Penis And Its Disorders

BY
DR SHIVAY GUPTA
PG SCHOLAR
DEPT OF SHALYA TANTRA
SHRI BMK AYURVEDA MAHAVIDYALAYA
Important terms
 Glans- The glans penis is the sensitive bulbous structure
at the distal end of the human penis.
 Corona glandis- It refers to the circumference of the
base of the glans penis .In human males which forms a
rounded projecting border, overhanging a deep
retroglandular sulcus, behind which is the neck of
the penis.
 Prepuce - technical term for foreskin.
 Frenulum – Thin strip of skin connecting the glans to the
shaft on the underside of penis.
Anatomy of Penis

 Penis is the male organ of copulation

a) Root or attached portion.
 The root of penis is situated in superficial perineal pouch.
 It is composed of 3 erectile tissues , namely two crura & one
bulb.
 Each crura is firmly attached to margin of pubic arch & covered
by ischiocavernosus muscle.
 Bulb is attached to the perineal membrane in between the two
crura & covered by bulbospongiosus.
 Its deep surface is pierced by urethra ,which transverses it to
reach the corpus spongiousum.
 This part of urethra shows a dilatation on floor called
intrabulbar fossa.
b) Body or free portion
 Free portion of penis is completely enveloped by skin.
 It is continuous with the root in front of the lower part of pubic
symphysis.
 It is composed of three elongate erectile tissues, right and left
corpora cavernosa & median corpora spongiosum.
 Penis has two surfaces , Ventral which faces backward and
downwards & dorsal which faces forward and upward.
 The corpora cavernosa do not reach the end of penis , they
terminate under cover of glans penis in a blunt conical extremity.
 They are surrounded by strong fibrous envelope called the tunica
albuginea.
 The corpus spongiosum is the forward continuation of the bulb of
penis. Its terminal part is expanded to form a conical enlargement
called the glans penis.
 Throughout the whole it is transversed by urethra and surrounded
by fibrous sheath.
 Base of penis has a projecting margin , corona glandis ,which
overhangs an obliquely grooved constriction knows as neck of
penis.
 Navicular fossa – it is urethral dilatation with in glans .
 Skin over the penis is very thin & dark colour.
 At neck it is folded to form the prepuce /foreskin and on
undersurface of skin median fold called as frenulum.
 On corona glandis & neck of penis numerous sebaceous gland are
present which secrete sebaceous material smegma.
 Superficial fascia of penis consist of very loosely arranged
aerolar tissue devoid of fat.
 Deep fascia of penis is membranous and known as buck’s fascia
Ligaments of penis
 Fundiform ligament which extend downward from linea alba &
splits to enclose the penis, it lies superficial to suspensory
ligament.
 Suspensory ligament extends from pubic symphysis & blends
below with the fascia on each side of penis.
Arteries , Veins & Nerve Supply of Penis.

A. Internal pudendal artery

- Deep artery of penis runs in corpus cavernosum & breaks up
into arteries that follow a spiral course and known as helicine
arteries.
- Dorsal artery of penis supplies the glans penis, corpus
spongiosum, prepuce and frenulum .
- Artery of bulb of penis supplies the bulb , proximal half of
corpus spongiosum.
b. Femoral artery gives superficial external pudendal artery which
supplies the skin fascia of the penis .
 Superficial dorsal vein which lie in superficial fascia drain into
superficial external pudendal veins.
 Deep dorsal vein that lie subadjacent to deep fascia drains into
prostatic plexus of veins.
NERVES
 Sensory nerve supply is derived from dorsal nerve of penis and
illioinguinal nerve.
 Muscles of penis are supplied by perineal branch of pudendal
nerve.
 Lymphatics from glans drain into deep inguinal nodes & rest of
penis drain into superficial inguinal lymph nodes.
Hypospadias

 Most common congenital malformation of the urethra.

