Tuesday, 20 June 2017

Penile Problems

Most penile problems are better evaluated if you have a nerve block in place.

Dorsal Penile Nerve Block
The two dorsal nerves are at 10 and 2 o'clock positions at the root of the penis.
Ramifications of these nerves usually commence 1 cm distal to the penile root, and a nerve block should be just proximal to those.
The depth of the needle need not be more than 0.25 to 0.5 cm.
Aim to hit the pubic symphysis, and then go below.

Phimosis
Check for diabetic control
Palpate the glans - and if there is a lump, refer urgently to urology
Consider a steroid cream - like betnovate

Paraphimosis
Remove a catheter or any piercings first
Start with analgesia - a nerve block might be helpful!

Manual Reduction - put pressure or a compression bandage on the distal penis
Ice 
Sugar on glans and penis
Puncture oedematous band
After reduction, urology follow up as is likely to happen again!

Fracture of the Penis
Differential is rupture of the deep dorsal vein of the penis
- You don't hear a crack or popping sound
- Detumescence doesn't occur
- Needs to be surgically explored
- Can get urethral injury

Priapism
Most of the time, this is primary (idiopathic) 40%

Secondary causes:
  Haematological   (sickle cell, leukaemia, myeloma)
  Neurologic    (spinal cord injury - leave these alone, time heals)
  Traumatic   (genital, perineal) 10%
  Neoplastic   (bladder, prostate)
  Medication   (antipsychotic like chlorpromazine and haloperidol   antidepressants like fluxetine, anticoagulation, recreational drugs like cocaine, intracavernosal injections)

  - analgesia
  - hydration
  - exercise (run up and down the stairs)
  - cold bath, or maybe a warm bath
  - therapeutic masturbation can help
  - involve urology team for drainage. This needs written consent - there is a high risk of associated impotence. It involves consent, cleaning, inserting a needing into the side of the penis to a depth of 1cm, take blood gas, then aspirate up to 100ml thick dark blood.




References 
http://bestpractice.bmj.com/best-practice/monograph/765/treatment/step-by-step.html
https://wikem.org/wiki/Priapism 
http://www.foamem.com/2015/04/17/priapism/
http://pedemmorsels.com/phimosis/
http://learning.bmj.com/learning/module-intro/.html?moduleId=10057996&searchTerm=%E2%80%9Cphimosis%E2%80%9D&page=1&locale=en_GB 

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