PENIS PROBLEMS

The foreskin

At birth, the foreskin and the glans penis are joined. As boys start growing, an increase in hormones contributes to the foreskin and glans separating and the foreskin is then able to be pulled back. This happens in most boys at around three years of age.

The foreskin of an uncircumcised child should not be forcibly be pulled back as this can cause bleeding and injury. By forcefully retracting the foreskin, scarring can happen which can then cause problems with the foreskin retracting, which is called phimosis.

All uncircumcised adult men should have a genital examination by their doctor and have their foreskin retracted to check for signs of penis cancer.

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Penis lumps

There are different types of lumps and bumps that can appear on the penis, many of them are harmless. If you are concerned about any lumps on your penis, see your doctor to rule out sexually transmitted infections and penis cancer, albeit rare. Some common lumps include:

Cysts

Sometimes the sebaceous glands on the penis and scrotum can become enlarged and blocked, turning into cysts. These do not usually need any treatment. Sometimes they can become painful and infected if they continue to grow.

Ulcers

These appear as craters in the skin and often have a clear liquid or pus in the crater (red wound or a sore).

• A single ulcer is often quite serious and should be checked by a doctor immediately. Causes of a single ulcer include syphilis, tropical diseases and penile cancer.
• Multiple ulcers are more common and are less serious, but should still be checked by a doctor straight away. Herpes is the most common cause of multiple penile ulcers.

Papules

These are small lumps that are raised on the skin and most do not have a serious cause. One of the most common types of papules is called pearly penile papules and these appear as one or more rows of small, smooth lumps located in a circumference around the back of the glans penis (head of the penis). These look very similar to, and are often mistaken for genital warts. These papules are not infectious and do not need to be treated.

Causes of other papules include psoriasis, and sexually transmitted infections such as genital warts. Genital warts are caused by the human papilloma virus (HPV). Warts can often happen in clusters and can be very tiny. Genital warts are spread through skin-to-skin contact, so it is important to use condoms if you or your parter are infected. In women, HPV is associated with precancer changes in the cervix. Genital warts are treated by freezing them with liquid nitrogen. Although this gets rid of the warts, it does not get rid of the virus and warts may reappear on the skin or occur in the eye of the penis. This may need an inspection of the inside of the penis to fully treat the warts.

Plaques

Plaques are raised lumps that are bigger than one centimetre in diameter. They do not usually have a serious cause, but some are infectious and can develop into more serious conditions such as penile cancer. Some causes of plaques include balanitis (see below) and eczema.

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Balanitis

What is balanitis?

Balanitis is a very common inflammation of the glans penis (helmet of the penis) that can affect males at any age. This inflammation can affect circumcised males, however, it is more common in men who have not been circumcised.

What causes balanitis?

Balanitis often happens when the foreskin is not pulled back, or is unable to be pulled back due to scarring, and the inside of the foreskin is not kept clean. Inflammation caused by a bacteria or fungus is common and can be caused if the sensitive skin under the foreskin collects sweat, dead skin and bacteria. Balanitis can also be caused by irritation from chemicals in soap, clothing, washing powder and the latex in condoms. Allergies to certain drugs, viruses such as human papilloma virus (which can cause genital warts) and obesity can also contribute to balanitis.

In adults, balanitis can be a sign of diabetes. After urinating, some urine may become trapped under the foreskin. The combination of a moist area and glucose in the urine can lead to bacteria growing and then infection. If you have balanitis and the condition keeps happening, speak to your doctor and ask to be tested for diabetes.

What are some of the signs of balanitis?

Men with balanitis may experience the following complaints:

• Inability to pull back the foreskin;
• Itchiness;
• Rash;
• Sore or tender glans penis;
• Redness or swelling;
• Discharge from the penis.

How is balanitis treated?

Treatment for balanitis depends on the cause of the inflammation. Most often, washing the penis and under the foreskin with soap and warm water is recommended. If the cause is from allergic reactions to washing powders etc., try using different brands and other chemicals. If there is an infection, the doctor may prescribe antibiotics or antifungal medication. In severe cases of balanitis, circumcision may be recommended.

