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The prostate 455
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are common. Systemic symptoms, such as myalgia
and arthralgia, may be present.
The aetiology of the syndrome is unclear; occult
infection, an autoimmune process and pelvic
abnormality have all been suggested. Treatment
options include an empirical course of antibiotics,
α- blockers if there are LUTS, and non- steroidal, anti-
inflammatory drugs. Investigation for neuropathic
pain or psychosocial assessment may be appropriate
in some patients.
muscle
Prostate cancer
Pathology
Prostate cancer is the most common cancer in men
in the UK, with 1 in 8men being affected in their
lifetime. Prostate cancer typically affects those over
50 years of age, and risk increases with age and it is
estimated to affect 80% of men aged 80; it is
morecommon to die with the disease than from it.
Those with a family history, and those of black race,
have the highest lifetime risk (1in 4).
Macroscopic appearance
The tumour is usually situated in the posterior part of
the prostate beneath its capsule and appears as an
infiltrating, hard, pale area.
Microscopic appearance
The tumour is almost always an adenocarcinoma.
The degree of differentiation is quoted in terms of the
Gleason grade,
Spread
• Local: there is invasion of the periprostatic tissues
and adjacent organs (i.e. the bladder, urethra,
seminal vesicles) and, rarely, invasion around and
ulceration into the rectum.
1
Donald Gleason (1920–2008), Pathologist, Minneapolis,
MN, USA. e Gleason grade is a histological score based
on the degree of dierentiation, such that grade 1 is well
dierentiated and grade 5 is poorly dierentiated. Two
scores are given, the rst reecting the dominant pattern
in the biopsy, the second reecting the next most common
pattern. Hence the range goes from 2 to 10. us a Gleason
4+3would be a worse prognosis tumour than a 3+2, for
example.
1
usually from 6 to 10.
•
Lymphatic: to the iliac and para- aortic nodes.
Blood- borne: especially to the pelvis, spine and
•
skull, usually as osteosclerotic lesions. Secondaries
may also be found in the liver and lung.
Clinical features
Prostate cancer may be detected without symptoms
on the basis of an elevated PSA and/or an abnormal
digital rectal examination, or present with symptoms
that are identical to those of benign enlargement. The
patient may also present with advanced disease with
symptoms from secondary deposits, particularly with
pain in the back from vertebral metastases or even
with spinal cord compression or cauda equina
syndrome.
Rectal examination of the prostate may reveal four
different stages (the Tumour component of TNM
staging; Figure45.1).
T1
The prostate feels benign, with no palpable
tumour.
T1a: Incidental finding in ≤5% resected tissue in
TURP.
T1b: Incidental finding in >5% resected tissue in
TURP.
T1c: Tumour identified on prostate biopsy
triggered by raised PSA.
T2
A hard nodule in one lobe of the prostate or
abolishing the normal sulcus between the two
lateral lobes. The tumour is confined to the
prostate.
T2a: Tumour involves half of one lobe or less.
T2b: Tumour involves more than half of one
lobe.
T2c: Tumour involves both lobes.
A hard mass in the prostate together with
T3
infiltration of the tissues on one or both sides of
the prostate (T3a) or into the seminal vesicles
(T3b).
T4 A hard mass in the prostate which is fixed to
the pelvic side wall and/or is invading the bladder,
external sphincter, rectum, levator muscles.
Special investigations
• PSA concentration in the blood is usually raised in
the presence of prostate cancer (Box45.1). A PSA
over 20 ng/mL suggests disseminated disease.
PSA is also useful as a tumour marker to follow the
response to treatment.
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Vas
deferens
Seminal
vesicle
T1: No tumour palpable clinically
T3: Tumour extends outside
capsule or into seminal vesicles
T2: Tumour palpable but
confined to prostate
T4: Tumour extends into
pelvic side wall or bladder
Box 45.1 Prostate- specific antigen (PSA)
PSA is an enzyme produced by epithelial cells of the
prostate gland, by normal as well as malignant cells.
It is may be raised in the following circumstances:
•
Increasing age.
•
Benign prostatic hyperplasia.
•
Ejaculation.
•
Prostate biopsy.
•
Prostate stimulation, e.g. rectal examination.
•
Prostatitis.
•
Urethral catheterization.
