Page 278 - Medicine and Surgery

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274 Chapter 6: Genitourinary system

Phimosis Aetiology/pathophysiology
They arise from the collecting tubules of the epididymis,
Definition
as a thin-walled cyst containing watery or slightly milky
Narrowing of the penile orifice due to contraction of the
fluid.
foreskin.
Aetiology/pathophysiology Clinical features
Aswelling in the scrotum located above and behind the
Normally the foreskin does not retract at birth and it
testes, thus some patients attend saying they have devel-
may be months to years before it becomes retractile. In
oped a third testis. Cysts may be small, multiple, and are
congenital phimosis, the orifice is too small from birth
frequently bilateral and transilluminate brightly.
causing difficulty in micturition. If the foreskin is not
retractable beyond childhood, there may be difficulty
in cleaning under the foreskin predisposing to infection Management
(balanitis) and carcinoma of the penis. As the cysts are totally benign, they are best left alone.
Surgery to remove the cyst(s) risks damaging the sper-
Clinical features matic pathway, such that bilateral operations can cause
Ayoung child with congenital phymosis may have dif- sterility, and more conservative removal often leads to

ficulty with micturition, with ballooning of the pre- recurrence.
puce as it becomes full of urine.
In adolescence and adulthood, if the foreskin does not

retract fully, pain may be felt on erection and with Impotence
sexual intercourse.
Definition
Inability to achieve or sustain a sufficiently rigid erection
Complications
in order to have sexual intercourse. Occasional episodes
Recurrent balanitis may occur due to secretions col-

of impotence are considered normal, but if erectile dys-
lecting under a poorly retractile foreskin. Balanitis
function precludes more than 75% of attempted inter-
causes pain and a purulent discharge.
course, a man is considered ‘impotent’. Also called male
If apoorly retracting foreskin remains retracted after

sexual dysfunction.
an erection it can act as a tight band causing oedema
and engorgement of the glans (paraphimosis) due to
disruption of venous blood flow. Incidence/prevalence
Phimosis increases the rate of penile cancer by at least
This has been underestimated in the past, due to the
10-fold. reluctance of men to discuss this and the assumption
that impotence is inevitable with advancing age. With
Management greater understanding, increased availability of treat-
Symptomatic phimosis is treated by elective circum- ment and more widespread discussion of the problem,
cision. Circumcision is not required in asymptomatic 40% of men aged 40 are recognised to have some degree
young children, unless for religious reasons. In cases of of sexual dysfunction, increasing by approximately 10%
acute paraphimosis, the band is excised under general with each decade.
anaesthetic if the foreskin cannot be drawn forwards and
circumcision is advocated.
Aetiology
The cause is pyschogenic in 25% of cases, drugs (25%)
and endocrine abnormalities (25%). The other 25% are
Epididymal cysts
caused by diabetes, neurological and urological/pelvic
Definition disease.
Epididymalcystsarefluidfilledswellingsconnectedwith Psychogenic causes can be divided into following:
the epididymis that occur in males. If the fluid contains Depression, causing loss of libido and erectile dys-
sperm, it is called a spermatocele. function.Manyimpotentmenalsobecomedepressed.