د.أحمد تركي
Phimosis
Phimosis is the inability to retract the foreskin over the glans penis due to narrowing, constriction, and or adhesions. Forceful retraction of the phimotic foreskin during infancy is ill advised and may result in fissures and eventual scarring of the distal foreskin. Poor genital hygiene may result in chronic infection causing adhesions between inner foreskin and underlying glans penis as well as fibrosis resulting inability to retract foreskin. Complication of phimosis includes balanitis, posthitis, paraphimosis, voiding dysfunction, and penile carcinoma.
Patient may present with complains of erythema, itching, discharge, or pain.
Minor phimosis can be managed with improved genital hygiene and sometimes topical application of corticosteroid cream. Mild balanoposthitis can be treated with broad spectrum oral antibiotics. Severe balanitis may require emergency dorsal slit circumcision aided by local anesthesia. Elective circumcision should be considered for persistent symptoms or recurrent infection.
Paraphimosis
Refer to retracted foreskin becoming trapped proximal to the glans penis resulting in edema, inflammation, and pain. Left untreated it can progress to ischemia of the glans penis and eventual gangrene. Treatment consists of initial firm compression to decrease edema followed by manual reduction often aided by placement of a lubricant at the level of the proximal glans penis. However, dry gloved hand are essential in gaining traction of the outer foreskin when pulling it back over the glans into the anatomic position. In rare instances direct incision of the constricting band may be necessary to allow manual retraction. Paraphimosis is frequently the result of partially phimotic foreskin and election circumcision may be indicated.
Urethral injury
Urethral injuries associated with pelvic fracture occur in 3% of males and 6% of females. Only minority of patients will have concomitant bladder injuries.
Mechanisms
Pelvic fractures are the most common cause of posterior urethral injury in males. The classic injury is a distraction at the prostatomembranous junction. Variations occur including complete and partial disruption, and the tears occur either above or below the urogenital diaphragm. Multivariable analysis of fracture pattern showed that displaced fractures of the pubis and medial one third of the inferior pubic ramus are independently associated with urethral injury in men.
Anterior urethral (penile and bulbar) injuries are commonly caused by straddle injury, in which the corpus spongiosum is crushed against the pubic symphysis; other mechanisms include penile fracture, amputation, or penetrating injuries to the genitalia.
Initial evaluation
Signs and symptoms of urethral injury are variable, and thus careful history, physical examination, and radiographic imaging are critical to determine the location, nature, and the extent of injury. Blood at urethral meatus, the classic sign of injury to urethra, indicate that imaging should be performed. Other signs include a palpable bladder, butterfly perineal hematoma, and the high ridding prostate.
The sensitivity and the specifity of urethrography are high in men.
Management
Traumatic posterior urethral distraction injuries in men have traditionally been managed by means of suprapubic cystostomy, with reconstruction delayed for 3-6 months. Most urethral injuries can undergo immediate realignment, suture not prefers for male posterior urethral distraction defects, realignment renders definitive reconstruction unnecessary in a significant percentage of men, and allow early removal of the suprapubic cystostomy.
Anterior urethral injuries in men are best treated with immediate repair, especially for those without major tissue loss, but those injuries associated with major tissue loss or defect > 2cm treated by suprapubic cystostomy (urinary diversion), realignment and subsequent reconstruction.
Urethral stricture disease
Definition
Is fibrotic tissue that renders the normally compliant urethral lumen inelastic. This result in narrowing of the urethral lumen and slowing of urine flow through it.
The term urethral stricture is correctly used to describe lesions of the anterior urethra. In contrast, posterior urethral strictures are really urethral distraction defect that occur in setting of the pelvic fracture.
The anterior urethra begins at the urogenital diaphragm and includes the bulbar urethra and penile urethra.
Etiology
A. Trauma
1. Anterior urethra:
Straddle injuries can injure the bulbar urethra and penetrating injuries can involve the anterior urethra.
2. Posterior urethra:
Urethral distraction defect as result of pelvic fracture occur at the membranous urethra.
B. Iatrogenic
From traumatic catheterization, urological instrumentation, or self injury
From traumatic Foley catheter removal.
