BALANOPOSTHITIS Balanitis is inflammation of the glans penis. Posthitis is inflammation of the foreskin. Balanoposthitis is inflammation of both the glans and foreskin. When foreskin retraction is attempted, the glans and apposing prepuce appear purulent, excoriated, malodorous, and tender. When recurrent, it can be the sole presenting sign of diabetes. Treatment consists of cleansing the area with mild soap, assuring adequate dryness, application of antifugal creams (nystatin or clotrimazole), and possibly circumcision. If secondary bacterial infection is present, a broad-spectrum antibiotic, usually a cephalosporin, should be prescribed.
PHIMOSIS Phimosis is the inability to retract the foreskin proximally and posterior to the glans penis ( Fig..91-5). Causes include infection, poor hygiene, or previous preputial injury with scarring. Scarring at the tip of the foreskin can occlude the preputial meatus, infrequently causing urinary retention. Hemostatic dilation of the preputial ostium relieves the urinary retention until definitive dorsal slit or circumcision can be done.
PARAPHIMOSIS Paraphimosis is the inability to reduce the proximal edematous foreskin distally over the glans penis into its naturally occurring position ( Fig..91i5). The resulting glans edema and venous engorgement can progress to arterial compromise and gangrene.
Paraphimosis is a true urologic emergency. Paraphimosis can often be reduced by compression of the glans for several minutes to reduce edema and allow for successful reduction of the foreskin back over the now smaller glans. Tightly wrapping the glans with a *2-inch elastic bandage for 5 min is one method to reduce edema. Infrequently, several puncture wounds with a small needle (22 to 25 g) can help edema fluid be expressed out the glans. A local anesthetic block of the penis is also helpful if the patient cannot tolerate the pain of compression. If these methods are unsuccessful, local infiltration of the constricting band with 1% plain lidocaine followed by superficial vertical incision of the band will decompress the glans and allow foreskin reduction. This procedure should be done by an emergency physician unless a urologist is immediately available.
ENTRAPMENT INJURIES Various objects can be placed around the penis, initially occluding the venous, and subsequently the arterial, blood supply. String, metal rings, and wire have been wrapped around the penis for sexual, experimental, or accidental reasons. One of the most insidious objects that can become entrapped behind the coronal ridge is human hair, usually found in young circumcised boys aged two to five years ( Fig 91-6). The child presents with swelling of the glans. The offending hair may be invisible within the edematous coronal sulcus. If the hair has been chronically occluding, the urethra and dorsal nerve supply of the penis may be partially or completely involved. Removal of the offending object requires ingenuity and care. Urethral integrity (retrograde urethrogram) and distal penile arterial blood supply (Doppler) must be assured prior to emergency department discharge.
FRACTURE OF THE PENIS An acute tear or rupture of the corpus cavernosa tunica albuginea is rare but easily diagnosed. The penis is acutely swollen, discolored, and tender. The history is of trauma during intercourse or other sexual activity, when a sudden "snapping sound" occurs. Even though the urethra is infrequently injured, a retrograde urethrogram may be necessary to assure urethral integrity. Surgical treatment consists of hematoma evacuation and suture apposition of the disrupted tunica albuginea.
PEYRONIE'S DISEASE The patient complains of gradual onset of dorsal penile curvature with erections; it is painful and may preclude successful vaginal penetration during intercourse. Examination of the dorsal penile shaft will disclose a thickened plaque involving the tunica albuginea of the corpora bodies without urethral involvement. Reassurance and urologic referral are warranted. Peyronie's disease of the penis has been noted in association with Dupuytren's contractures of the hand.
PRIAPISM Priapism is a urologic emergency that presents as a painful, hard, pathologic erection in which both corpora cavernosa are engorged with stagnant blood. Even though the glans penis and the corpus spongiosum are characteristically soft and uninvolved, urinary retention may develop. Impotence has been reported to occur in 35 percent of cases who have sustained erections for prolonged periods of time; thus, expedient treatment and early urologic consultation is required. The potential for medical-legal liability mandates meticulous documentation in these cases.
A large number of cases of priapism in adults are pharmacologically related, either to intracavernosal injection for impotence or oral agents for hypertension or mental disorders. Most cases of priapism in children are due to hematologic disorders, usually sickle cell disease. Case reports have attempted to relate a variety of other drugs, metabolic conditions, and trauma to priapism, although the pathophysiologic mechanisms are speculative in most cases.
Priapism is classified into high-flow (nonischemic) priapism and low-flow (ischemic) priapism. The former is rare, most often nonpainful, and usually results from traumatic fistulae between the cavernosal artery and the corpus cavernosum. The latter is more common, is usually quite painful, and is diagnosed by the aspiration of dark acidic intracavernosal blood from the corpus cavernosum.
Low-flow priapism is further categorized as reversible or nonreversible depending upon etiology and the response to medical treatment ( Table.91-1). Regardless of specific etiology, initial therapy with terbutaline, 0.25 to 0.5 mg subcutaneously in the deltoid area, repeated in 20 min as needed, is the most effective therapy. Traditional therapies of sedation or ice water enemas are ineffective. Pseudoephedrine 60 to 120 mg orally has been reported effective in some cases that present early (less than 4h). Priapism due to sickle cell disease is most consistently reversed by simple or exchange transfusion. Corporal aspiration followed by irrigation (either with plain saline or with a-adrenergic agonists, i.e., phenylephine (neosynephrine)) is the primary treatment method for persistent priapism. The urologic consultant usually performs this procedure, but if one is not readily available, the emergency physician may need to intervene. Reversible priapism may respond to these treatments, while nonreversible priapism usually does not respond and requires surgery.
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