PENILE PROBLEMS

A number of problems can affect the appearance or function of the penis in adult life. We will consider three broad categories of problems - foreskin problems, penile angulation and erectile difficulties.

 

FORESKIN ISSUES

Many skin conditions can affect the foreskin. The commonest include minor thrush (candida) infections, where sore redness on the skin can be treated with an appropriate cream. Other causes include sexually transmitted infections, so if something new occurs, it's worth seeing your GP for advice or attending  a sexual health clinic particularly if you have had a new sexual partner. A tight, non-retractable foreskin is not usually due to infection alone however.


When the foreskin becomes very tight, with difficulty retracting, this becomes known as phimosis. This is usually due to scarring and inflammation on the foreskin, and can be due to a condition known as Balanitis Xerotica Obliterans (BXO), otherwise known as Lichen Sclerosis. Only rarely is it due to a cancer on the penis, but if there is a lump or growth visible, then this should be examined urgently.

The cause of foreskin tightening is not known, but urine is a chemical irritant to the skin, so always try to keep the foreskin clean and dry - if any concerns dab the foreskin dry with toilet paper after passing urine. Don't try to overstretch the skin though, as if it is scarred, forcibly stretching it can cause more trauma and tear / scar the skin. If the foreskin becomes stuck back in the retracted position, then try to pull it forward by gentle pressure, sometimes helped by a bit of ice to cool the penis and shrink it down. Don't leave it stuck back as this can then cause a lot of swelling and pain, and ultimately mean medical assitance is required.

A tight foreskin can be treated in the early stages with a steroid cream such as hydrocortisone or betnovate for a month. This can help the inflammation to settle and loosen up the skin. If no improvement is seen, or if the skin is very thickend and scarred, then it is likely to require a circumcision. This is where the foreskin is removed entirely, and can be done with local anaesthetic (injections whilst you are awake) or a general anaesthetic with you asleep for 20 minutes or so. It is done as a day case without needing to stay in hospital, but you'll likely need a week off work and avoid sexual activity for a month after. If the foreskin is OK and the main problem is the cord (frenulum) underneath being too tight, then a smaller procedure (frenuloplasty) can be offered. A further lesser procedure is to make a relaxing incision into the foreskin, which allows it to be pulled back but may end up with an inferior cosmetic result. 

The main risks of circumcision are occasional infection or haematoma (bleeding), discomfort for a few days, and reduced sensation to the end of the penis, as the foreskin has many nerve endings. Of course if the foreskin is painful, then you are likely to be more comfortable after. Please see the leaflet below for more information.

 

PENILE CURVATURE

Occasionally the penis can be curved from birth, sometimes associated with abnormalities of development of the urethra (water pipe). If the penis starts to curve alter in life though, then a condition known as Peyronie's disease is the most likely cause. The exact cause for this condition is not known, but it is thought that minor trauma to the erect penis can cause injury to the tough tissue which contains the erection, and this can then scar forming nodules and pain. Ultimately if the tissue won't stretch out properly during erection, then bending of the shaft of the penis on erection can occur. This angulation can be severe enough sometimes to make sexual intercourse difficult or impossible. Sometimes the erection can become weaker also, as the scar can cause problems with the usual blood flow mechanism which allows erection to occur. In the early stages the condition can cause pain on erection. Normally it subsides after 6 to 12 months, and the angulation stabilises.

In the early stages of the disease whiler it is still active, many tablet treatments have been tried, but there is little evidence for their effectiveness. Using penile stretching devices or vacuum pumps to help limit the angulation can be used early on. Shock wave treatment is advocated by a few individuals, but again the evidence for its effect is limited.


Once the condition is more chronic and the nodule (plaque) stabilised, then injectable treatments have been used to try to dissolve the plaque. More usually, treatment is aimed at straighening the penis sufficiently to allow intercourse, by a variety of surgical procedures. These have a range of potential side effects however, including penile shortening, the need for circumcision and impotence. 

For more information on Peyronie's diease please click below.

 

ERECTILE DYSFUNCTION

Problems with erections are common at any age, due to a variety of reasons. Common causes include psychological factors such as anxiety, stress, new relationships, or other causes such as tiredness or excess alcohol intake. If you're able to get strong erections at some times, for example if you wake up with a good erection, or it's not a probem when you're alone, then it is likely everything is working fine and it's more a psychological issue. If however you don't get a usable erection at any time, then it's more likely something underlies the problem.

Commonly associated factors can include increasing age, high blood pressure, raised cholesterol, diabetes, heart disease, low testosterone and occasionally neurological conditions or previous cancer treatment. Smoking, alcohol, some recreational drugs and some medications can also contribute.  If you see your GP, you will be asked about and likely tested for some of these. 

Treatment options usually start with tablets such as sildenafil (originally branded as Viagra), or other similar medications. If these  prove unhelpful, then further options include a cream to put on the end of the penis, or other ways of releasing the normal erection causing chemicals - either by pellet into the water pipe, or injections into the penis. A vacuum device and constriction ring can help too. If all else fails a penile implant can be inserted, but these are only rarely indicated.