•
Urinary retention.
•
Urinary tract infection.
•
Vigorous exercise.
•
Cycling.
•
Prostate cancer.
• Multiparametric magnetic resonance imaging
(mpMRI) is used increasingly to identify the primary tumour and for staging.
• Transrectal ultrasound (TRUS) guided prostate
biopsy: TRUS is used to guide needle core
Figure45.1 The clinical staging of
prostatic carcinoma.
biopsies, which are performed systematically
through the gland obtaining 10–15 cores. These
should confirm the diagnosis and grade of tumour.
It is associated with perineal pain, blood in urine,
faeces, and semen, and carries a risk of severe
sepsis.
Bone scan is indicated if the PSA is greater than
•
20ng/mL, or a T3 or T4 tumour, or if there is bone
pain or other symptoms suggestive of bony metastases, the presence of which the bone scan will
demonstrate.
•
CT scan to stage the tumour, looking for nodal
(iliac and para- aortic) or solid organ metastases
(e.g. lung, liver, brain).
The role ofPSA indiagnosis
PSA has revolutionized prostate cancer diagnosis
since its discovery. PSA is not a cancer- specific marker
but an organ- specific marker, meaning it can be elevated without prostate cancer being present in conditions such as BPH, prostatitis, urinary retention and
urinary tract infection. Lastly, PSA can be variable
with transient rises in PSA which are not sustained on
repeat testing. In asymptomatic patients with a
The prostate 457
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normal digital rectal examination, an elevated agespecific PSA on two readings several weeks apart is
needed before commencing further investigations for
prostate cancer. An abnormal rectal examination in
conjunction with an elevated PSA is always an indication for further investigation.
Multiparametric magnetic
resonance imaging
Multiparametric MRI (mpMRI) now allows assessment of the prostate using different image acquisition
techniques from which the prostate imaging reporting and data system (PI_RADS) score can be used to
estimate relative risk of prostate cancer being present.
mpMRI allows the identification of suspicious areas
within the prostate for targeted biopsy, thus increasing the diagnostic yield of what is a relatively invasive
investigation. Hence, mpMRI should be performed
before biopsy.
Prostate biopsy
Prostate biopsies have traditionally been taken via the
transrectal route with ultrasound guidance under
local anaesthesia. More recently, there has been an
increased interest in performing biopsies via the
transperineal route. This reduces the risk of lifethreatening sepsis associated with the transrectal
route, which has remained at around 1% even with
antibiotic prophylaxis.
Treatment
Treatment is based on the likelihood of tumour
confinement to the gland, derived from its degree of
histological differentiation (the Gleason grade score),
the PSA concentration and the clinical tumour stage
(see earlier in this chapter). These have been formulated into a series of Prognostic Groups (CPG,
Table45.1). Equally the patient’s overall fitness, their
perception of risk and what are acceptable side effects
or treatment also play a role in reaching a shared decision, particularly in low-
risk localized disease.
Localized disease
The active treatments available for localized disease
(Cambridge Prognostic Groups 1 to 3) are as follows:
Active surveillance.
•
• Radical Prostatectomy.
Radical Radiotherapy.
•
Active surveillance
Active surveillance is designed to avoid harmful side
effects from radical treatment in patients with lowrisk disease (CPG 1), and to offer an alternative to
patients with intermediate disease (CPG 2 and 3) who
do not want radical treatment; it is not appropriate for
patients with hightable 45.1). The goal is to keep a patient’s prostate
cancer under surveillance but in the ‘window of curability’, and offer curative treatments should the
patients disease progress or change.
In the first year, PSA is checked every 3 to 4months,
with digital rectal examination and mpMRI scan at
12 – 18 months. Thereafter, PSA is checked every
6months, and a rectal examination performed every
12months, with further mpMRI and prostate biopsies
according to local preference, or if indicated by evidence of disease progression. The patient will then be
offered one of the radical treatment options.
