to its
anatomical position

38. Epidemiology
• Relative uncommon condition
• The incidence in unknown
• Few cases have been reported in literature
• Almost always an iatrogenically or inadvertently induced
condition

39. Aetiology
IATROGENIC CAUSES:
• Penile examination
• Urethral catherization
• Cystoscopy
OTHER CAUSES:
• Self-inflicted injury to the penis
• Secondary to penile erection

40. 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

41. Clinical Presentation• HISTORY
• Age
• Occurs in young men
• Symptoms
• Swelling
• Penile pain
• Obstructive voiding
symptom
• Past Medical History
• No history of
circumcision
• History of endoscopic
surgery of the bladder or
urethra
• PHYSICAL
EXAMINATION
• Presence of the foreskin
• Colour of the glans
• Degree of constriction
• Palpation of the glans

42. 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

43. MEDICAL THERAPY
• Non-pharmacological
• Ice packs
• Manual Reduction
• Pharmacological
• Injection of hyaluronidase into oedematous prepuce
• Osmotic agents (Mannitol soaked-guaze)

44. MANUAL REDUCTION
• A gloved hand is circled
around the distal penis
• A circumferential pressure
is applied to disperse the
oedema

45. SURGICAL THERAPY
• Minimally invasive
• Puncture technique
• Blood aspiration
• Dorsal slit
• Circumcision

46. 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

47. 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

49. FOLLOW-UP
• Follow-up examination in 2-3 weeks

50. COMPLICATIONS
Associated with Paraphimosis:
• Infection
• Swelling of the glans
• Ischemia and necrosis
Associated with Dorsal Slit:
• Infection
• Bleeding
• Urethral Injury
• Shortening of penile skin

51. OUTCOME AND PROGNOSIS
• Does not occur after a proper circumcision
• Outcome of dorsal slit is excellent

52. Hypospadias

53. DEFINITION
An abnormal ventral opening of urethral meatus located
anywhere from the ventral aspect of glans penis to
perineum

54. CLASSIFICATION OF HYPOSPADIAS
• Is based on the position of meatus
• Anterior
• Glanular
• Subcoronal
• Middle
• Distal penile
• Midshaft
• Proxiaml penile
• Posterior
• Penoscrotal
• Scrotal
• Perineal

55. 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

57. 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

58. 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

59. 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

60. 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

61. 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

62. 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

63. COMPLICATIONS OF REPAIR
Immediate complications
• Postoperative bleeding
• Infection
Long-term complications
• Urethrocutaneous fistula
• Meatal/Urethral stenosis
• Diverticulum
• Hair in the urethra

64. THANK YOU