 Out of 350 males one suffers from hypospadias.
 It is a condition in which external meatus of urethra is situated at
some point on the under surface of penis or perineum.
 The inferior aspect of prepuce is poorly developed “hooded
prepuce”
Types

a) Glandular Hypospadias
 In this ectopic meatus is situated on the under surface of the
glans. Their is often a blind depression at the normal site of
external meatus.
 In this variety the in growth does not or it fails to canalise.
b) Coronal
 The external meatus is situated at corona glandis i.e at the
junction on the under surface of the glans with the body of the
penis.
C) Penile
 The external meatus is situated at any part of the under surface of
the body of penis . Chordae is a prominent feature & in extreme
cases penis may become curved ventrally.
d) Penoscrotal
 The ectopic urethral opening is situated at the junction of penis &
scrotum.
e) Perineal Variety
 The scrotum is split and urethra opens btw its two halves .It is
often associated with bilateral undescended testis.
Pathology

 In penile variety the urethra & corpus spongiosum distal to

ectopic opening are absent . These are represented by a fibrous
cord.
 Due to contracture of this cord , penis gets curved ventrally,
which is known as chordee.
 Hypospadias is almost always associated with small penis, as
development of phallus and genital folds are affected.
 In some case the prepuce takes the form of a hood and is called
hooded penis.
Complications

 Obstruction to urinary outflow

 Stream of the urine may be deflected downwards thus spoiling
the underwear.
 Due to presence of the chordee , in penile variety , erection is
difficult and painful.
 Intercourse may be difficult due to chordee.
 Infertility is associated with penoscrotal and perineal variety.
Treatment

 In glandular hypospadias no treatment is required except

meatotomy & dilatation of the external urethral meatus.
 Denis – Browne’s operation is simple and most accepted.
 Stage 1 – straightening of penis(11/2 to 2 years)
 Stage 2 – Reconstruction of urethra.(5 – 7 years)
Straightening Of Penis
 A transverse incision is made on the ventral aspect of penis distal
to external meatus.
 Incision is extended laterally upto the prepuce on each side.
 The skin flaps are undermined , fibrous cord is exposed.
 The cord is dissected free and removed.
 After this the external meatus will receed towards perineum.
 The skin wound is repaired longitudinally.
 If there is any tension in the suture line , release incision is made at
midline on the dorsum of penis.
RECONSTRUCTION OF URETHRA
 The urinary bladder is drained by perineal urethrostomy.
 A malecot catheter is introduced into bladder through a small incision
at the bulbous part of urethra.
 A u shaped incision is made ,starting from the glans, the two limb sof
the incision join just proximal to meatus.
 The lateral flaps are undermined , not only each side but also
backwards.
 When this undermining has reached scrotum, a small drainage wound
is made to avoid haematoma formation.
 The lateral flaps are now sutured together in the midline
over the isolated strip of skin left btw limb of u shaped
incision.
 To relieve tension in a release incision may be required at
midline along the dorsum of penis.
Postoperative
 At the dorsum of penis where release incision is made ,
wound should be dressed with soframycin /penicillin.
 Antibiotics should be given , sutures are removed after 1
week
 Urethrostomy tube is removed after fortnight and fistula
closes by itself with in a week.
Epispadias

 In this congenital anomaly the external opening is situated

on the dorsum of the penis.
Types
 Glandular
 Penile
 Total
- Like hypospadias , in penile variety of epispadias the penis
is curved upwards.
- In penile variety operation is performed at age of 3 years
almost in fashion of Denis- Browne.
- Margins of the groove distal to the external opening are
made raw and undermined & sutured in the midline over a
catheter , this is known as Duplay’s operation.
 Ectopia vesicae ( Exstrophy of bladder)

 This is a congenital abnormality that occurs due to

incomplete development of the infra umbilical part of
anterior abdominal wall associated with incomplete
development of anterior wall of the bladder.
Clinical Features
 Male are affected more (4:1)
 Red mucous membrane of posterior bladder wall protrudes
out with visible efflux of urine from ureteric orifice.
 Umbilicus is absent.
 In males , epispadias is present with rudimentary prostate
and seminal vesicles.
 Testis is normal.
 Bilateral inguinal hernia is common.
Problems
 Repeated soakage
 Pain
 Ulceration
 Renal failure
 Recurrent pylonephritis
Treatment

 Operation is ultimate choice.

 Performed btw 4-6yrs of age.
 Initial diversion of urine to sigmoid colon / rectum is done.
 Iliac osteotomy and closure of abdominal wall is done.
 Correction of epispadias.
Complications
 Condition has got high mortality due to infection and renal
failure.
Balanoposthitis

 Inflammation of the glans is called balanitis.

