THE FORESKIN
The penis is enclosed by a loose sleeve of thin, hairless skin rich in muscle fibres. This has expansile and contractile properties that allow it to respond to changing penile length during erection.
In uncircumcised males, this sleeve of skin folds over on itself to form the foreskin (prepuce). Only 4 per cent are retractile at birth. Most foreskins remain firmly stuck to the glans during the first few years of life and should never be forcibly retracted. The adhesions between the glans and foreskin slowly break down and by the age of three years, 90 per cent of boys' foreskins can slide to and fro over the helmet to some extent. Remnants of the cells attaching the foreskin to the glans may prevent full retraction in up to 60 per cent of nine year olds, but have usually disappeared by the age of 17 years.
After full separation, the mature foreskin remains tethered to the glans on the underside to form a ridge of skin, the frenulum, which contains a small artery. The frenulum and glans especially the corona, or ridge are usually the most sensitive parts of the penis.
The mature foreskin acts as a cover to protect the glans while flaccid and to keep it in a moist, sensitive state. During erection, the foreskin slips back to clothe the elongating penile shaft.
Smegma
Bacteria, yeasts, stale urine and sloughed skin cells rapidly accumulate under the foreskin to form a white, smelly, cheesy substance known as smegma.
It starts to develop at an early age and is seen in 1 per cent of seven year olds, and 8 per cent of 17 year olds. Smegma that is allowed to build up can cause irritation and soreness. Smegma has also been linked with the development of cancer of the penis, although this is unproven.
Males over the age of seven years who have an intact foreskin should be taught how to retract it and wash underneath regularly, at least once a day preferably after every urination. This procedure should be done gently and carefully, as forceful retraction, especially if adhesions are still present, can cause injury, scarring and even a phimosis (see below).
After washing under the foreskin it is important to draw it back over the glans so a paraphimosis does not form (see below).
Phimosis
Phimosis is a tightness of the foreskin so that it cannot be drawn back over the widest part of the glans. This may be normal up until the age of two or three years, but in 10 per cent of boys it is still present beyond the age of three. Phimosis is often associated with an excessively long foreskin that contains an abnormal amount of fibrous scar tissue. Sometimes it develops at a late age following a foreskin tear that heals to leave a contraction.
A tight phimosis may cause difficulty in urinating, so that the foreskin balloons when passing water. This can be distressing, especially if urine trapped under the foreskin continues to leak after urination has finished. Even if the foreskin cannot be retracted, easing it back gently while passing water usually helps.
Phimosis in older males causes pain and difficulty with erection, masturbation and love-making. It also predisposes towards tearing of the foreskin, balanitis (see below) and cancer of the penis. Surgical correction by circumcision is the usual treatment.
Paraphimosis
Paraphimosis is a constriction of the penis behind the glans, due to an extremely tight foreskin. This usually occurs when the tight foreskin is drawn back to expose the glans (e.g. during sexual activity; during catheterization) and is then not sub-sequently pulled back over. The tight foreskin constricts circulation at the end of the penis and gross swelling of the glans and foreskin results. If this is not treated, the tissues will eventually become gangrenous.
In most cases the foreskin can be massaged back over the glans using an ice-pack to reduce swelling, squeezing the glans to expel excess fluid and applying a lubricating gel. This should not be done as a DIY procedure, but left to the skill of a surgeon. It is painful and often requires an anaesthetic. If manual reduction proves impossible, circumcision is essential. Some surgeons cut the constricting band first and let swelling subside before circumcising. Others perform circumcision straightaway.
Circumcision
During circumcision, the loose sleeve of foreskin which rolls over the glans is surgically excised. This is usually performed for religious reasons, but is also done for aesthetic and for perceived sexual or health benefits.
One American study suggested that hospital admission for urinary tract infection was 11 times more likely in uncircumcised male infants during the first year of life than for circumcised males. This suggests that circumcision improves local hygiene, and requires further investigation.