risk disease (CPG 4 and 5, see
Table45.1 Risk stratification forlocalized or locally advanced prostate cancer
Cambridge
Prognostic Group Level of risk
1 low <10μg/L AND ≤6 AND T1
2 10–20μl/L OR 3+4 AND T1– T2
3 intermediate 10–20μl/L AND 3+4 AND T1– T2
4 >20μl/L OR 8 OR T3
5 high TWO of: PSA>20μg/L OR 9 to 10 OR T4
Prostate- specic
antigen
Gleason
score
4+3 AND T1– T2
Clinical
tumour stage
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Radical prostatectomy
Radical prostatectomy is typically performed using
robotic systems to reduce hospital length of stay. This
minimally invasive approach has radically changed
how patients are managed after surgery, with some
centres discharging patients within 24 hours of their
surgery. The procedure involves removing the prostate,
seminal vesicles and possibly the pelvic lymph nodes,
with anastomosis of the bladder neck to the urethra just
distal to the excised prostate. The long- term side effects
include erectile dysfunction in half the patients, and
urinary incontinence in approximately 13%.
Radical radiotherapy
Radical radiotherapy can be given by external beam or
transperineal placement of radio- iodine seeds
(brachytherapy) and can be combined with androgen
deprivation therapy (ADT) depending on tumour risk.
Long-
term incontinence rates are lower at 5% as are
erectile dysfunction rates at 36%, but the treatment
does carry a higher rate of faecal incontinence at 4%.
Radiotherapy also carries a small risk of triggering
another malignant process in the radiotherapy field.
Watchful waiting
Watchful waiting is part of a strategy for ‘managing’
prostate cancer and is aimed at people with localized
prostate cancer who do not ever wish to have curative
treatment, or they are not fit enough to undergo radical treatments. Watchful waiting involves the deferred
use of hormone therapy with the objective to maintain quality of life. It avoids the use of surgery or radiation, but implies that curative treatment will not be
attempted.
Metastatic prostate cancer
Prostate cancer is often discovered at a stage when it
has already spread beyond the prostatic capsule and
may well have involved other organs, particularly the
bladder base and bones. The mainstay of treatment of
advanced disease is androgen deprivation and chemotherapy, with an emphasis on prolonging life and
minimizing symptoms.
•
Docetaxel, which inhibits cell proliferation by
stabilizing microtubules within the tumour cells.
•
Gonadotrophin- releasing hormone agonists, trip-
torelin, goserelin and leuprorelin, are the mainstay of treatment. They inhibit the release of
luteinizing hormone from the anterior pituitary,
with consequent reduction of testicular production of testosterone. Initiation of therapy may
cause a flare of testosterone production, and
hence a flare of disease, so a short 3of anti-
androgen therapy (e.g. bicalutamide) is
given when treatment commences.
Gonadotrophin- releasing hormone (GnRH) antag-
•
onist, e.g. Degarelix for the first- line treatment of
androgenhas a direct mechanism of action that blocks the
action of GnRH on the pituitary with no initial
surge in gonadotrophin or testosterone levels.
• Orchidectomy for prostate cancer is very seldom
done nowadays, but can often relieve symptoms
and produce dramatic remissions in the course of
the disease. It is still offered as an alternative to
GnRH agonists.
Palliation produced by hormonal treatment of prostatic cancer suppresses PSA to normal levels for an
average of 2 years, after which it slowly rises, with
symptoms returning a few months later. When the
cancer is refractory to hormone therapy, the average
life expectancy decreases significantly. Multiple new
treatments have been developed for 2
line use and overall 5- year survival for metastatic
prostate cancer is now 30%.
Radiotherapy may relieve the pain of bony deposits
and can also be used for local control to supplement
hormonal therapy.
dependent advanced prostate cancer. It
week course
nd
line and 3rd
Additional resources
Case 115: A man with difculty passing urine and
with an interesting X- ray
Case 116: Sciatica with a sinister cause
Case 117: A patient with a very distended bladder
The male urethra
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Arthur McPhee
Learning objectives
✓ To know the congenital anomalies of the male urethra.
✓ To know the dierent types of urethral injury and their management.
✓ To know the causes, investigation and treatment of urethral stricture.
spongiosum. If the genital folds fail to develop or fuse
Anatomy
The six parts of the male urethra are often subdivided by
urologists into anterior and posterior regions, as follows.
The posterior urethra comprises:
Prostatic urethra, traverses the prostate gland.
•
• Membranous urethra, passes through the external
sphincter and fascial perineal membrane.
