Penoscrotal Conditions Overview

With the exception of testis cancer, most conditions of the penis and scrotum are benign although they can still be very bothersome. Listed below are some of the more common conditions:

Penoscrotal Conditions

Erectile Dysfunction

Erectile dysfunction is the inability to obtain or maintain an erection for satisfactory sexual activity.  Treatment is usually based on a stepwise ladder of options listed below.

Healthy lifestyle and weight loss

The commonest cause for erectile dysfunction is injury to the arteries that supply blood to the penis. In the same way that a healthy lifestyle protects from heart disease, the same advice applies to erectile dysfunction. Control of cardiovascular risk factors involves a heart healthy diet and lifestyle to keep weight to a normal BMI, control of cholesterol, diabetes and hypertension.

Viagra-like oral agents (Phosphodiesterise-5 inhibitors)

Viagra (sildenafil) and similar medications such as Cialis (tadalafil) and Levitra (vardenafil) temporarily increase the blood supply to the penis by relaxing the muscles in the arteries, allowing more blood flow. They are usually taken an hour prior to sexual activity. They cannot be taken with nitrates which are used to treat angina. Common side effects include headaches, nasal congestion, temporary vision colour changes in blue and green, nausea and gastric reflux. It usually takes a number of attempts before knowing whether these medications work.

Vacuum pump and construction ring

A vacuum pump is applied to the penis so that the blood is “sucked” in to give an artificial erection. A constriction ring is placed at the base of the penis once an adequate erection is achieved to keep the blood in the penis. This treatment works for most causes of erectile dysfunction and is medication free. Some problems include a slightly cold and blue erection.

Intracavernosal injections

In this situation, medication is directly injected into the penis to produce an erection. Education on the technique is provided in the office and a test dose is usually given so that the correct dose is prescribed.

Scrotal Enlargement

Generally, enlargement of the scrotum, with the exception of the testis itself, is a benign condition and there are many structures that can produce a swelling. An ultrasound of the scrotum usually outlines the abnormality.

An epididymal cyst (spermatocoele) is a benign cyst that develops in the small organ that sits above the testis which matures sperm as it leaves the testis. A hydrocoele is a fluid collection in the sac surrounding the testis. Both of these conditions are treated by surgery if they become large and symptomatic usually due to their size. Otherwise, they can be safely observed with reassurance.

A varicocoele is like varicose or distended veins that drain the testis. They are almost always benign and more common on the left. Occasionally they cause a dull, dragging sensation if they are very large. Treatment is by interventional radiology techniques where a puncture is made in the large vein in the groin and the testicular vein is blocked with a coil or small particles. Very occasionally this is offered for fertility issues.

Testis Cancer

Testis cancer is usually noted due to painless enlargement of the testis itself. It is often seen on a scrotal ultrasound.  An urgent referral is usually required as this tumour grows rapidly. Treatment is to remove the testis through a groin incision to confirm the type of tumour. Depending on whether it has spread or not, further treatment is by observation or chemotherapy.

Peyronie’s Disease

This is a benign condition of unknown cause that produces scarring in the penis leading to a bent penis when erect.  Sometimes it is also associated with erectile dysfunction.

The initial active phase is associated with pain and increasing angulation. There is not much scientific evidence that any medication or treatment can prevent it, but rubbing Vitamin E cream into the scar or “plaque” may reduce its size and is unlikely to do any harm.

After 6-12 months, the quiescent phase is characterised by stabilisation of the plaque and angulation, and resolution of the pain. In most cases, if successful sexual activity can be maintained, conservative treatment is advised. In severe cases, an operation can straighten the penis but it is usually associated with a risk of shortening and erectile dysfunction.

Phimosis & Circumcision

Phimosis occurs when the foreskin is too tight, or the tip of the foreskin narrows and is unable to be pulled back to expose the head of the penis. Usually it is due to scarring of the foreskin for unknown reasons. If it is only mild, topical steroid ointments may help. Often when there is scarring that cannot be reversed a circumcision is required.

Vasectomy

A vasectomy is a form of permanent male contraception. A scalpel free technique is used were a puncture in the upper part of each scrotum is made to pull out a segment of the vas. This is the tube that transmits sperm from the testes to the prostate. A segment is removed and the two cut ends cauterised, tied and sutured at different levels to reduce the risk that they join back together again. The skin puncture site is closed with dissolvable sutures and skin glue. Two sets of firm underpants should be worn even when sleeping for around a week after the procedure to minimise any swelling or bruising.

The vasectomy does not work immediately. Usually a semen sample is tested 3 months afterwards to confirm there is no more sperm, but in some cases it can take up to 7-8 months to confirm that the vasectomy has been successful (special clearance).