Penile Disorders and Diseases
The penis is a complex organ comprised of a network of specialized nerves, muscles, vessels, and tissues that work in coordination to facilitate urination, erection, and ejaculation. There are a number of penile disorders and diseases that can undermine the function and/or structure of the penis, some of which are congenital (inherited), neurological (related to nerves), neoplastic (characterized by tumors), or infectious in origin.
Specialists in diseases of the urinary tract and male reproductive organs, called urologists, are typically called upon to diagnose and treat conditions affecting the penis. These include conditions affecting sexual function.
11 Conditions That Urologists Commonly Treat
Peyronie’s disease (PD) is a connective tissue disorder characterized by the formation of fibrous plaques on soft tissues of the penis that cause the organ to bend abnormally. While it is normal for a penis to have some level of curvature while erect, PD is characterized by the abrupt and abnormal change to the structure (and sometimes function) of the penis.
Symptoms of PD include:
- Abnormal curvature of the penis when erect (either up, down, or to the side)
- Pain with erection or during sexual intercourse
- Hardened lesions at the site of the abnormal bend
- Palpable scar tissues beneath the skin’s surface, often resulting in “divots” or indentations
Some level of erectile dysfunction (ED) is common in people with Peyronie's disease, although not everyone will experience this. Others may experience ED initially but see it gradually improve over time. PD can occur at any age, although it primarily affects those between the ages of 45 and 60. Race is not a factor.
The exact cause of PD is unknown, but it is believed to be the result of a buildup of plaque on the inner lining of the penis due to repeated sexual trauma or injury. Over time, plaques on the tunica albuginea (the sheath covering the spongy columns of tissue that fill with blood inside the penis) can suddenly “give way” and cause the abnormal bend.
There are no sure-fire remedies for PD. Vitamin E supplementation, other oral or topical medications, penile traction, and physical therapy have all been used to varying degrees of success.
In 2013, the Food and Drug Administration (FDA) approved Xiaflex (collagenase clostridium histolyticum injections) which can help correct PD by dissolving penile plaques. This is the only FDA-approved medication for Peyronie’s disease. It has been studied in patients with greater than 30 degrees of curvature and showed an average 34% improvement in penile deformity.
For people with severe penile deformity, a surgery called the Nesbit procedure may be used as a last resort. Excision and grafting is another surgical technique that may be performed. These surgical procedures are considered after trial of medical therapy options, also including intralesional verapamil (an alternative to Xiaflex, not FDA-approved).5 Penile implants may also be used to enhance sexual function.
Penile cancer is a relatively rare form of cancer affecting the penis. It is diagnosed in fewer than one of every 100,000 people with penises in the United States, or roughly 2,000 cases per year.
Around 95% of penile cancer cases involve squamous cell carcinoma, the type of cancer that affects cells on the outer layer of skin as well as those lining hollow organs. Melanoma and Merkel cell carcinoma are less common causes.
Symptoms of penile cancer can vary by the stage of the disease and may include:
- Thickening of the foreskin or glans (head of the penis)
- A reddish, velvety rash under the foreskin
- Bleeding or discharge from under the foreskin
- Difficulty retracting the foreskin
- Small crusty bumps
- Flat, bluish-brown growths
- Swollen lymph nodes in the groin
- Pain or burning with urination
- Penile discharge or bleeding
Risk factors of penile cancer include human papillomavirus (HPV) infection, HIV infection, phimosis (the inability to retract the foreskin), and being over the age of 50. Smoking is also a risk factor.
Penile cancer is definitely diagnosed with a biopsy. Depending on the stage and grade of cancer, treatment may involve surgery, radiation therapy, chemotherapy, or biological drugs.
Penile cancer can be treated by urologic oncologists, surgeons who specialize in cancers of the urinary tract and male reproductive organs.
Although the prognosis for penile cancer can vary by the stage of the disease and other factors, the relative five-year survival rate for all stages is around 65%.
The urethra is the tube through which urine is channeled from the bladder and exits the body. In people with penises, the urethra runs through the length of the penis and ends at the tip of the glans. In addition to passing urine, the urethra is the vessel through which semen is ejaculated during sex.
There are two congenital disorders that cause the malformation of the penile urethra:
Hypospadias is a birth defect in which the opening of the urethra is on the underside of the penis instead of at the tip.
Hypospadias affects around one of every 250 male births and not only affects the appearance of the penis but can lead to abnormal spraying during urination and problems with ejaculation. Hypospadias can also cause a characteristic downward curve of the penis (called chordee).
Hypospadias can be treated surgically, although this is generally delayed until the age of consent unless the defect is causing severe problems.
Epispadias is a birth defect in which the urethra does not fully form, causing urine to exit from an abnormal place in the body. In people with penises, the opening will often be on the top or side of the penis, or even along the entire length of the penis.