The anterior urethra comprises:
• Bulbar urethra passes through the bulb of the
penis in the perineum.
Penile urethra, passing through the penis, often
•
called the spongy urethra since it passes through
the corpus spongiosum.
•
Sub- meatal urethra, that portion within the glans.
• External meatus visible at the tip of the penis.
completely, the tube is either short or absent. The urethra thus opens onto the ventral surface of the penis
anywhere from the perineum up to the glans.
Hypospadias is associated with three abnormalities:
• Ventral opening of the urethra on the penis.
• A hooded foreskin, due to deficient development
of the ventral part of the foreskin.
•
Chordee, a downward curvature of the penis on
erection associated with proximal hypospadias.
Treatment is complex and should be reserved for
specialist centres. The essential components of
reconstructive surgery include correction of penile
chordee, urethroplasty for urethral reconstruction
and appropriate skin coverage to obtain a satisfactory
cosmetic appearance. The foreskin is utilized as a skin
flap; therefore, circumcision before correction of the
abnormality is contraindicated.
46
Congenital anomalies
Hypospadias
The male urethra is formed by the inrolling of the
genital folds, which themselves form the corpus
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
Epispadias
Epispadias, where the urethra opens dorsally on the
penis, is associated with other anterior abdominal
wall defects including exstrophy of the bladder as part
of the exstrophymore commonly in males. Prenatal screening detects
a large proportion of exstrophy patients but epispadias is typically detected at birth.
Surgery to correct this abnormality is again complex and should be performed in specialist centres.
epispadias complex, and occurs
460 The male urethra
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Posterior urethral valves (see also
Chapter45)
A valve- like membrane at the level of the verumontanum. This can obstruct the flow of urine, resulting in
chronic retention of urine and uraemia in infants.
Urethral injury
andtrauma inthe male
Urethral injury and trauma may be generally divided
into anterior urethral injuries and posterior urethral
injuries and then subdivided into those injuries
caused by iatrogenic trauma, blunt trauma and those
by penetrating trauma.
Anterior urethral injuries
In anterior urethral injuries, the bulbar urethra is the
site most commonly affected by blunt trauma, compressing the bulbar urethra against the pubic symphysis and leading to injury/rupture through
compression. This can be through straddle injuries,
such as falling astride a bicycle cross bar, or blunt
force such as a kick to the perineum. Penetrating
anterior injuries are rare and are typically associated
with other penile, testicular or pelvic injuries.
Iatrogenic injury is unsurprisingly the most common cause of urethral trauma with most injuries
being associated with urethral catheterization. These
are typically false passages created by forceful insertion of the urinary catheter and incorrect inflation of
the retaining balloon within the urethra.
Clinical features
The history of injury to the pelvis or perineum
should prompt suspicion. There can also be a delay
in both signs and symptoms, which can be of delayed
onset in relation to the injury itself. The important
features are:
•
Blood at the external urethral meatus is the ‘clas-
sic’ sign of urethral trauma but the absence of
blood does not exclude an injury.
•
Urinary retention, in a complete injury.
•
Haematuria and pain on voiding (incomplete
injury) should also raise suspicion of an injury in
the context of trauma.
Swelling of the penis, scrotum and perineum
•
secondary to urinary extravasation and
haematoma.
Digital rectal examination should be performed to
exclude rectal injury (blood on glove or palpable
defect), which can be present in up to 5% of cases. The
presence of a ‘highfrom the anterior urethra, is a well- known but unreliable feature.
riding prostate’, disconnected
Special investigations
• CT scan, often done as part of a trauma series in
patients with pelvic trauma.
•
Retrograde urethrogram, using dilute water-
soluble contrast medium will identify extravasation or loss of continuity, and localize the site of
injury. Extravasation with bladder filling suggests
incomplete injury, extravasation with no bladder
filling is suggestive of complete posterior urethral
injury.
Posterior urethral injuries
Posterior urethral injuries, both blunt and penetrating, are typically associated with significant trauma.
Blunt urethral injuries are almost always as a result of
pelvic fractures with the risk increasing with the severity
of the fracture, and are most commonly associated with
road traffic accidents. Pelvic fracture urethral injuries are
again subdivided into partial and complete rupture.
