Penile and Foreskin Problems

Basics

DESCRIPTION

  • Penile problems:
    • Buried penis
      • Hidden or concealed penis, poor skin fixation at the penoscrotal/penopubic junction resulting in buried or hidden appearance
      • May be normal in obese children with large suprapubic fat pad
    • Penile curvature (chordee)
      • Bending of the penis with erection, can be lateral, ventral (most common), or dorsal curve
      • Chordee is usually associated with abnormal foreskin.
      • Often associated with an abnormal or wandering median raphe
    • Webbed penis
      • Penoscrotal webbing or poor separation of penile skin from scrotum, obscuring penoscrotal angle
    • Balanitis
      • Inflammation of the glans
      • Probably overdiagnosed owing to drainage of smegma or urea dermatitis from failure to retract foreskin during voiding in toilet-trained boys
      • When infections present, there can be significant cellulitis of the penis, edema, and fever.
      • Most commonly caused by gram-positive organisms. Yeast is another causative organism.
  • Foreskin problems:
    • Balanoposthitis
      • Inflammation of glans and prepuce (foreskin)
      • Seen in 4% of uncircumcised boys age 2 to 5 years
      • See balanitis.
    • Phimosis/penile adhesions
      • Physiologic attachment of prepuce to glans, which it protects and gradually separates to allow retraction of the foreskin
      • Ring of fibrotic scar tissue that prevents the foreskin from being retracted
    • Paraphimosis
      • When narrow prepuce is retracted behind the glans, constricting penile shaft causing glanular and foreskin edema and preventing replacement of prepuce over glans
  • Postcircumcision problems:
    • Penile adhesions
      • Attachments of the foreskin back to the glans after circumcision
      • Penile skin bridges are dense scar adhesions that cannot be separated.
    • Meatal stenosis
      • Urethral meatus narrowing
      • Significant meatal narrowing will produce an upwardly deflected urine stream, which is narrow and strong; in severe cases causes straining and prolonged voiding
    • Epidermal inclusion cysts
      • Small, enlarging white lesions growing subcutaneously along the scar from circumcision

ETIOLOGY

  • Buried/webbed penis
    • Scrotal attachments attending along ventral penile surface to varying degrees
    • Penis tethered by abnormal attachments of dartos tissue
  • Penile curvature (chordee)
    • Asymmetry in tunica albuginea of corporal bodies and compliance of corpora cavernosa
  • Balanoposthitis/balanitis
    • Unclear etiology: possible infection, mechanical trauma, contact irritation, and contact allergies
  • Phimosis
    • Physiologic phimosis: inability to retract foreskin due to natural adhesions between prepuce and glans: Epithelial debris (smegma) over time separates foreskin from glans, normal.
    • Pathologic phimosis: probably results from recurrent bouts of foreskin irritation from improper hygiene habits such as voiding through the foreskin or repetitive forceful retraction
  • Penile adhesions
    • Physiologic adhesions: The prepuce has adhered down to the glans after circumcision.
    • Surgical adhesions (skin bridges): adherence between the scar of the circumcision and the glans due to healing of the crushed tissue where the foreskin was removed and the glans
  • Meatal stenosis
    • Narrowing of the urethral meatus secondary to recurrent irritation of the meatus, likely from rubbing against moist diapers; occurs almost exclusively in circumcised boys
  • Epidermal inclusion cysts
    • Caused by small islands of epithelium buried beneath the skin surface that progressively accumulate desquamated skin cells

RISK-FACTORS

GENETICS

Epidermal inclusion cysts may occur from congenital rests of skin cells buried during development, but these are rare and occur along the median raphe of the penis or scrotum.

GENERAL-PREVENTION

Some penile and foreskin problems may be prevented with proper hygiene and caretaker education.

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