What Can Wrong with Your Willy?

WHAT CAN WRONG WITH YOUR WILLY?

ANDREW LIENERT UROLOGIST ONESIXONE UROLOGY 161 GILLIES AVE, AUCKLAND IT CAN BEND IT CAN BREAK IT CAN GROW IT CAN SHRINK YOU CAN DECORATE IT PENILE CONDITIONS Foreskin + glans Shaft + corpora - phimosis - SCC - paraphimosis - balanitis - fordyce spots - frenular tear - fracture - skin bridges - peyronie’s - SCC - priapism - BXO - pearly papules - trauma - veruca - smegma PENILE ANATOMY PHIMOSIS PHIMOSIS: CHILDREN

PHYSIOLOGICAL PATHOLOGICAL PHIMOSIS: CHILDREN TREATMENT

PHYSIOLOGICAL PATHOLOGICAL - 95% newborns have - Infection phimosis - 10% 4 yr olds - Pain - ‘Ballooning’ common - Tight white band - Steroid cream - Less likely to - 0.05% betamethasone resolve with cream - 1% hydrocortisone - Apply BD 4-6 weeks - 60-90% success - ‘Stretching’ - circumcision PHIMOSIS: ADULT

- Usually due to balitiis xerotica obliterans (BXO) or chronic infection / inflammation from poor hygiene or incontinence - BXO Beware of a - Male equivalent of lichen sclerosis tumour beneath - Chronic inflammation leading to fibrosis - White bands or patches a phimosis in - Thickening of skin older men - phimosis - Unlikely to resolve with steroids - Can trial if only minor scarring - Circumcision usually necessary BXO BALANITIS / POSTHITIS BALANITIS: INFECTIVE BALANITIS: INFECTIVE

Organisms: - streptococcus most common - fungal - STI’s: Herpes, syphilis, gonorrhoea Treatment: - swab; especially if there is pus - antifungal or antibiotic; ?both - may be difficult to distinguish from non-infective causes so can consider steroid as well - should respond within 1-2 weeks BALANITIS: NONINFECTIVE

Zoon’s Balanitis Drug reaction Allergic reaction (tetracycline) BALANITIS: KEY POINTS

1. It is hard to determine cause and treatment may have to be ‘best guess’ 2. Consider biopsy if: a. No response to treatment b. Raised, ulcerated lesions TIGHT FRENULUM

May tear and bleed or cause pain during intercourse

Frenuloplasty is treatment of choice SKIN BRIDGES PEARLY PENILE PAPULES

These are not STDs

Found in 30% uncircumcised men

Can be treated although generally this is not necessary SMEGMA PARAPHIMOSIS PARAPHIMOSIS

WHAT WORKS WHAT DOESN’T Manual reduction Ice - requires quite a bit Salt of force! Aspirating - Painful ‘popping the cyst’ Leaving it alone! Dorsal slit PARAPHIMOSIS PARAPHIMOSIS: DORSAL SLIT GENITAL WARTS GENITAL WARTS - Caused by Human Papiloma virus - Virtually all sexually active adults have been exposed - Lifetime risk >80% - Most infections transient and asymptomatic - Most visible warts will resolve spontaneously - HPV 16 + 18 linked to penile cancer but rarely cause visible warts - But history of warts increases risk of penile cancer - Treatment: - Imiquimod (aldara) or podophylotoxin (condyline) - Cryotherapy / trichloroacetic acid - Laser therapy / Surgical excision - Assess / treat partner WARTS: WHICH TREATMENT?

Observe Topical cream Cryo / TCA WARTS: WHICH TREATMENT? Surgical excision + / - Cream

Likely to need multiple treatments PIERCINGS Prince Albert

Ampalling

Apadravya SCC PENIS SCC PENIS

- LETHAL DISEASE - 50% 5 yr survival across all stages - If your worried refer for a biopsy - Risk factors: - Uncircumcised - Older age; rare below age 50 - Smoker - HPV and genital warts: RR 3.7 - HIV - Phimosis / poor hygeine / smegma build up SCC IN-SITU - Erythroplasia of queyrat - Bowenoid papulosis - Diagnose via biopsy - Treatment: - Effudix cream - Imiquimod cream Biopsy if: - Cryotherapy - MOHS microsurgery - No response to treatment - Raised / ulcerated - Significant risk factors SCC TREATMENT

Should be completely excised to ensure accurate staging SCC: KEYPOINT

If your suspicious that a lesion may be an SCC either biopsy or refer for a biopsy because SCC is a lethal disease which is usually curable if found early enough. FORDYCE SPOTS PENILE FRACTURE UROLOGICAL EMERGENCY Repair within 24 hours improves outcomes

Classic history: Sudden pain during intercourse

Immediate detumescence

Early, rapid swelling and bruising of penile shaft PRIAPISM

Sustained erection for >6hrs Urological emergency: leads to ischemia of corpora PRIAPISM

- Risk factors: - Intra-cavernosal injections: alprostadil, papaverine - PDE-5 inhibitors: rarely cause this - Medication: antidepressants, antipsychotics - Recreational drugs: heroin / cocaine, ?alcohol - Sickle cell anemia - Hematological: Leukemia / thallasemia

Prompt specialist management essential: permanent erectile dysfunction results if left for >24 hours PRIAPISM: INITIAL MANAGEMENT

- Place 16g or 18g butterfly needle into corpora cavernosa near base of penis, approaching from lateral - Aspirate 10-20ml of blood - Leave butterfly needle in - If erection still present a few minutes later then aspirate again but this time inject alpha-agonist - Phenylephrine 1000mcg:1ml dilute to 10ml and inject 0.5- 1.0ml; i.e 50-100mcg dose - Need to monitor BP / pulse / ECG if possible - Repeat every 10-15mins for 1 hour - If unsuccessful then surgery required PEYRONIE’S DISEASE PEYRONIE’S PEYRONIE’S

• Fibrosis of the corpora cavernosum leading to deformity of the erect penis • Penile trauma, especially during intercourse thought to be cause • Some weak data showing genetic association • Prevalence estimated at 1-3% • 30% of men with Peyronie’s also have erectile dysfunction • Associatted with other connective tissue disorders • Dupuytren’s PEYRONIE’S: NATURAL HISTORY

ACTIVE PHASE CHRONIC PHASE • Lasts 6-12 months • No longer painful • Painful, tender • Bend stable plaque • Plaque may still be • Active inflammation palpable • Deformity may change with time • 20% improve • 40% worsen • 40% stay same PEYRONIE’S: TREATMENT IN ACTIVE PHASE PEYRONIE’S: TREATMENT IN ACTIVE PHASE

ORAL INTRA-LESIONAL Vitamin E Verapamil Colchicine Interferons Collagenase Potassium aminobenzoate L-Arginine Pentoxifylline Steroids ESWL Tamoxifen Penile traction device PEYRONIE’S: TREATMENT IN ACTIVE PHASE

GOOD ERECTIONS POOR ERECTIONS • Plication • Penile prosthesis • Excision and grafting PENILE TRAUMA PENILE TRAUMA ZIPPER INJURY

Zipper injury is the commonest cause of penile trauma AMPUTATION hjghghg bvgvb