Epispadias is a far more rare and serious defect than hypospadias, affecting one of every 100,000 male births. In addition to urethral deformity, epispadias will often manifest with an abnormally small penis and an abnormally formed bladder neck.
Epispadias is rarely left untreated as it can lead to serious complications, including urinary incontinence, recurrent kidney infections (due to urinary reflux), kidney or ureter damage, and infertility.
Reconstructive surgery is key to normalizing urinary and sexual function. Urethral reconstruction can start as early as 6 months of age with additional procedures scheduled later in life to repair malformations of the bladder neck, pelvis, and adjacent structures.
The foreskin, also known as the prepuce, is a double-layered fold of tissue and skin that covers the glans of the penis. It is traversed with tiny blood vessels and nerves and contains mucous membranes that can keep the glans moist and lubricated.
There are three conditions affecting the foreskin that urologists commonly treat:
Phimosis is the inability to retract the foreskin over the head of the penis. Phimosis can be an otherwise normal condition affecting uncircumcised children but tends to resolve on its own by the age of 3.
When it occurs in adults, phimosis can cause aggravating and potentially severe symptoms, some of which can worsen over time. These include:
- Pain with erection
- Scarring of the foreskin
- Swelling and redness of the glans
- Ballooning of the foreskin during urination
- Difficulty urinating
- Pain with intercourse
- Recurrent urinary tract infections (UTIs)
When it occurs during adulthood, phimosis is often the result of an infection or inflammatory condition such as balanitis (see below) or lichen sclerosis (a chronic inflammatory skin disorder). On the flip side, phimosis can cause balanitis.
Treatment options include topical steroid creams to reduce inflammation and make retraction easier. Manual stretching exercises can gradually increase the opening of the foreskin (often with the aid of a tubular device called a “flesh tube” that keeps the skin stretched). Circumcision is an option if all else fails.
Paraphimosis is the inability to return a retracted foreskin back to its original position over the head of the penis. While it is often regarded as a “cousin” to phimosis, paraphimosis is arguably more severe as it can restrict blood flow, causing the glans to become swollen and dark purplish in color.
If the foreskin cannot be returned to its normal position, the blockage of blood flow can cause edema (tissue swelling), tissue death, and gangrene.
Paraphimosis most commonly occurs when a healthcare professional forgets to pull the foreskin back to its normal position after a medical exam or a patient does not place it back in normal position after cleaning. Penile infections and physical trauma to the penis can also lead to paraphimosis.
Paraphimosis that causes any sign of blood flow obstruction—or continues for several hours even without symptoms—should be regarded as a medical emergency.
Balanitis is the inflammation of the head of the penis. When the foreskin is involved, it is referred to as balanoposthitis. Balanitis and balanoposthitis occur primarily in people with uncircumcised penises.
Balanitis is most common in people over 40 but can also affect children, albeit uncommonly. Poor hygiene, chemical irritants (such as detergents and lubricants), morbid obesity, reactive arthritis, and diabetes are all known risk factors.
Symptoms of balanitis/balanoposthitis include:
- Redness, swelling, tenderness, and itchiness of the glans
- Smegma (oily penile secretion under the foreskin)
- Difficulty urinating
- Urinary tract infection
Balanitis is most commonly addressed with improved hygiene but may also involve treatment with topical antibiotics or topical antifungals. In some cases, oral antibiotics for people with recurrent or severe balanoposthitis, circumcision may be recommended.
There are conditions that can affect the sexual function of the penis, including the ability to achieve an erection, orgasm, or ejaculation. The penis is also vulnerable to infections acquired during sex, some of which can be serious.
Sexually Transmitted Infections
Because the penis is largely external, people often believe that it is easier to detect signs of a sexually transmitted infection. This is not always the case. With some sexually transmitted infections (STIs), there may be no notable symptoms, or the signs may be mistaken for other medical conditions.
Among STIs commonly seen in people with penises:
- Chlamydia: A bacterial STI that can cause pain with urination, penile discharge, and swollen testicles
- Gonorrhea: A bacterial STI that can cause pain with urination and a yellow-green discharge
- Hepatitis A: A viral liver infection that can be passed through the oral-fecal route and unprotected sex
- Hepatitis B: Another viral liver infection passed through blood and bodily fluids that may be asymptomatic during early-stage infection
- HIV: A chronic viral infection primarily passed through sex that may initially manifest with flu-like symptoms and later lead to severe immunodeficiency
- Herpes simplex virus (HSV): A chronic viral infection that can cause cold sores or genital herpes
- Human papillomavirus (HPV): A viral STI that may be unnoticed during early infection but increase the risk of certain cancers in later life
- Syphilis: A bacterial STI that may cause ulcerative sores on the penis during early-stage infection but lead to severe complications in the tertiary stage of infection
The consistent use of condoms and a reduction in the number of sex partners can go a long way toward preventing many sexually transmitted infections.