It is estimated that 90 per cent of American males are circumcised, although decreased popularity of the operation means that 40 per cent of American babies now remain uncircumcised. Around 20,000 circumcisions are performed in England each year.
Circumcision is a fairly simple procedure when performed on newborn babies. A thimble-like object is placed over the tiny glans and the foreskin pulled up over it. A second instrument is then clamped down over the foreskin to cut it off. This is known as the bellclamp method and is usually performed within the first few weeks of life without anaesthetic. In older males, for whom circumcision is medically indicated, the foreskin is excised and stitched under general anaesthetic.
After circumcision the skin of the glans penis loses its soft, moist texture and becomes darker, toughened and dry. An increased amount of fibrous protein keratin is laid down and the glans becomes more like normal skin, losing its mucous membrane characteristics. Some sensitivity may be lost.
The complications of circumcision include:
• excessive bleeding in up to 10 per cent of cases.
1 per cent of boys need re-operation to tie off the bleeding point and evacuate clotted blood.
• discomfort a quarter of older boys find it too uncomfortable to wear underpants for at least a week.
• ulceration and narrowing of the urethral opening at the tip of the penis.
• infection and even blood poisoning (septicaemia) are uncommon in hospital cases, but occasionally occur after ritual circumcision.
Rare side-effects, possible where the circumcision is performed by untrained operators, include:
• the removal of too much skin
• damage to the glans and corpora cavernosa, especially if stitches are placed too deep in older males
• thrombosis of blood vessels, leading to gangrene
• penile amputation.
Foreskin Redevelopment
A Dr Bigelow in the US has perfected a technique that re-develops a circumcised foreskin. This is referred to as 'uncircumcising'. The skin covering the end of the penile shaft is gently stretched and encouraged over the glans using a specially shaped plaster (adhesive bandage). This is worn continuously and cut to allow urination.
The skin of the glans quickly becomes less tough, more moist and increasingly sensitive as the new sleeve of skin starts to develop. As the stretched skin covering the penile shaft expands, further tension is required. Either small lead weights or a funnel-shaped expansion device is used during the end stages of foreskin redevelopment. A full foreskin will reform over 26 years, depending on how tightly the original operation was performed. Surgical restoration of the foreskin using skin grafts is also possible.
Balanitis
Inflammation of the glans is known as balanitis. Inflammation of the foreskin is posthitis if both occur together, the problem is referred to as balanoposthitis.
Balanitis causes symptoms of redness, soreness and itching on the end of the penis. This affects 4 per cent of young boys, usually before school age. Older males are also affected, most commonly with the yeast Candida albicans, which causes thrush. Little red spots appear and there may be a build-up of yeasty smegma under the foreskin. Screening of the urine is important to exclude sugar diabetes, in which balanitis is often the first sign.
Other causes of balanitis include infection with common skin bacteria, sexually transmissible diseases and chemical irritation.
Balanitis is largely preventable by proper hygiene and frequent washing under the foreskin. In mild cases, simple bathing with salt water (saline) twice a day will cause rapid resolution of symptoms. Stopping using soap may also do the trick. A study among 43 men with mild balanitis showed that by washing the penis with water alone, almost all cases resolved. Soap, by raising the pH balance of the skin, exacerbates inflammation caused by mild infection. Some cases of balanitis are also due to detergent allergy or irritation.
Moderate to severe balanitis due to thrush needs treatment with an anti-fungal cream (e.g. clotrimazole). If the infection is bacterial, antibiotic cream or tablets will quickly solve the problem. If balanitis is severe, with gross swelling of the foreskin, or if it is recurrent, circumcision may be required.