C. Infection
Gonococcal urethritis classically causes anterior, mostly penile urethra strictures.
Clinical presentation
The classical history is that of obstructive urinary symptoms, that is , slowing of urinary stream, decreased caliber of the stream, increase in voiding time, incomplete bladder emptying, and post void dribble.
Obstruction of the urine often leads to upstream infection such as prostatitis or epididymo-orchitis.
Diagnosis
Clinical diagnosis based on the history. Clinical suspicion can be supported by a flow rate.
1. Urethroscopy can be used to confirm a clinical suspicion.
2. Retrograde Urethrogram (RUG) and Voiding Cystourethrogram (VCUG) used for accurate assessment of length and location of stricture.
Treatment
Most treatment that involve dilation and incision can certainly treat the acute problems of urinary obstruction but do not have good long term success rates (30-50%). Formal urethroplasty, utilizing a variety of techniques, can provide long term success rates near 90%.
1. Urethral dilatation can performed in the office with local anesthesia with lidocaine jelly. Urethral sounds or filliform and followers can be employed to perform dilatation. Both techniques are not without risks, urethral false passage and trauma may lead to more complex strictures.
2. Direct vision incisional urethrotomy is performed endoscopically under sedation or general anesthesia and involves visualizing the stricture and incising with cold knife at the 12 o clock and Foley catheter is then placed for 2-10 days. The success rate depends on the length and location of the stricture. Short term (<6months) success rate are excellent but long term success rate is only 50%.
Regime of urethral self dilatation after this procedure can extend the time of urethrotomy.
3. Open reconstruction
The optima choice of techniques for formal open reconstruction of a urethral stricture is dependent on the length and the location of the urethral stricture as determined by the urethrography.
A. Anastomotic urethroplasty indicated in bulbar stricture less than 2cm but the penile urethra in an impotent man cannot be managed by this procedure due to the resultant of chordee.
Success rates between 90 and 95%.
B. Substitution urethroplasty is used for bulbar stricture more than 2cm and for most pendulous urethra. Foley catheter is left for 3 weeks at which time VCUG is performed to confirm healing.
Buccal mucosa for substitution urethroplasty has achieved huge popularity.
Urethritis
The scientific foundation for the diagnosis of urethral inflammation dates from 1879 when Neisser demonstrated the bacterium, now known as Neisseria gonorrhoeae, in stained smears of urethral, vaginal, and cunjunctival exudates. His discovery made possible the distinction between gonococcal (GC) urethritis and nongononcoccal urethritis (NGU).
Symptoms of urethritis include urethral discharge accompanied by burning on urination on or an itching sensation.
Gonococcal Urethritis
Gonorrhea is the second most commonly reported infectious disease in the United States.
Diagnosis
The pathognomonic finding is an increased number of leukocytes on Gram stain of urethral smear or first-voided urine specimen. GC urethritis is diagnosed if intracellular gram-negative diplococcic are observed. NGU is more likely if they are not present.
Urethritis can be documented on the basis of any of the following signs:
1. Mucopurulent or purulent discharge.
2. Gram stain of urethral secretion demonstrating 5 white blood cells per oil immersion field. The gram stain is preferred rapid diagnostic test for evaluating urethritis. It is highly sensitive and specific for documenting both urethritis and/or the presence of gonococcal infection, gonococcal infection is established by documenting the presence of WBC containing intracellular gram negative diplococcic.
3. Positive leukocyte esterase test on first-void urine or microscopic examination of first-void urine demonstrating 10 WBCs per high power field.
Endocervical smears from women and rectal specimens require careful interpretation because of colonization with other gram negative coccobacillary organisms. The isolation and identification of the N. gonorrhoeae are still currently accepted gold standard for the diagnosis of gonococcal infections. Specimens should be inoculated into selective media.
Treatment
Cefixime 400 mg orally in a single dose, or ceftriaxone 125 mg IM in a single dose, or ciprofloxacin 500 mg orally in single dose, plus if chlamydial infection is not ruled out azithromycin 1 gm orally in a single dose or doxcycline 100 mg twice a day for 7 days.