 Inflammation of prepuce is called posthitis.
 As the preputial sac is in contact with the glans, opposing
surfaces are involved almost hence balanoposthitis is used.
Predisposing factors
 Candida albicans
 Monilial infection
 Herpes genitalis
 Drug hypersensitivity
 Diabetes
 Poor hygiene
Symptoms
 Itching , pain , discharge.
Treatment
 Broad spectrum antibiotics.
 Local hygiene
 Diabetes control
 In case of severe inflammation dorsal slit is made for
quick healing , after complete healing circumcision.
 Balanitis Xerotica obliterance

 Aetiology is unknown.
 Men btw age 20 to 40 years are mostly affected.
 Main complaint is urinary symptoms with meatal
stenosis/ phimosis.
 Lesion appears as white plates on the surface of
glans. prepuce becomes thickened , fibrous and
difficult to retract.
 Phimosis

 When the orifice of the prepuce is too small to permit

its normal retraction over the glans penis.
Aetiology
1.Congenital – In these cases prepucial orifice is
narrow since birth. In extreme cases the prepucial
sac balloons out at micturation & weak thin stream
of urine flows.
2. Acquired
a) Inflammatory- Scarring following long standing
inflammation of the glans, prepuce or both.
b) Traumatic – vigorous trauma to the prepuce may
cause prepucial fibrosis resulting in narrowing of the
opening of prepuce.
It may also result from forceful streching.
c) Neoplastic – underlying carcinoma may lead to
narrowing of prepucial orifice.
* Old subject who is recently complaining of phimosis.
Clinical features

 History – congenital phimosis present in first few

years of life & Acquired phimosis later in life acc to
cause.
 Difficulty in micturation is main symptom, mother
often complains that when child micturates the
prepuce balloons out and the urine comes out in thin
stream.
 In an old age case of phimosis patient may present
with recurrent balanitis.
 Occasionally patient may present with paraphimosis.
Local examination

 Diagnosis is easy, when the opening of the prepuce

is so small that it cannot be retracted over the glans
penis.
 In case of adult , infection of prepuce , glans penis
should be examined.
 Presence of carcinoma beneath prepuce should be
ruled out.
Complications

 Balanoposthitis
 Prepucial stone or calculus
 Paraphimosis
 Residual ureter , hydroureter , hydronephrosis.
 Carcinoma
Treatment

Circumcision
 Incisions given – Dorsal slit , Circumferential incision in both
layers of prepuce about half cm distal to corona.
 Operation is usually done in G.A in case of children , in adults
L.A can be used.
 First of all sub prepucial adhesions are severed by blunt
dissection with probe.
 Two pair of artery forceps are applied to prepuce and a dorsal slit
is made with scissors 1 cm of the corona.
 Then prepuce with the mucous membrane layer is divided
parallel to corona glandis 1cm distal to it till frenum is reached .
 Artery forceps is applied to secure the artery of frenum &
division are done
 All the bleeding vessels are ligated , particular care is taken
for artery of frenum.
 Catgut can be used to suture artery of frenum.
 Skin of prepuce is sutured to mucous membrane by fine
interrupted catgut sutures.
 Wound is dressed with soframycin ointment.
 PARAPHIMOSIS
 When a phimotic prepuce is forcibaly retracted over
the glans penis and it is stuck behind the glans penis
a condition is created called as paraphimosis.
 The constricting band of phimotic prepuce behind
the corona glandis causes obstruction to venous
outflow leading to oedema and congestion of glans.
 The glans swells leading to more difficulty in
retracting back the prepuce.
 The prepucial constricting band also gets
oedematous and swollen.
 Main symptom is severe pain & swelling of glans penis.
Treatment
 1ml isotonic saline & 150units of hyaluronidase is
injected into each lateral aspect of the swollen ring.
 Swelling is gradually reduced due to reabsorption of
oedema and after 15 min reduction can be done.
 Multiple puncture may be made on the oedematous
prepuce in the idea to drain the fluid out.
 If above method fails , then in G.A constriction band is
dorsally slit ,thereafter the narrow cuff of the skin which
forms constricting band is excised.
Lymphogranuloma Venereum