Penetrating posterior urethral injuries are rare and
are typically associated with gunshot injuries in
which there is a high probability of associated
intrabdominal injuries. The associated injuries of
posterior urethral trauma in the male can often be
threatening and will often dictate the patient’s
lifeinitial assessment and management.
Management
Satisfactory management depends on a high index of
suspicion leading to early diagnosis.
Anterior urethral injuries
Early management of anterior urethral injuries can be
divided into either urinary diversion, via suprapubic
or transurethral catheterization, or immediate exploration and reconstruction.
Exploration and reconstruction are reserved for
non- life- threatening penetrating injuries and penilefracture - related injuries. In cases with significant
defects or where the presence/risk of infection is very
high (e.g. bite wounds), this is done as part of a staged
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repair.
Urinary diversion is typically performed either
through suprapubic catheterization or endoscopic
realignment with urethral catheterization. These are
typically the interventions of choice in cases of life
threating pelvic injury.
Posterior urethral injuries
Management of posterior urethral injury is typically
performed in the first instance by an attempt at either
urethral catheterization by an experienced clinician
or with ultrasound guidance, or open suprapubic
catheter insertion. Subsequent early management
(2 days to 6 weeks) can either be in the form of an
early urethroplasty or early realignment but management of the associated pelvic injuries means that
repair beyond 6 weeks (‘deferred urethroplasty’) is
the standard treatment.
Complications
• Stricture formation often occurs following injuries
to the urethra because of scarring; subsequent
repair may be necessary.
Impotence occurs in half the patients, as a conse-
•
quence of either a pelvic injury involving the terminal branches of the internal iliac arteries or
injury to the nerves supplying the penis.
Urethral stricture
Urethral stricture disease can be broadly grouped into
anterior urethral stricture and posterior urethral
stricture.
Posterior urethral strictures are associated with
trauma, as described above, or can be present as a result
of previous surgical interventions such as transurethral
prostatectomy (TURP) or radical prostatectomy.
Anterior urethral strictures can have many
causes:
Congenital: meatal stenosis in hypospadias.
•
Infection/inflammation:
•
a Gonococcal urethritis.
b Non- specific urethritis, for example
Chlamydia.
c
Balanitis xerotica obliterans.
• Tra uma:
a Blunt trauma, e.g. straddle injury.
The male urethra 461
•
Iatrogenic
Urethral instrumentation including
a
catheterization.
Previous urethral or prostatic surgery.
b
Clinical features
Typically, the patient with a urethral stricture may complain of difficulty passing urine, with a poor stream and
straining to empty his bladder. He is often younger than
50 years (in contrast to men with benign prostatic disease). Patients may also present with urinary infection
and acute retention as a consequence of the stricture.
Special investigations
• Urinary flow rate: the stricture limits the flow of
urine, and measurement of the flow rate shows a
flat plateau.
Urethrogram will demonstrate the location and
•
length of the stricture.
•
Urethroscopy will visualize the stricture and facili-
tate treatment.
Treatment
Optical urethrotomy or urethral dilatation are common first- line treatments for uncomplicated strictures. Optical urethrotomy has the benefit of being
performed under direct vision compared to traditional urethral dilatation. However, newer urethral
dilators have been developed with hydrophilic coatings and channels for guidewires so that dilatation
can be performed using a Seldinger
are increasingly popular in the acute setting.
Urethral strictures have a high chance of recurrence depending on the length of the stricture and the
degree of corporal fibrosis, although 50% will require
no further treatment after either optical urethrotomy
or urethral dilatation.
Recurrent strictures can be treated by further
optical urethrotomy or urethroplasty, with either
simple resection of the stricture with end- to- end
anastomosis of the ends, or interposition of a graft of
buccal mucosa.
The management of acute retention due to urethral
stricture is outlined in Chapter45.
1
Sven Seldinger (1921–1998), Radiologist, Karolinska
Hospital, Sweden. e technique involves rst passing a
wire through the lumen, and then railroading instruments,
stents, cannulas, etc. over the wire.
1
technique, and
47
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47
The penis
Arthur McPhee
Learning objectives
✓ To understand phimosis, paraphimosis, balanitis and their treatment.
✓ To know about carcinoma of the penis, its presentations and treatment.
✓ To know the causes of erectile dysfunction and its treatment.
