49. Congenital malformations, inflammations and tumors of the penis

From greek.doctor

Congenital malformations of the penis

Three congenital malformations of the penis are important, whereas two of them are similar:

  • Diphallus – the presence of an accessory penis. Extremely rare
  • Epispadias – distal urethral orifice is present on the dorsal/superior aspect of the penis
  • Hypospadias – distal urethral orifice is present on the ventral/inferior aspect of the penis

Of the latter two, hypospadias is more common. It occurs when the urethral folds fail to close.

Epispadias occurs when the genital tubercle grows abnormally. It’s associated with bladder exstrophy.

Inflammation of the penis

Balanitis means inflammation of the glans, while balanoposthitis means inflammation of the glans and prepuce. Balanitis is often due to candida albicans or anaerobic bacteria.

Phimosis refers to a tight foreskin that can’t be retracted completely. Paraphimosis refers to a foreskin that has been retracted and cannot be returned to the original position.

Phimosis is physiological in young children, but it’s presence in anyone older than that is pathological. It may be congenital but is most frequently acquired. The acquired form is due to fibrosis of the prepuce as a complication of balanitis or balanoposthitis.

Paraphimosis occurs when the foreskin is retracted improperly, often during medical procedures. As the foreskin is retracted improperly the blood supply of the glans is reduced, which may cause it to swell, further worsening the paraphimosis. It may become a medical emergency that needs surgery to prevent gangrene.

Plasma cell balanitis is an uncommon condition that causes red patches on the penis. The cause is unknown. The condition may resemble precancerous lesions.

Lichen sclerosus is a chronic inflammatory condition of the skin with characteristic white plaques. It often affects the genital regions. Penile lichen sclerosus may cause scarring of the glans and prepuce. It’s a precancerous lesion and therefore increases the risk of cancer.

Peyronie disease or penile fibromatosis was described during the soft tissue tumor chapters. It’s a type of fibromatosis, a type of fibrous growth. It forms fibrous plaques in the penis, which causes abnormal bending of the penis and painful erections.

Priapism refers to any prolonged erection that occurs without or after stimulation has ceased. It may occur due to sickle cell disease, trauma, embolization, drugs or neurological defects. It may cause ischaemia of the penis, which causes necrosis after 48 hours and should be treated as a medical emergency.

Tumour-like conditions

Condyloma acuminatum, commonly known as a genital wart, can occur on the penis. It occurs after infection by HPV 6 or 11 and is characterised by koilocytic change. It’s most frequently seen in sexually active young adults. The lesions themselves may be flat, papillary or warty. They regress spontaneously in 50% of patients.

Tancho nodules or paraffin granulomas or paraffinomas are nodules that occur as part of a granulomatous inflammation after injection of certain materials like paraffin, Vaseline or silicone into the penis. It may be performed as a form of penile enlargement. It may cause necrosis due to decreased circulation.

Fournier gangrene is a type of necrotizing fasciitis that occurs in the external genitalia or perineum, most commonly in the scrotum. It occurs due to staphylococcal or streptococcal infection. Predisposing factors include DM (which decreases wound healing), alcoholism and immunosuppression. It’s a life-threatening condition as it may lead to sepsis.

Tumours of the penis

There are four precancerous lesions (carcinoma in situ) in the penis:

  • Penile lichen sclerosus
  • Bowen disease – appears as scaly lesions on the shaft of the penis
  • Erythroplasia of Queyrat – appears as reddish plaques of the glans of the penis
  • Bowenoid papulosis – appears as reddish papules on the shaft

Bowenoid papulosis rarely progresses into invasive carcinoma.

Squamous cell carcinoma accounts for 95% of cases of penile cancer. It most frequently occurs in older uncircumcised men with poor hygiene.

The risk factors are:

  • Poor hygiene, especially under the prepuce in uncircumcised men
  • HPV 16 or 18 infection
  • Smoking

Poor hygiene of the glans allows retention of smegma. This causes balanitis. Chronic balanitis predisposes to squamous cell carcinoma.

Morphology: Penile carcinoma begins as a grey, crusted and popular lesion, most commonly on the glans or prepuce. Eventually the tumor becomes ulcerated.

Penile cancer spreads to the inguinal lymph nodes by lymphatic dissemination and often to the lung by haematogenous dissemination.

Tumours of the scrotum

Cancer of the scrotum is also most commonly squamous cell carcinoma. It has historical significance, as it was the first cancer to be associated with an environmental factor. Percivall Pott, a surgeon in the 1700s, discovered that chimney sweepers developed scrotal cancer much more frequently, due to their exposure to soot.