What are phimosis, paraphimosis, balanitis, hypospadias and how is a prostate exam performed?

Penile Conditions and Prostate Examination

Phimosis

Phimosis is a condition in which the foreskin cannot be retracted over the glans penis, which can lead to complications such as difficulty with urination, painful erections, and increased risk of penile cancer. 1, 2

• Physiologic phimosis is common in males up to 3 years of age but can persist into older age groups 2
• Pathologic phimosis can be caused by conditions like lichen sclerosus, chronic inflammation, or scarring from infection 1
• In adults, phimosis can present as difficulty with sexual intercourse (male dyspareunia), tight foreskin (constrictive posthitis), and painful erections 1
• Approximately 30% of phimosis occurring in adults is due to lichen sclerosus 1

Treatment of Phimosis:

• First-line treatment: Topical steroids with gentle retraction exercises 3, 4
  • For adults: Clobetasol propionate 0.05% ointment once daily for 1-3 months 3
  • For children: Betamethasone 0.05% ointment twice daily for 4-6 weeks 3, 5
• Success rates of topical steroid treatment range from 68-96% 4, 6, 7
• Circumcision is indicated for cases that fail to respond to medical management 3

Paraphimosis

Paraphimosis is an emergency condition where the retracted foreskin cannot be returned to its normal position, causing painful swelling of the glans penis and potential vascular compromise. 1, 2

• Can occur after retraction of the foreskin in uncircumcised men with urethral or glans piercings 1
• Treatment approaches:
  • Manual reduction after penile nerve block 1
  • Injection of hyaluronidase to reduce edematous fluid if manual reduction fails 1
  • Surgical intervention with dorsal slit if conservative measures fail, typically followed by circumcision 2

Balanitis

Balanitis is inflammation of the glans penis, often associated with inflammation of the foreskin (balanoposthitis), which affects 4-11% of uncircumcised boys and can lead to phimosis. 2, 7

• Risk factors include poor hygiene, phimosis, and diabetes 1
• Can present with erythema, pain, discharge, and difficulty retracting the foreskin 1
• History of balanoposthitis is associated with poorer response to topical steroid treatment for phimosis 7
• Treatment involves:
  • Improved hygiene
  • Topical or systemic antibiotics for bacterial infections
  • Topical antifungals for candidal infections 7
  • Addressing underlying causes such as diabetes or phimosis 1

Hypospadias

Hypospadias is a congenital condition where the urethral opening is located on the underside of the penis rather than at the tip of the glans. 5

• May be masked by phimosis and only discovered after treatment of the phimosis 5
• Severity varies based on the position of the urethral opening:
  • Glandular (on the glans)
  • Coronal (at the corona)
  • Penile (along the shaft)
  • Penoscrotal (at the base of the penis)
• Treatment is surgical correction, typically performed between 6-18 months of age 5
• Complications of untreated hypospadias include difficulty with urination, sexual function, and psychological impact 5

Performing a Prostate Examination

A digital rectal examination (DRE) is an essential component of the urological assessment in men, particularly for evaluating the prostate gland. 1

Preparation:

• Explain the procedure to the patient and obtain consent 1
• Position the patient either:
  • Lateral decubitus (side-lying) with knees flexed toward chest
  • Standing and bending forward with elbows on the examination table
  • Lithotomy position (supine with knees flexed) 1

Technique:

• Put on gloves and apply lubricant to the index finger 1
• Inform the patient before touching and instruct them to relax 1
• Gently insert the lubricated, gloved index finger into the rectum, directed toward the umbilicus 1
• Rotate the finger to palpate the entire posterior surface of the prostate 1

Assessment:

• Normal prostate: Walnut-sized, rubbery consistency, smooth surface, with a palpable median sulcus 1
• Evaluate for:
  • Size (normal or enlarged)
  • Consistency (soft, firm, or hard)
  • Surface (smooth or irregular)
  • Tenderness (present or absent)
  • Nodules or induration (may suggest malignancy) 1
• Prostate-specific antigen (PSA) testing should be considered alongside DRE for comprehensive prostate assessment 1

Clinical Significance:

• DRE is not required for evaluation of erectile dysfunction but is important when benign prostatic hyperplasia is suspected 1
• Findings that warrant further investigation include:
  • Hard or nodular areas (potential malignancy)
  • Significant asymmetry
  • Tenderness (suggesting prostatitis)
  • Significant enlargement (suggesting benign prostatic hyperplasia) 1