Phimosis
Phimosis is narrowing of the preputial orifice, leading
to difficulty retracting the prepuce (foreskin); the literal Greek translation is ‘muzzling’. It can be divided
into physiological, pathological or idiopathic.
Clinical features
The most common symptoms in adults are inability
to retract the foreskin or pain during intercourse. In
children, the foreskin may balloon and the urinary
stream may be reduced to a dribble. Physiological
phimosis is very common and typically resolves without intervention as children age.
Treatment
Young children
While non- retractile prepuce is a common presentation in childhood, the natural history of physiological
phimosis is that it will resolve with age. Natural history studies have shown around 8% of 6–7will have a non- retractile foreskin but this percentage
reduces to 1% of 16–17- year- olds. In the absence of
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
year- olds
recurrent infections/balanitis, circumcision is not
typically recommended, as the condition can be
expected to improve.
Older children andadults
Initial treatment for physiological phimosis is typically with topical steroid cream and stretching
exercises. If the symptoms are persistent and troublesome, circumcision is considered the definitive
surgical management.
Phimosis caused by scarring after recurrent balanitis
is more typically managed with primary circumcision.
Paraphimosis
Paraphimosis results from retracting a tight foreskin
proximally over the glans. The foreskin acts as a constricting band, interfering with venous return from
the glans, which, therefore, swells painfully. Once
swelling starts, it becomes increasingly difficult to
replace the foreskin.
Paraphimosis most commonly follows urethral
catheterization; the foreskin is retracted over the
glans to expose the meatus for cleaning the glans
prior to catheter insertion. Once the catheter is
inserted, if the foreskin is not replaced promptly, it
can constrict the venous return, producing a paraphimosis. Hence it is important to always ensure that the
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patient’s foreskin is pulled forward again after the
insertion of an indwelling catheter. Paraphimosis may
also occur after an erection.
Treatment
Once a paraphimosis has become established, it can
be challenging to reduce. Traditional advice is to
apply a swab soaked in 50% dextrose to reduce some
swelling by osmosis. This may be followed by direct
pressure to the glans for a few minutes to allow the
foreskin to be reduced to its normal position. If
thepatient struggles to tolerate the manual pressure
required for reduction, a local anaesthetic penile
block can be performed to facilitate this.
Should reduction still prove difficult with local
anaesthetic block, the clinician can consider performing the ‘Dundee Technique’. With an appropriate
local anaesthetic block performed and the area
cleaned with anti- septic solution, a 25G needle is
used to perform a series of up to 20 punctures in the
oedematous foreskin to release the oedema. Once
manual pressure has been applied again, oedema
should reduce rapidly allowing the foreskin to be
reduced to its natural position.
Under rare circumstances where paraphimosis
has been present for many hours, a dorsal slit may
be required to achieve appropriate resolution. The
dorsal slit is used rather than a circumcision as
there is a much greater risk of removing too much
skin with a circumcision in the presence of distorted
anatomy.
After any episode of painful paraphimosis, patients
are typically offered circumcision at a later date to
prevent recurrence.
Balanitis
Balanitis is an acute inflammation of the foreskin
and glans, with possible causes including infection
and allergic dermatitis. Management depends
on the underlying condition and causative organism. It is important to test the urine for sugar to
exclude diabetes, which may predispose to the
inflammation, in which case Candida may be the
infecting organism.
Recurrent balanitis may result in phimosis from
scarring.
Treatment
The parents should clean the penis daily with lukewarm water and dry it gently. The foreskin should not
be forcibly retracted if it is still fixed, and potential
irritants such as soap, bubble bath and baby wipes
should be avoided. Nappies should be changed
frequently.
•
For suspected allergic dermatitis, the suspected
cause (e.g. soap, bubble bath) should be avoided
and 1% hydrocortisone cream applied for up to
14days.
•
For suspected non- specific dermatitis, topical 1%
hydrocortisone cream and an imidazole cream
may be used for up to 4days.
For suspected or confirmed candida balanitis, a
•
topical imidazole cream for up to 14days.
For suspected or confirmed bacterial balanitis, oral
•
antibiotics, e.g. flucloxacillin, depending on sensitivities for 7days.