Ejaculation is the discharge of semen as the result of an orgasm. Ejaculatory problems are among the most common form of sexual dysfunction in people with penises and can affect individuals of all ages.
Ejaculation problems are broadly classified into four groups:
- Premature ejaculation: Defined as ejaculation prior to sexual contact or within a minute of sex, premature ejaculation is often caused by stress or anxiety as well as medical conditions such as hormonal imbalances, neurotransmitter dysfunction, and prostate or urethral infection.
- Delayed ejaculation: Difficulty reaching an orgasm despite sexual stimulation is referred to as delayed ejaculation. This can also be caused by stress or anxiety as well as prostate surgery, low testosterone levels, diabetic neuropathy, excessive alcohol use, and certain medications like antidepressants, diuretics, and antihypertensives.
- Retrograde ejaculation: This is an abnormal condition in which semen flows into the bladder rather than out of the urethra. It can be caused by an enlarged prostate, prostate surgery, bladder neck surgery, diabetes mellitus, multiple sclerosis, and Parkinson’s disease as well as antidepressants, antihypertensives, and prostate medications (such as tamsulosin or Flomax).
- Anejaculation: The inability to ejaculate is referred to as anejaculation. This can be caused by psychological factors as well as medical conditions such as diabetes and multiple sclerosis. Because ejaculation problems often have psychological, physiological, and medical components, the treatment may require the input of a psychologist or psychiatrist as well as a urologist.
Erectile dysfunction (ED) is defined as the inability to achieve and sustain an erection firm enough for sexual intercourse. Also known as impotence, ED is a condition thought to affect 1 in 10 people with penises, with 43% experiencing some level of ED at some point in their life.
There are numerous intersecting causes of EC, including:
- Alcohol and substance abuse: Including amphetamines, cocaine, opiates, and marijuana
Medications: Including antidepressants, diuretics, high blood pressure medications, tranquilizers, muscle relaxants, and others
- Neurological disorders: Including Parkinson’s disease, multiple sclerosis, stroke, multiple sclerosis, and spinal cord injury
- Older age: With most studies showing that the risk of ED triples from age 40 to age 70
- Pelvic surgery: Including bowel resection and prostate surgery
- Psychological states: Including depression, anxiety, fatigue, and stress
- Smoking: Which increases the risk of ED by 1.5- to 3-fold compared to non-smokers
- Vascular diseases: Including hypertension, coronary artery disease, and heart failure
Read Also : Treatment Of Erectile Dysfunction
Patients presenting with ED without a history of cardiac problems should have a baseline cardiac workup starting with their primary care physician.
ED is typically treated with medications called phosphodiesterase 5 (PDE5) inhibitors that cause the dilation of blood vessels and the relaxation of smooth muscles of the penis. They including Cialis (tadalafil), Levitra (vardenafil), Stendra (avanafil), and Viagra (sildenafil).
Other treatment options include Caverject (alprostadil injection), Muse (alprostadil suppository), vacuum erectile devices, and penis pumps or implants. Testosterone replacement therapy can further augment most types of treatment for ED.
Studies have also found that moderate to vigorous aerobic exercise performed four times weekly for 40 minutes can significantly improve erectile dysfunction.
There are five PDE5 inhibitors approved by the U.S. Food and Drug Administration (FDA) for treatment of ED:
- Viagra (sildenafil) tablets, approved 1998
- Cialis (tadalafil) tablets, approved 2003
- Levitra (vardenafil) tablets, approved 2003
- Staxyn (vardenafil) dissolvable tablets, approved 2010
- Stendra (avanafil) tablets, approved 2012
Other treatments include:
- Numbing cream
- Lidocaine spray
- Using more than one condom
- Masturbating a few hours before having sex
- Natural remedies can also be considered when treating premature ejaculation:
- Ayurvedic herbal medicine or Generic Medicine
- Chinese herbal medicine like Yimusake tablets or Qilin pills
- Zinc supplements
- Dietary changes
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People will sometimes delay seeing a urologist out of the sheer embarrassment of having to discuss things like erectile dysfunction, premature ejaculation, or symptoms involving the penis or foreskin.
Even though certain urological conditions are relatively common, it is important not to ignore them. This is especially true if there are sudden changes in sexual or urinary function, or you notice changes in the appearance, color, texture, or size of the penis or foreskin.
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In some cases, an investigation may reveal a more serious underlying condition that can be treated or controlled. Early diagnosis and treatment almost invariably afford better outcomes than holding off.