Pregnant women should not be treated with quinolones but should be treated with cephalosporin.
Complication
May be local or systemic complications:
Local:
Male: may be spread into the posterior urethra, epididymis and seminal vesicles this can lead to urethral stricture, epididymitis and even sterility.
female: is major cause of pelvic inflammatory disease (PID) which results from ascent of infection from endocervix into the fallopian tubes.
Systemic:
Arthritis, tenosynovitis, dermatitis, meningitis and myopericarditis.
Nongonococcal Urethritis
Chlamydia Trachomatis
Among the more than 20 sexual transmitted that have been indentified, Chlamydia is the most frequently reported.
C. trachomatisis an intracellular bacterium with multiple serotypes, it is transmitted during vaginal, oral, or anal sexual contact with an infected partner. C trachomatis account 30-50% of cases of NGU.
Common clinical manifestations of chlamydial infection in men include urethritis, epididymitis, and proctitis. The urethritis present 1-3 weeks after infection with clear urethral discharge and dysuria. Chlamydial infection may disseminate systemically in 1-3%of patients. Classically known as Reiters syndrome, it present with classic triad of reactive arthritis, urethritis and conjunctivitis.
Treatment
Treatment should be initiated as soon as possible after diagnosis. Single dose regimens have the advantage of improved compliance.
Azithromycin 1 gm orally in single dose or doxycycline 100 mg twice a day for 7days.
Alternative regimens: erythromycin base 500 mg orally four times a day for 7 days or ofloxacin 300mg twice days for 7 days.
Carcinoma of the penis
Is essentially sequamous cell cancer of the penile skin, the primary lesion is usually occur on the glans penis or inner surface of the foreskin, invasion of the corporeal bodies and the urethra is more common than metastatic disease.
Incidence:
Is extremely rare in the united states, accounting for less than 0.5% of adult male malignancies.
The incidence increase in less developed countries where it may account 10% of cancer in men.
Etiology:
Penile cancer is almost never seen in men circumcised at or near birth, leading to speculation that chronic irritation may be causative factors.
Viral origion(human papilloma virus type 16) also has been suggested.
History of smoker also has been suggested increase the risk of the penile carcinoma.
Classification of the penile carcinoma:
1.epithelial dysplasia : like leukoplakia (associated with chronic irritation often found adjecent to the carcinoma), and balanitis xerotica obliterance( which is severe chronic inflammatory lesion of the glans and the prepuce).
2.carcinoma in situ: which is malignant changes without invasion of the basement membrane example : erythroplasia of the queyrat and bowen disease.
3.sequamous cell carcinoma: account for 90% of the penile cancer.
4.basal cell carcinoma : which is exrememly rare tumor .
5. melanoma.
6.sarcoma.
Route of spread:
Via the regional lymph nodes to the superficial and deep inguinal lymph nodes and then to the iliac lymph nodes. Lymphatic drainage of the prepuce to the superficial and deep inguinal lymph nodes while the lymphatic drainage of the glans, urethra and the corpora to the deep inguinal lymph nodes then to the iliac lymph nodes.
Diagnsis:
Diagnosis is established by the punch or excisional biopsy in the operating room.
Staging:
Jackson staging system which based on degree of local invasion and metastatsis to lymph nodes and other organ.
Stage1: tumor confined to the glans or prepuce.
Stage2: invasion of the corpora no nodal or distant metastatsis.
Stage3: tumor confined to the penis, regional lymph nodes metastatsis present.
Stage4: tumor beyond penis, inoperable regional nodes or distant metastatsis.
Treatment;
Lesion located entirely in the prepuce may be cured by circumcision alone if 2cm margin free is achievable, small lesion located in the glans may be treated effectively by laser therapy.
More invasive tumor locate in the distal end of the penis can be treated by partial penectomy while lesion involve the whole of the penis or the base of the penis is treated by total penectomy.
Palpable adenopathy is present in 50-60% of patient at presentation only 30% had histological evidene of tumor,so inguinal lymphadenectomy is indicated in those adenopathy does not resolve after approperiate antibiotic therapy.