If there is no improvement after 7days of treatment,
topical hydrocortisone should be stopped (if used)
and a swab repeated. Very rarely, and almost exclusively in adults, it will be necessary to perform a
biopsy to achieve a diagnosis.
Penile cancer
Pathology
Carcinoma of the penis is uncommon in Europe and
the USA (<1in 100000), but more common in Africa
and Asia (19 in 100000). Infant and childhood circumcision is protective with cases being virtually
unknown among populations who are circumcised
soon after birth. Penile cancer is common in regions
with high rates of human papilloma virus (HPV)
infection (HPV types 16 and 18 predominantly), with
approximately oneHPV- related carcinogenesis. Its viral link explains the
higher incidence in the immunosuppressed. Smoking
is also associated with penile cancer.
Macroscopic appearance
The premalignant stage is a persistent red patch on
the penis progressing to either a papillary growth on
the glans or an infiltrating ulcer; the latter is more
common.
third of cases being attributed to
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Microscopic appearance
The lesions are squamous carcinomas, which are
usually well differentiated.
Spread
• Local: the tumour may fungate under or through
the prepuce. Proximal spread along the shaft may
destroy the substance of the penis.
Lymphatic: the inguinal lymph nodes are fre-
•
quently involved, often bilaterally.
•
Blood- borne spread occurs late and is unusual.
Clinical features
Penile cancer affects the glans in almost half of all cases,
followed by the prepuce, and coronal sulcus, with the
shaft of penis only rarely being affected. The presentation can range from an area of erythema to a fungating
lesion with palpable inguinal lymphadenopathy.
It is common for men to present late, when the
tumour has ulcerated through the prepuce or until
some of the penis has been destroyed, presumably
because of the embarrassment caused by the site of
the tumour. Carcinoma of the penis never occludes
the urethra and so it does not cause retention of urine.
Treatment
Diagnosis is confirmed by biopsy. Subsequent treatment
is dictated by the stage of the tumour. Where the cancer is
superficial and has not spread, penile preserving treatment with either topical chemotherapy, laser ablation,
glans resurfacing or glansectomy with reconstruction.
Advanced lesions are managed with either partial
or total amputation of the penis (penectomy), with
inguinal lymph node sampling, or block dissection if
the nodes are involved. Radiotherapy may also be
required. This operation, although mutilating, does
not interfere with micturition because the external
sphincter is preserved. After a total amputation of the
penis, the patients usually micturate sitting down.
Overall survival is around 75% at five years, but is
better for early stage cancers.
Erectile dysfunction
The prevalence of erectile dysfunction in the adult
male population is 20% and is correlated with
increasing age.
Erection requires increased arterial flow into the
erectile tissue of the penis, together with occlusion of
venous outflow. Erection is mediated via efferent
parasympathetic fibres from S2, S3 and S4. Reflex
erection requires afferent signals via the pudendal
nerve, while psychogenic erection requires outflow
from the brain via the spinal cord.
Aetiology
Impotence most commonly occurs as a consequence
of ageing, such that 70% of 70- year- olds have some
difficulty with obtaining an erection (although 70% of
olds also have sexual intercourse). Aside from
70 yearageing, the other causes of erectile impotence are as
follows:
Neurogenic
Causes of neurogenic impotence include the following:
Congenital: spina bifida.
•
• Spinal causes: spinal cord injury, spinal cord tumour.
• Central causes: hypothalamic injury, cerebral
infarction/tumour.
Postsurgical causes: for example, pelvic surgery
•
such as anterior resection, abdominoperineal
excision of the rectum and radical prostatectomy,
due to damage of the pelvic parasympathetic
nerves.
Vascular
Hypertension (and its treatment) is commonly associated with erectile dysfunction. Arterial disease
affecting flow in the internal iliac arteries, as may
result from aortoiliac disease, can cause impotence
and buttock claudication (Leriche’s syndrome
1
).
Hormonal
• Diabetes mellitus, the most common hormonal
cause, probably acting via a diabetic neuropathy.
Erectile dysfunction may be a presenting symptom of diabetes in men.
Erectile dysfunction is the inability to achieve, or
sustain, an erection sufficient for sexual intercourse.
1
René Leriche (1879–1955), Professor of Surgery,
successively at Lyon, Strasbourg and Paris, France.
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