Penis

Penile foreskin Hypospadias Hidden penis Penile torsion Phimosis Meatal stenosis

Penile foreskin that covers the head of the penis (glans penis) is part of normal development in males. There are times when the foreskin is not fully developed around the head of the penis. This will usually indicate an underlying penis issue. There are risks and benefits associated with a circumcision. Those will be listed below in the different penile pathology sections. Also keep in mind that the foreskin during birth is called physiologic fibrosis and does not need to be pulled back until around 3 to 5 years of age. However, at times circumcision or pulling back of the foreskin is recommended when there is evidence of balanitis or urinary obstruction.

Circumcision should be discussed carefully with the physician, and are based on the child’s parents’ cultural, societal, and/or religious beliefs.

Pros

• Easier to clean

• Can be performed with just local lidocaine

• Very little recovery

• Decrease urinary tract infection under age 1

• Eliminates penile cancer

• Recommended if patient has a urologic conditions that can increase urinary infection

Cons

• Bleeding and infection during or after the procedure

• Poor appearance of the penis or an incomplete circumcision

• Urethral or penile injury (rare)

Hypospadias is a condition which is usually a congenital disorder, however it may be caused by trauma or botched penile surgery. The majority of hypospadias, that are not iatrogenic but congenital in nature, tend to be developed prior to birth. They are frequently associated with curvature or chordee of the penis as well as a foreskin deficiency. This will result in foreskin on top of the penis but nothing on the underside. This will be covered under another topic. Hypospadias itself is a medical term that refers to the malformation of the urethra or ‘pee hole’ which results in opening of the meatus on the underside of the penis instead of at the tip of the glans penis.

There are no good data is available to pinpoint a specific factor that caused the hypospadias or the chordee. There is some links to maternal age above age 35 and it can occur if another sibling has hypospadias.

Benefit for surgical correction:

• Normal appearance of the penis

• Penetration during intercourse

• Urination with a straight stream

• Body image as the child grows older

Complications of surgery

• Wound break down

• Fistula (spring a leak in the repair)

• Scarring at the tip of the meatus

• Infection

• Bleeding

Hidden penis is not an uncommon etiology. It is due to the suprapubic fat pad as well as poor anchoring at the penopubic and the penoscrotal junction. This four quadrant anchoring is what allows the penis to be extruded. In adults, hidden penis surgery is also known as penile elongation surgery. The surgical principles in adults are the same as in children, which is four quadrant anchoring at the base of the penis.

While in adults, penile elongation surgery is mostly done as a cosmetic procedure, in children it is done due to clinical issues. In infants it usually presents as a penis that is rarely seen even with erections. The majority of the time it also presents with the foreskin getting stuck to the head of the penis and looks like an incomplete circumcision. This can also present with bleeding and pain when parents try to pull the skin back to clean the penis. In infants or children who are not circumcised, the penis will appear short and have a “volcano” appearance. In older children it can present as a “belly button” appearance of the penis and many time the child complains of having no penile shaft to hold. Many times it is associated with a suprapubic fat pad which can exacerbate the appearance. Treatment typically involves a combination of weight loss and surgery. In infants, usually surgery alone will correct the hidden penis.

Hidden penis has to be differentiated from micro penis, which is a distinct entity. Micro penis is rare and is diagnosed if the penis is 2.5 standard deviation below the normal. If hidden penis is suspected at birth, circumcision should not be performed as the foreskin is needed for skin coverage during surgical repair.

Penile torsion is a urologic condition in which the penis is twisted to the left or right side. 90-95 percent of torsion twists to the left side. It occurs in about 10 percent of the population.

This can be noticed when the median raphe (dark line that travels from the scrotum to the underside of the penis) twists to the left or right side. Usually this will also involve the whole penis as well as the meatus twisting to the same side. Penis curvature occurs commonly with penile torsion. This will usually lead to deflection of urine, and potential vaginal penetration issues. Also, this issue can cause the penis to have a snake like appearance, which may affect body image in older children.

If your son or you notice any abnormalities with the look or have issues with urinary deflection call my office for an evaluation and consultation.

Phimosis is a normal phenomenon that occurs in boys age 3 to 5. It is known as physiologic phimosis. Unless the boy has a UTI, an infection, or problems urinating there is no need to pull the foreskin back.

However if the child has any issues as noted above, after the infection is treated, a steroid cream will be applied to the penis at the tight skin twice per day for one month. This will soften the area of tightness to allow the foreskin to be pulled back without trauma. This is successful in 90 percent of patients. 10 percent usually will require circumcision.

After age 3-5 than the skin should naturally be able to be pulled back. If it can’t be pulled back at that time than steroid cream will be started and used on the penis for 1 month. Most will be able to be pulled back. If the steroid does not work than circumcision is an option.

Meatal stenosis is scarring at the tip of the penis where urine comes out. This typically occurs in boys who have had circumcision. The thought is that it may be due to irritation from diapers or underwear which causes a reaction to the meatus itself. Natural progression of this scarring can lead to progressive difficulty urinating. However this can also occur in an uncircumcised boy due to repeated balanitis.

If the foreskin is scarred and causing ballooning of the foreskin, usually a trial of steroid cream for 1 month will soften the skin. This can allow opening of the obstructing scar tissue at the head of the penis and the meatus (pee channel).

If the meatus (pee channel) is scarred, this will usually require surgical excision and advancement of fresh urethral tissue to the head of the penis.