 Acute as well as chronic disease caused by a Virus

Chlamydial trachomatis.
 Mainly transmitted by sexual intercourse, involves the skin
& regional lymph nodes.
 In females perirectal lymph nodes are involved.
Clinical features
 Primary lesion at site of introduction of agent is
insignificant ,Lesion is fleeting , painless .
 After 2weeks progressive swelling and enlargement of
Inguinal lymph nodes.
 Overlying skin becomes red and fluctuation develops.
 The swelling of the nodes create large and painful bubos
 In beginning the nodes are discrete as inflammation
proceeds nodes become matted.
 Gradually necrosis develop and fluctuant sac are formed
.the bubos may rupture through the skin to produce
draining sinus.
 In male the adenopathy is almost localised to inguinal
region & is bilateral
 In females adenopathy may or may nit affect the lymph
nodes depending upon site of lesion.
 In later stage , lymphatic obstruction may lead to oedema &
elephantiasis of the external genitalia.
Investigations
 Frie skin test
 Isolation of causative agent is more definite test,
Indrect immuno-fluorescence test for specific
antibodies to lyphogranuloma venerum antigen.
Treatment
 Oxytetracycline/erthromycin 500mg 4 times daily
 Sulphonamides 1gm 4 times a day is curative.
Granuloma Inguinale

 It is a chronic granulomatous condition of genital region ,

caused by Calymmatobacterium granulomatis or better
known as Donovania Granulomatis.
 It is a gram –ve bacteria.
 Incubation period is 7 days to 1month
Clinical features
 Initial lesion is inflammatory papule at site of inoculation,
perineum , vagina , cervix or penis.
 Extragenital lesion are seen in lips , oral cavity , oesophagus
& larynx.
 The original papule enlarges , ulcerates & become chronic
spreading lesion having a necrotic centre and raised
inflammatory border.
 The border is red , rounded due to accumulation of
granulation tissue.
 Ulcer bleeds if touched & is painless.
 Extensive inflammatory scarring may cause lymphatic
obstruction and Elephantiasis.
Investigation
 Confirmatory test is finding Donovan bodies in silver stains of
smears of exudates or biopsy .
Treatment
 Oxytetracycline is given 500mg 4times a day for 20days.
 Streptomycin 4gm in divided dose for 5days
Peyronie’s Disease

 In this fibrosis occurs in one corpus cavernosum leading to

formation of an indurated plaque.
 Aetiology is unknown , Trauma is incriminated as initiator .
Clinical features
 Patient usually above 40 yrs of age
 Pain and curving of penis on errection
Condyloma Acuminatum

 Occurs due to HPV and sexually transmitted.

 Such lesion mainly grow in moist mucocutaneous surface
including vagina, anal , urethral mucosa.
 In penis lesions are mostly seen in coronal sulcus & inner
surface of prepuce.
 These are usually sessile or pedunculated , red papillary
excrescences that vary from minute lesion of 1 to several
millimetres in diameters.
Treatment-
 Podophllin 25% & trichloroacetic acid is applied .
 Cryosurgery is successful in this.
Thank you
 The superficial perineal pouch (also superficial perineal
compartment/space/sac) is a compartment of the perineum.
 Structure[edit]
 The superficial perineal pouch is an open compartment, due to
the fact that anteriorly, the space communicates freely with the
potential space lying between the superficial fascia of the
anterior abdominal wall and the anterior abdominal muscles:
 its inferior border is the fascia of Colles, the deeper membranous
layer of the superficial perineal fascia that covers the inferior
border of the muscles of the superficial perineal pouch.
(The fascia of perineum is a deep fascia that covers the
superficial perineal muscles individually).
 its superior border is the perineal membrane (inferior fascia of
the urogenital diaphragm).
 Contents[1][edit]
 Muscles
 Ischiocavernosus muscle
 Bulbospongiosus muscle
 Superficial transverse perineal muscle
 Erectile bodies
 Corpus cavernosum (of penis and of clitoris)
 Corpus spongiosus (of penis)
 Vessels
 Posterior scrotal arteries (males)/Labial arteries (females)
 Artery to bulb (males)/vestibule (females)
 Urethral artery
 Nerves
 Posterior scrotal nerves (males)/Posterior Labial nerves(females)
 Other
 Crura of penis (males) / Crura of clitoris (females)
 Bulb of penis (males) / Bulb of vestibule (females)
 Bartholin's glands (female)