Balanitis xerotica obliterans
Balanitis xerotica obliterans is a common problem that affects the penis in childhood or old age; its cause is not fully understood. The glans or foreskin develops a characteristic white appearance and the skin seems thickened and stiff. This may cause narrowing of the urethral opening (meatus the hole at the tip of the penis) and can interfere with passing water. Circumcision is usually performed to prevent fibrosis, scarring of the foreskin, and phimosis (see phimosis). Occasionally, the urethral opening needs surgical widening. It is important to have this differentiated from leukoplakia, a pre-malignant condition (see below).
Balanitis of Zoon
This is an unusual problem that affects middle-aged and elderly men. It produces shiny, smooth red patches on the glans which may develop into painful, raw, velvety plaques. A biopsy is needed to eliminate the possibility of malignancy (see below) and, if balanitis is present, will reveal that the skin is infiltrated with characteristic immune cells known as plasma cells. The condition can then be treated by circumcision.
Lymphocoele
Occasionally, excessive sexual activity or masturbation results in a raised, whitish weal on the edge of the glans, just beneath the rim. This is due to swelling and blockage of a lymph drainage channel. The only treatment needed is to refrain from sexual activity and let things settle down. As with all lumps however, a diagnosis should be confirmed by a doctor, preferably one in a genito-urinary or special clinic.
Peyronie's Disease
In Peyronie's disease the flaccid penis looks normal but curves dramatically on erection to resemble a banana. When curvature is severe, erection is painful and intercourse impossible.
Peyronie's disease is caused by fibrosis the progressive replacement of spongy erectile tissue with scar tissue. The fibrotic area does not expand during erection, so the penis curves towards the area of rigidity. Treatment with vitamin E tablets (200 mg per day) or cream is sometimes recommended, as vitamin E helps to maintain tissue elasticity. When erection becomes painful, or intercourse difficult, surgery is essential. Some surgeons excise the fibrosed tissue, while others remove a wedge of tissue on the opposite side to encourage a straight erection. If Peyronie's disease is advanced, the best solution may be to implant a penile prosthesis (see surgical implants).
Priapism
Priapus was the Greek God of fertility, whose phallus weighed as much as the rest of his body. Priapism describes the onset of a prolonged, painful erection unaccompanied by sexual desire, which will not deflate. The shaft of the penis becomes rigidly erect due to swelling of the corpora cavernosa, while the glans and corpus spongiosum remain flaccid.
Priapism is painful and may be triggered by certain drugs, injury or any blood disorder (e.g. leukaemia, sickle cell disease). More often however, it occurs for no apparent reason during sexual activity.
Priapism is a surgical emergency. The penis must be decompressed within four hours, otherwise trapped blood starts to clot and inflammation, scarring and impotence result. Unfortunately, treatment is often delayed as the man is too embarrassed to seek medical help or assumes the erection will just go away on its own.
Emergency deflation (which should only be performed by a doctor) involves inserting a large needle into the corpora cavernosa and aspirating the thickened, trapped blood. This blood will be almost black in colour due to lack of oxygen. Saline irrigation of the spongy tissues is then performed and, in stubborn cases, drugs may be injected. If all else fails, the erection is coaxed away by opening the corpora cavernosa and joining them to the corpus spongiosum. This allows drainage, but will prevent any erectile activity in the future without the use of an implanted penile prosthesis.
Erythroplasia of Queyrat
This condition produces bright red, velvety plaques that are slightly elevated and have a sharply defined edge. It usually affects the glans and tends to be painless. Erythroplasia of Queyrat is a pre-malignant condition, which in some cases develops into a penile cancer if left untreated. If only the foreskin is affected, treatment is by circumcision. If the glans is also involved, local radiotherapy or the application of powerful, cytotoxic creams is necessary.
Leukoplakia
Leukoplakia describes an area of white, boggy skin on the glans caused by abnormal proliferation of skin cells. It resembles patches of grey-white paint and is usually painless. A biopsy to examine cells under the microscope will show that they are larger than normal and that the lower layers have been infiltrated by white immune cells (lymphocytes). This condition is also pre-malignant and may develop into a cancer if left untreated. The white patches are therefore removed under anaesthetic.
