Penile abnormalities

Peyronie's Disease

• Definition: A wound healing disorder in which subclinical penile trauma leads to fibrotic plaque formation within the tunica albuginea, resulting in penile curvature, pain and often associated erectile dysfunction

• Aetiology: Abnormal healing process following minor, often unnoticed trauma; associated with cardiovascular risk factors, smoking, diabetes, obesity, and Dupuytren’s contracture

• Clinical Presentation:

  • Penile curvature that may progress over 6–12 months with a palpable, fibrous plaque (commonly dorsal)

  • Penile shortening and narrowing with a hinge effect during erections

  • Variable penile pain, particularly during the active inflammatory phase, which typically resolves within 12 months as curvature stabilises

  • Co-existing erectile dysfunction is common, with up to 30% of patients also having diabetes

• Diagnosis:

  • Primarily clinical based on history and physical examination in the flaccid state; degree of curvature is better assessed during an erection (patient may overestimate curvature when flaccid)

  • Penile duplex ultrasound may be utilised by specialists to assess plaque characteristics, including calcification and vascular flow

• Management:

  • Conservative measures include observation in cases of minimal curvature with preserved sexual function

  • Oral therapy (e.g. PDE5 inhibitors) may be considered for co-existent erectile dysfunction and potential antiscarring effects, though evidence is limited

  • Intralesional therapy with collagenase injections has shown modest improvement in curvature (approx. 37% reduction) and is recommended for patients with a curvature less than 60° and non-calcified plaques; requires specialist administration and multiple treatment cycles with penile modelling exercises

  • Surgical intervention (tunica albuginea plication, plaque incision with grafting, or penile prosthesis implantation) remains the gold standard for patients with stable, chronic disease who have significant sexual dysfunction or psychological distress; surgery is typically considered after a minimum of 3 months of stable, pain-free disease

• Additional Considerations:

  • Patients should be counselled that no treatment fully restores the penis to its pre-disease state and realistic expectations must be set

  • Emotional and psychological support is important due to the significant impact on quality of life and self-esteem

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Balanitis

• Definition: Inflammation of the glans penis that may involve the foreskin, commonly seen in uncircumcised males and often due to irritant contact, poor hygiene or candida infection

• Clinical Presentation in Uncircumcised Men:

  • Redness, swelling, pain and dysuria, often related to poor hygiene, urine trapping or irritant dermatitis

  • May also present as a candidal infection with satellite pustules, particularly if associated with nappy rash in infants

• Clinical Presentation in Circumcised Men:

  • More frequently due to dermatoses such as psoriasis, lichen sclerosus, or contact dermatitis

• Management for Uncircumcised Men:

  • First-line treatment with topical hydrocortisone 1% combined with clotrimazole applied twice daily for 2 weeks

  • For recurrent or persistent cases, consider a single dose of oral fluconazole 150 mg; emphasise improved hygiene and use of soap-free cleansers

• Management for Uncircumcised Boys:

  • Recommend soap-free washing, lukewarm saltwater soaks and barrier creams to protect the skin

  • Use topical hydrocortisone for inflammation and consider antibiotics if streptococcal infection is suspected

• Additional Considerations:

  • Educate caregivers on proper care of the uncircumcised penis including avoiding forcible retraction during cleaning to prevent paraphimosis

  • In cases with extensive inflammation or secondary infection, a multidisciplinary approach may be required to address both skin care and underlying medical issues

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Circumcision Indications

• Indicated in cases of pathological phimosis where scarring (e.g. balanitis xerotica obliterans) prevents retraction and causes urinary difficulties

• Considered for recurrent urinary tract infections or persistent infectious balanitis following resolution of acute inflammation

• Should be performed in a safe, child-friendly environment by trained personnel with appropriate postoperative care and analgesia

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Additional Notes

• Emphasise that a non-retractable foreskin in infants is a normal variant and should not be forcibly retracted as this increases the risk of paraphimosis

• Smegma accumulation is normal before the foreskin becomes fully retractable; routine gentle cleaning is sufficient

• Ballooning during urination may occur in non-retractable foreskins; treat with topical steroid cream (0.05% betamethasone applied sparingly to the preputial ring) if symptomatic

• Zipper injuries and hair tourniquets are recognised causes of acute penile injury requiring prompt, often simple, intervention

• Reassure patients that most penile abnormalities are managed conservatively with surgical options reserved for refractory or severe cases

• A multidisciplinary approach including referrals to urology or dermatology may be necessary in complex or recurrent cases

• Postoperative care following circumcision includes managing crusting and inflammation of the glans with liberal application of barrier creams such as Vaseline and monitoring for significant bleeding or infection

• In cases of priapism in older children, initiate conservative measures (e.g. cold packs, urination, cold bath) promptly and arrange urgent urology referral if not resolved within 2 hours, with special consideration in those with sickle cell disease