Penile Abnormalities

Phimosis

• Definition: Inability of the foreskin to retract over the glans; can be physiological (normal in young boys) or pathological (due to scarring, often from forced retraction or lichen sclerosus)

• Clinical Features:

  • Physiological phimosis is common in infants and generally resolves by puberty (99% by 17 years)

  • Pathological phimosis is characterised by a tight preputial ring, ballooning during urination and recurrent balanitis

• Management:

  • First-line treatment with topical corticosteroid cream (eg, 0.05% betamethasone applied twice daily for 6–12 weeks) combined with improved hygiene

  • Advise against forcible retraction to avoid further scarring

  • Consider circumcision if conservative management fails or if complications such as urinary retention occur

• Notes:

  • Evaluate for associated conditions such as balanitis xerotica obliterans if scarring is present

  • Reassure caregivers that non-retractile foreskin in young children is often normal and improves with time

  • Monitor for pain during voiding or evidence of infection, which would warrant re-assessment

____________________________________

Paraphimosis

• Definition: Occurs when the retracted foreskin cannot be returned over the glans, causing a constricting band that may compromise blood flow

• Clinical Features:

  • Presents with a painful, swollen foreskin that remains retracted behind the glans

  • Risk of ischaemia and necrosis if not promptly reduced

• Management:

  • Immediate management includes providing analgesia and applying a firm compression bandage for 10–15 minutes to reduce oedema followed by manual reduction

  • If reduction is unsuccessful, repeat the compression technique or use local anaesthesia and refer urgently to urology

  • Post-reduction, advise caregivers to avoid retraction for several days and ensure complete replacement of the foreskin over the glans

• Notes:

  • Recognise paraphimosis as a urological emergency, particularly if signs of ischaemia (dusky or dark tissue) are present

  • Emphasise that forced retraction during cleaning is a common cause and should be avoided

  • Follow-up is essential to monitor for any recurrence or complications

Priapism

• Definition: A persistent, often painful erection lasting more than 4 hours that is not related to sexual arousal

• Types:

  • Low-flow (ischaemic) priapism: Most common; characterized by a rigid, painful erection with risk of ischaemia; associated with conditions such as sickle cell disease, use of PDE5 inhibitors or trauma

  • High-flow (non-ischaemic) priapism: Typically painless and less rigid; usually secondary to arterial injury following trauma

• Clinical Features:

  • Low-flow priapism presents with severe pain and rigidity, posing a risk for permanent tissue damage if not treated promptly

  • High-flow priapism may present with a persistent erection but minimal pain

• Management:

  • For low-flow priapism:

    • Initiate conservative measures such as encouraging physical activity and urination, use oral pseudoephedrine (eg, 120 mg) if appropriate

    • If symptoms persist, refer urgently to urology for corporal aspiration and intracavernosal injection of phenylephrine

  • For high-flow priapism:

    • Manage conservatively with urology consultation; consider interventions like arterial embolisation if conservative management fails

• Notes

  • Low-flow priapism is a true urological emergency requiring prompt intervention to prevent ischaemic damage and subsequent erectile dysfunction

  • Avoid cold packs in patients with sickle cell disease, as they may worsen vaso-occlusion

  • Patient education is crucial, and early recognition of priapism signs can prevent long-term complications

  • Document the duration of the erection and any associated symptoms to guide management decisions

____________________________________

Notes

• Provide thorough education to patients and caregivers on proper genital hygiene and safe practices to avoid trauma

• Multidisciplinary management including referral to urology is essential for cases with complications or where initial management fails

• Regular follow-up is crucial to monitor treatment response and prevent recurrence of complications