Cancer of the Penis
Cancer of the penis is a rare cancer of old age and usually occurs in the furrow between the ridge of the glans and the foreskin. It is rarer than usual in males who were circumcised as young boys, and never develops in men who were circumcised at birth. Cancer of the penis has therefore been linked with retained smegma, perhaps because the bacteria produce cancer-inducing chemicals known as carcinogens.
If you notice any ulceration or a discharge from underneath the foreskin, have this checked as soon as possible. This is especially important if you notice you can no longer pull the foreskin back. It may be tethered by an early growth.
Early diagnosis of penile cancer allows treatment with anti-cancer creams (e.g. 5-fluoro-uracil) or radiotherapy, but more advanced disease requires partial amputation of the penis with all its associated psychological problems. Where possible, the penis is only amputated an inch below the tumour, which usually allows an acceptable cosmetic result. Normal urination, erection and a sex life can then resume.
If the tumour is extensive, total amputation of the penis may be required. The urethral opening is then redirected to open behind the scrotum. The man will have to sit to urinate, but will be able to control his bladder.
In most cases, it is thought that proper foreskin hygiene can prevent cancer of the penis developing. If uncircumcised, always retract your foreskin gently to wash away retained smegma, at least once a day. Ideally, experts suggest this should be done after every urination.
Penile Injury
A tight foreskin commonly tears during intercourse and may cause profuse bleeding. A tear heals only to break down again when intercourse is next attempted. This is remedied by an elective circumcision to prevent recurrence. An alternative procedure is frenuloplasty, in which the frenulum is divided crosswise and sewn up lengthwise, thereby lengthening it.
Another common injury is the catching of a long, loose foreskin in a trouser zip. This is also treatable by circumcision, although several cases have been successfully reduced in casualty departments after soaking the affected area in a lubricating oil.
More dramatic injuries to the penis are not uncommon. They can result from seeking sexual gratification with machines such as vacuum cleaners or electric polishers. This practice is dangerous as vacuum cleaners often contain rotating blades that effectively shred the glans.
Loss of concentration as orgasm becomes imminent is a frequent cause of slipping when other machinery is used. A steady trickle of macerated penises and degloved scrotums attend the Accident and Emergency departments of hospitals each year. In one famous case involving an electric shoe-shining belt, the injured man tried to staple his torn scrotum together with an industrial stapler and only later discovered he was missing a testicle.
Non-sexual trauma to the penis may result from industrial injuries, sports injuries and being thrown forwards from a bicycle onto the handlebars. Surgical exploration to assess and repair the damage is almost always needed.
Penile Fracture
It is possible to fracture an erect penis. This usually occurs when a hard thrust misses the vagina and impacts against the woman's pubic bone. One of the corpora cavernosa ruptures and blood leaks into the surrounding tissues. A definite cracking sound is heard followed by severe penile pain, bruising and swelling.
A fractured penis requires surgical exploration to repair the rupture and empty blood clots. The penis is then splinted with wooden spatulas, and erections discouraged using drugs, until the penis is fully healed.
Penile Mutilations
Lorena Bobbit hit the headlines when she cut off her husband's penis with an 8-inch knife. Shortly afterwards, another woman snipped off her husband's testicles with a pair of shears. Both women were acquitted with much publicity, but mutilation of the male penis is not as uncommon as previously believed. Asian women have been indulging in this practice for years: during the 1970s over 100 Thai males lost their penis to their wives' wrath, usually while innocently asleep. In Hong Kong, three cases have occurred over the last decade.
It has also occurred in Britain: in the late 1980s a man was attacked by his girlfriend with a Stanley knife. This caused a severe diagonal slash injury to the penis with virtual amputation. The damage was surgically repaired and, happily, the man has since fathered two children.
More recently, early in 1994 a Chinese woman cut off her husband's pride and joy because a fortune-teller advised it would grow back bigger and better than ever to restore their fading relationship.
