Congenital and acquired conditions that affect the male genitalia; some may require emergency evaluation and treatment.
Diagnosis based on clinical findings identified in a wide variety of age groups from newborn to adult.
Localised occurrences of inflammation and infection are amenable to medical treatment; surgery with varying degrees of reconstruction may be required.
Inadequate, untimely, and failed treatment may have long-term consequences of sexual dysfunction or cosmetic deformity of the penis.
Anatomical penile abnormalities encompass a variety of disorders of the soft tissues of the male genitalia. Phimosis is the inability to retract the foreskin (distal prepuce) proximally over the glans penis. Congenital phimosis is expected in children younger than 3 years of age, and may be a normal finding up until the age of puberty. Acquired (pathologic) phimosis is the inability to retract the foreskin proximally over the glans penis in postpubertal males, or in patients in whom scarring has developed from chronic infection and inflammation (balanoposthitis), or as a result of repeated forced retraction of congenital phimosis. Paraphimosis is a condition in which the foreskin of the penis retracts proximal to the coronal sulcus (glans penis) and becomes fixed in position.
Congenital penile curvature, sometimes called congenital chordee, is a condition where the penis is curved, typically either ventrally or to one side. Rarely, dorsal curvature is noted. Congenital penile torsion can also occur, typically in a counter-clockwise direction. It can occur in conjunction with hypospadias or in isolation.
Hypospadias is a common birth defect where the urethra is located in an abnormal position on the ventral surface of the penis. Severity can range from the distal form (i.e., the urethral meatus is located in the glans or distal shaft and typically occurs with incomplete prepuce), to the less common proximal form (i.e., the urethral meatus is located from the perineum to the proximal shaft; typically occurs with ventral curvature, a cleft scrotum, and incomplete prepuce). Megameatus with intact prepuce (a mild variant of distal hypospadias) can occur with an intact prepuce, and is only noted at the time of circumcision or retraction of the prepuce at an older age.
A concealed penis is a normally developed penis that seems short because it is buried in pre-pubic fat tissue, enclosed in scrotal tissue, or trapped due to scar formation after circumcision. Congenital buried penis, also called congenital megaprepuce, is a rare condition that often presents as a genital mass present with urination in the newborn. It is characterised by excessive inner preputial skin with a tight phimotic ring, leading to severe ballooning of the penile skin and scrotum with urination.
History and exam
Key diagnostic factors
- presence of risk factors
- newborn and toddler age
- abnormal location of urethra
- incomplete prepuce
- penile curvature and/or torsion
- recent genital examination or procedure
- history of short or small penis
- penile pain and swelling
- foreskin adherent to glans
- penile adhesions and smegma
- penile cicatrix
- penile glans oedema
- prominent pre-pubic fat pad
- presence of hernia or hydrocele
Other diagnostic factors
- forced retraction of foreskin
- recent penile trauma
- history of balanitis or balanoposthitis
- urinary obstruction or retention
- necrosis of penile skin
- discoloration of glans
- penile length discrepancy
- history of UTI
- history of pelvic or genitourinary surgery
- erectile dysfunction
- uncircumcised penis (paraphimosis)
- indwelling urinary catheter (paraphimosis)
- parental unawareness (phimosis)
- balanitis xerotica obliterans (phimosis)
- penile trauma (phimosis)
- recurrent balanitis and balanoposthitis (phimosis)
- low birth weight (hypospadias)
- premature delivery (hypospadias)
- maternal gestational diabetes, obesity, or hypertension (hypospadias)
- family history (hypospadias, congenital penile curvature and/or torsion)
- obesity (buried penis)
- circumcision (trapped penis)
- penile and lower abdominal scarring (buried penis)
- hernia or hydrocoele (buried penis)
1st investigations to order
- clinical diagnosis
phimosis <12 years old, congenital or physiological
phimosis ≥12 years old
congenital penile curvature and/or torsion
concealed penis <3 years old
concealed penis ≥3 years old
- Encircling foreign body
- Trapped penis
- Guidelines on paediatric urology
- Canadian Urological Association guideline on the care of the normal foreskin and neonatal circumcision in Canadian infants
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