To avoid future bouts of balanitis, do not use strong soaps and chemicals, and pull back the foreskin and clean it daily.

What is Balanitis Xerotica Obliterans, (BXO)?

Balanitis Xerotica Obliterans (BXO) is not to be confused with balanitis (inflammation of the glans penis). BXO is a rare condition where scar tissue forms in the foreskin. A ring of white tissue develops at the tip of the foreskin, tightening the foreskin at the tip, and this may prevent the foreskin from retracting (phimosis). BXO may spread to the glans penis, but this is not common.

It is important to speak to your doctor if you are concerned about white scarring of your foreskin, to distinguish BXO from early penis cancer. BXO is a progressive disease and it is usually treated by circumcision.

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Phimosis

What is phimosis?

Phimosis is when the foreskin is too tight, or the tip of the foreskin narrows and is unable to be pulled back to expose the head of the penis.

What causes phimosis?

Phimosis is often seen in children or young adults (primary or congenital phimosis). The condition is at its highest incidence rate before puberty.

Phimosis can also happen because of injury or damage that causes the foreskin to tear (secondary or acquired phimosis). As the tear heals, scar tissue forms which reduces the elasticity of the foreskin. This scar tissue can then stop the foreskin from stretching open far enough to pull back. The scarring from BXO can also cause phimosis.

Phimosis can often follow infection or inflammation such as balanitis. Adult men with phimosis should be checked for balanitis, diabetes and cancer.

Are there any other symptoms with phimosis?

Severe phimosis can cause pain when urinating, urinary retention, urinary tract infections and the skin on the penis can become infected.  In older men with severe phimosis, the foreskin can look swollen.

How is phimosis treated?

Phimosis can be treated with steroid creams applied once or twice daily for a couple of weeks. Studies have shown that the creams have a success rate of more than 85 per cent, and this can increase if the foreskin is gently stretched together with the cream application.

If the steroid creams do not work and phimosis is severe, circumcision is another option to consider.

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Paraphimosis

What is paraphimosis?

Paraphimosis happens when the foreskin has been retracted behind the head of the penis and cannot go back to its original position. If the foreskin stays in this position, it can cause pain, swelling and can stop blood flow to the penis. This is a serious medical problem and must be treated immediately or the penis can sustain long-term or permanent damage.

What causes paraphimosis?

Paraphimosis can happen at any age, and can be caused by injury to the head of the penis. It can also happen to infants if parents pull back their foreskin and do not pull it forward again afterwards.

How is paraphimosis treated?

The glans penis and the foreskin often swell up with paraphimosis. It is important to apply ice to reduce the swelling and then try and move the foreskin forward to the usual position. Other methods used to reduce swelling include injecting medicine that lessens swelling, or inserting a needle and releasing some blood. If the foreskin does not return to its normal position, a surgeon may have to cut the foreskin to release it, or circumcision may be necessary.

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Priapism

What is priapism?

Priapism is an erection that lasts for more than three hours and is usually very painful. Blood becomes trapped in the penis and does not return to circulation; it is not necessarily because of, or related to, sexual stimulation. If priapism is not treated, it can lead to permanent damage to the erectile tissue and the inability to get an erection at all. Priapism can happen to males at any age.

What causes it?

The most common cause of priapism is drug treatments for erectile dysfunction, in particular, penile injection treatments. About a quarter of other cases of priapism are associated with medical conditions such as advanced cancer, leukaemia and sickle cell anaemia. Other possible causes include damage to the nervous system, injury to the penis, the use of some medicines and illegal drugs. Sometimes the cause of priapism is unknown.

How is it treated?

It is important to see a doctor straight away because the sooner the prolonged erection is treated, the less damage will be done to the erectile tissue. If treatment is sought within four to six hours, the doctor may provide a decongestant medication to help the erection go down. Another option is for the doctor to use a needle and syringe to release the extra blood trapped in the penis. If this does not work, surgery may be needed to try and avoid permanent damage to the penis.

If priapism was caused by erectile dysfunction drugs, alternative treatments should be used instead. Also, if priapism has been caused by other medications, trying a different medication may help.

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