Conditions of the penis
The majority of conditions of the penis are benign conditions that are not serious but can be a source of discomfort in some men. Common conditions include a tight foreskin (phimosis), tight frenulum and a bend of the erect penis (Peyronie’s Disease).
Phimosis is when the foreskin of the penis is tight and is not able to fully retract behind the helmet of the penis (glans). This is extremely common in young boys, and in the majority of cases the foreskin can be retracted by the time of adolescence or early adulthood. In some men, the foreskin remains tight since childhood and this can be a source of discomfort during erections or sexual activity. This is called a “physiological” phimosis, as there is no underlying issue with the foreskin itself other than it is tight.
In other situations, the foreskin becomes tight as a result of the skin becoming gradually thicker and scarred. This is often due to a process called BXO (Balanitis Xerotica Obliterans), where there is inflammation of the skin of the foreskin and eventually the foreskin becomes scarred, white and tight. This scarring makes the skin of the foreskin relatively inelastic and as a result it can split, which leads to scarring and thus making the foreskin even tighter.
Phimosis is generally sorted by a circumcision, which removes the foreskin completely, leaving the glans exposed. The skin edges are stitched together using dissolvable sutures and the procedure usually only takes about 30-45 minutes and can be done under local or a general anaesthetic. Usually it is a day case procedure, meaning that the patient can go home the same day.
Sometimes a tight foreskin is due to a short, tight frenulum. The frenulum is the piece of skin that attaches the foreskin to the underside of the glans and if it is short or tight then the foreskin may have difficulty pulling back and sometimes the frenulum may become sore or tear during sexual activity.
A tight frenulum can be treated with a small procedure called a frenuloplasty, which releases the tight frenulum, allowing the foreskin to be pulled back more easily.
This is a condition where the penis develops a bend during erection. It is common for an erect penis to have a slight curve but sometimes this can become more pronounced or bend excessively either up or down, or to the left or right. In some instances the degree of bend can make it uncomfortable or difficult to have sex. We don’t fully understand what causes Peyronie’s disease but it is characterized by the formation of a lump (“plaque”) that causes the erect penis to bend more dramatically than before.
Peyronie’s disease tends to occur in men over 40, although it can occur at any age and usually is characterized by two distinct phases:
- An active phase, where symptoms develop and the curvature progresses. Often in this phase there is discomfort during erection and a lump develops that can be felt on the shaft of the penis. This phase of the condition can last 12-18 months.
- A quiescent (chronic) phase, whereby the symptoms of pain and discomfort settle. At this phase, the bend will usually get less pronounced or remain the same as before. Occasionally the bend may progress a few degrees further.
Peyronie’s disease often requires no treatment at all, especially if it is not painful for either partner to have sex. Some medicines have been used to treat Peyronie’s disease but there is not enough evidence to support their use. Shockwave therapy has also been described as a treatment, with the intention to break the plaque but again there is not enough evidence to prove its’ effectiveness.
Should the bend continue to be problematic and painful after 12 months or so, then surgery can be considered to correct the bend and this may involve:
- removing the plaque and attaching a patch of skin or vein
- removing a piece of tissue opposite the plaque to counteract the bend
- inserting a device to straighten the penis
Erectile dysfunction (impotence) is when a man is unable to obtain or maintain an erection adequate enough to achieve penetration and for the satisfaction of both partners. It is more common as men get older, with approximately 50% of men over 40 experiencing some erectile dysfunction at some point and is associated with high blood pressure, diabetes, high cholesterol, obesity as well as lifestyle factors such as alcohol, smoking and work or relationship stress. Other conditions such as heart disease and neurological conditions are contributory.
Your GP may have already done some investigations to investigate an underlying cause but one may not always be apparent.
Erectile dysfunction management is often multi-factorial, addressing different potential causes; for example you may be advised to lose weight, stop smoking or reduce alcohol intake in addition to having treatments to improve diabetes control, cholesterol levels and existing cardiac disease. The most common treatments used to improve erectile dysfunction are tablets such as Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra) or Avanafil (Spedra). Each one has slightly different characteristics so one drug may suit one man, but a different one may work better for somebody else. These drugs improve the flow of blood into the penis to aid erection but they do require sexual stimulation to work. They are generally very safe to use, but should be avoided if you take medication such as GTN or Isosorbide Mono-nitrate for angina.
If these drugs are not effective then there are numerous other treatment options available such as:
- Vacuum tumescence devices – these devices suck blood into the penis by creating a vacuum in the device and the blood is held in place by the application of a constricting ring at the base of the penis.
- Injections of chemicals called prostaglandins (e.g. “Caverject”) that induce an erection.
- The use of pellets (“MUSE”) that are placed in the water pipe (urethra) which then dissolve and are absorbed into the erectile tissue to create an erection (there is a similar treatment using cream that is available “Vitaros”).
- Insertion of an inflatable prosthesis into the erectile tissue – this is used in severe cases where all other treatment options have been tried but failed. Such procedures are usually performed in specialist centres that perform large numbers of such procedures each year.
Penile cancer is rare, with only about 600 cases being diagnosed per year in the UK and most often affects men over the age of 50.
Symptoms to be aware of include
- An ulcer, sore or growth that doesn’t go away within 4 weeks.
- Bleeding from underneath the foreskin or from the penis.
- Foul-smelling discharge.
- A change in colour or persisting rash on the penis.
- A lump in the groin.
If penile cancer is suspected then a biopsy will be taken from the abnormal area (if this is on the foreskin then a circumcision is generally performed), and if confirmed then treatment may be medically based or surgical, depending on the nature of the cells seen at the biopsy. Because of its’ rarity, penile cancer surgery is performed in centres by surgeons with specialist experience who have performed large numbers of penile cancer operations.