History
Phimosis
Congenital or physiologic phimosis is clinically asymptomatic so is not a cause for concern. It is often associated with "ballooning" of the foreskin during voiding. This is a self-limited phenomenon that, in the absence of pathologic phimosis, does not indicate urinary tract obstruction. Pathologic, or true, phimosis is far less common. Symptoms include skin irritation, dysuria, bleeding, and occasionally enuresis or urinary retention. Physical examination usually reveals white cicatricial scarring at the preputial ring.
Pathologic phimosis may be due to balanitis xerotica obliterans (BXO), a genital form of lichen sclerosus et atrophicus. This condition affects both men and boys and represents an absolute indication for circumcision, which may be curative. The etiology of BXO is unknown, and it may represent a premalignant state. Clinically, it presents as severe phimosis and possibly meatal stenosis, glanular lesions, or both.
In older men, when the phimosis is severe, the distal foreskin often appears swollen and erythematous with cracked fissures (see image below). Men who are affected report pain and discomfort during sexual activity or when they attempt to retract the foreskin. Unlike in the pediatric population, lower urinary tract voiding symptoms are absent. In older men, acquired phimosis is often associated with poor hygiene but may be a product of diabetes mellitus.
In a prospective study comparing 28 men with acquired phimosis and preputial fissures to 28 controls with acquired phimosis without preputial fissures, the incidence of undiagnosed diabetes with a combination of acquired phimosis and preputial fissures was 100% compared to a 7.1% incidence of diabetes in patients with acquired phimosis but no preputial fissures. The researchers noted that over 60% of the cohort studied were younger than 45 years old and concluded that phimosis with preputial fissures was a specific sign of undiagnosed DM in young men. Patients presenting with phimosis and fissures should undergo serum testing for diabetes. [31]
Phimotic foreskin. The distal foreskin is edematous, with cracked fissures. The patient was unable to retract the foreskin.
Buried penis
Most pediatric cases of buried penis present in neonates or prepubertal boys. The most common age range of patients at presentation is 6 months to 1 year. Adolescents who present with buried penis are usually obese, and weight loss should be advised. Patients may be uncircumcised or circumcised; the latter complicates repair. One series found that 77% of children presenting with buried penis had been previously circumcised, emphasizing a need for pediatric urologists to educate primary care physicians.
The reasons for presentation vary. Often, parents are concerned because they are unable to see the penis, which may also complicate proper hygiene. Occasionally, they may witness ballooning of the foreskin with voiding, and children may be persistently wet if they are voiding into the preputial sac.
Adolescents may report dysuria, dribbling between voids, trouble directing their urinary stream because of difficulty holding the penis, or embarrassment in the locker room. Some patients have a history of balanitis and balanoposthitis, and some have undergone a radical circumcision or even multiple circumcisions.
In addition to some of the symptoms seen in children, adults may present with sexual complaints. These include painful erection, sexual embarrassment, and difficulty with vaginal penetration, especially if the tip of the glans does not project past the male escutcheon. This condition may lead to the inability to void in a standing position and may cause the patient to soil himself while urinating in the seated position. Obesity and diabetes mellitus are commonly associated comorbidities.
When massive scrotal lymphedema is present in adults, a complete history should be obtained. Patients should be questioned on recent travel to Asia or Africa, which are endemic to lymphogranuloma venereum and Wuchereria bancrofti infestation, the most common infections seen in massive scrotal lymphedema. A history of recurrent epididymitis also may play a role. [27]
Physical Examination
All uncircumcised adult men should have the foreskin retracted to exclude occult carcinoma as a part of a complete urologic examination. Squamous cell carcinoma of the penis may manifest as an ulcerated fungating mass of the glans or the prepuce. Alternatively, carcinoma in situ or penile carcinoma may appear as a velvety macular lesion of the glans (erythroplasia of Queyrat) or the penile shaft (Bowen disease).
Phimosis
Physical examination usually reveals white cicatricial scarring at the preputial ring.
Meuli et al devised the following scoring system to rate the severity of phimosis: [32]
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Grade I - Fully retractable prepuce with stenotic ring in the shaft
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Grade II - Partial retractability with partial exposure of the glans
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Grade III - Partial retractability with exposure of the meatus only
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Grade IV - No retractability
Buried penis
On physical examination, which should include a supine evaluation, the penis may be concealed because it is buried in prepubic tissues; buried and enclosed in scrotal tissue (penis palmatus); trapped by phimosis, traumatic scar tissue, or postcircumcision cicatrix; or hidden secondary to a large hernia or hydrocele. A smooth transition from prepubic to penile skin indicates a buried penis. Trapped penis demonstrates a circumferential groove at the base of the penis.
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Phimotic foreskin. The distal foreskin is edematous, with cracked fissures. The patient was unable to retract the foreskin.
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Dorsal-slit technique. The redundant foreskin is clamped at the 12-o'clock position for 2 minutes for hemostasis.
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In the dorsal-slit technique, the clamped foreskin is incised sharply between the 2 hemostats.
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The dorsal slit is being completed, and the circumscribing incision (proximal skirt) has been made.
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Dorsal-slit technique. Redundant foreskin has been excised. The distal circumcision incision is 1 cm from the coronal sulcus.
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Dorsal-slit technique. Proximal and distal skirts are approximated circumferentially with absorbable sutures in an interrupted fashion.
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In the sleeve technique, the circumcision is started by making a circumscribing proximal incision. The incision is carried down to the Buck fascia.
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In the sleeve technique, a distal incision is made 1 cm proximal to the coronal sulcus.
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Sleeve technique. Redundant foreskin is clamped at the 12-o'clock position with 2 straight hemostats. Next, the foreskin is incised between the 2 hemostats.
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Sleeve technique. The excess foreskin is peeled off. The shaft of the penis is displaced downward using a stack of sponges as the redundant foreskin is removed.
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Sleeve technique. Excess foreskin has been removed completely.
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Sleeve technique. The edges of the penile skin are approximated with absorbable sutures.
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Sleeve technique. The circumcision is completed with excellent cosmetic result.
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The arterial blood supply of the penis arises from the internal pudendal artery. The internal pudendal artery gives off branches to the bulbar artery, cavernosal artery, and dorsal penile artery. The bulbar artery continues on as the bulbourethral artery to supply the urethra. The cavernosal artery gives rise to the helicine arteries that are end arteries. The dorsal artery of the penis gives branches off to the circumflex arteries.
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Dorsal view of the arterial and venous blood supply of the penis.
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Cross-section through the body of the penis.
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Preoperative photo of a buried penis in an adult.
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Same patient after penile reconstruction and removal of the pannus. Note the elliptical incision and marked improvement in perceived penile length.
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Same patient at the conclusion of the procedure. Although not seen in this picture, a Foley catheter may be left in place after the operation.
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Concealed penis secondary to a scrotal web.
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Repair in this patient involved releasing the scrotal web and degloving the penis. This patient was found to have deficient penile skin for reconstruction.
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Same patient after application of a split-thickness skin graft that was harvested from the left thigh.
