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Lacking Tumescence of Glans During Penile Erection
0022-534 7/85/1346-1220$02.00/0 Vol. 134, December
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1985 by The Williams & Wilkins Co.
Letters to the Editor RE: PENILE TOURNIQUET INJURY DUE TO A COIL OF HAIR J. Sheinfe/,d,, L. R. Cos, E. Erturk and A. T. K. Cockett
J. Urol., 133: 1042-1043, 1985 To the Editor. The authors report on a 7-year-old boy with uncomplicated penile strangulation by hair. In the discussion they indicated that the condition "... was reported first by Morgenstern in 1882.", "The patients always are children... ", "... we are unaware of any case reported in an uncircumcised child.". In a recent review of 60 cases in the literature1 it had been found that there were 2 elderly patients, aged 69 and 77 years, respectively,2 the earliest mention of penile hair strangulation dates back to 16123 and the condition does occur in uncircumcised individuals. I Respectfully, Farid S. Haddad Veterans Administration Medical Center Phoenix, Arizona 85012
insisted that we do something we performed a "glando-cavernous" anastomosis.• The operation was performed with the patient under local anesthesia, during a papaverine-provoked erection. Immediately after closure of the skin of the corona glandis the glans became swollen and the erection appeared normal. Two weeks postoperatively the patient reported that the erections had normalized and that the glans swelled during erection. He was still satisfied 3 months postoperatively. It is not known how frequently this condition will be seen or how often it will lead to sexual problems. However, it is significant since it is a condition that may be confounded with other types of erectile failures. Furthermore, it seems possible that the problem can be corrected with a simple surgical procedure. Respectfully, J. Ebbeh
1. Haddad, F. S.: Penile strangulation by human hair. Report of three cases and review of the literature. Urol. Int., 37: 375, 1982. 2. Dakin, W. B.: Urological Oddities. Los Angeles, 1948. 3. Guillimeau, J.: The Nursing of Children. London, 1612. LACKING TUMESCENCE OF GLANS DURING PENILE ERECTION To the Editor. During normal penile erection blood flow through the glans penis is increasing, resulting in tumescence and color change. I The importance of this reaction to sexual performance is not quite clear but it is known that some patients may maintain normal coital activity after amputation of the glans penis. Lacking tumescence of the glans during an otherwise normal erection was the complaint of 3 of 300 patients with various types of erectile insufficiency. These patients were able to have coitus and were told not to worry about this minor abnormality. When patient 4 presented with a similar complaint we decided to evaluate the condition. The patient was a 22-year-old student who had had erections with normal rigidity and tumescence of the glans until he was 15 years old when he was in a car accident and suffered a serious concussion. Since the accident he had not experienced tumescence of the glans during erection. It could not be established whether the patient had injured the penis during the accident. He was able to have coitus but he was ashamed of the appearance of the erect penis. An ultrasonic Doppler examination revealed a penile blood pressure index of 0.9, increasing to 1.2 after 5 minutes of penile ischemia. 2 The pulse curves from the left dorsal artery and both deep arteries appeared normal, while the curve from the right dorsal artery was abnormal before as well as after intracavernous injection of papaverine. An artificial erection could be obtained with infusion of 150 ml. per minute and maintained with 50 ml. per minute. 3 Full rigidity of the cavernous bodies was obtained by intracavernous injection of 20 mg. papaverine." During the artificial and the papaverine-provoked erection the glans penis remained flaccid and the patient stated that these erections were similar to his usual erections. The sensitivity of the glans was normal. Consequently, it seems as though the blood supply to the glans penis was insufficient, while the blood supply to the cavernous bodies seemed to be normal. After some considerations and because the patient
RE: PENILE DENUDATION INJURIES AFTER CIRCUMCISION J. R. Sotolongo, Jr., S. Hoffman and M. E. Gribetz
J. Urol., 133: 102-103, 1985 To the Editor. I write strictly in regard to the complication of neonatal circumcision and in reference to case 1 in the study. I concur with the management of this case as one way to manage the problem. Often, however, it also is advantageous to place 4 quadrant sutures and to approximate better an edge of the ventral foreskin to the edge of the remaining shaft skin. My disagreement with the study is that this is not a regeneration of the penile shaft skin. The denudation of the shaft skin in neonatal circumcision occurs usually as a result of failure to break down completely the ventral foreskin adhesions to the glans penis. Breakdown must be complete so that the entire corona is visualized. What usually remains after denudation of the penile shaft skin is the ventral foreskin, as demonstrated in part A of the figure in the article. It is my impression that part B of the figure shows that this skin is penile shaft skin and the evident healed suture line at the base of the penis. This is an example of what is termed "the hidden penis syndrome or pseudomicrophallus syndrome". When confronted with this complication my experience has been that it is important to recognize that usually the ventral foreskin is still adherent to the glans penis and that this allows the corrective repair of the complication without the need of a skin graft.
1220
Respectfully, PaulSmey Section of Pediatric Urology University of Texas Branch at Galveston Galveston, Texas 77550-2776
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1985 by The Williams & Wilkins Co.
Letters to the Editor RE: PENILE TOURNIQUET INJURY DUE TO A COIL OF HAIR J. Sheinfe/,d,, L. R. Cos, E. Erturk and A. T. K. Cockett
J. Urol., 133: 1042-1043, 1985 To the Editor. The authors report on a 7-year-old boy with uncomplicated penile strangulation by hair. In the discussion they indicated that the condition "... was reported first by Morgenstern in 1882.", "The patients always are children... ", "... we are unaware of any case reported in an uncircumcised child.". In a recent review of 60 cases in the literature1 it had been found that there were 2 elderly patients, aged 69 and 77 years, respectively,2 the earliest mention of penile hair strangulation dates back to 16123 and the condition does occur in uncircumcised individuals. I Respectfully, Farid S. Haddad Veterans Administration Medical Center Phoenix, Arizona 85012
insisted that we do something we performed a "glando-cavernous" anastomosis.• The operation was performed with the patient under local anesthesia, during a papaverine-provoked erection. Immediately after closure of the skin of the corona glandis the glans became swollen and the erection appeared normal. Two weeks postoperatively the patient reported that the erections had normalized and that the glans swelled during erection. He was still satisfied 3 months postoperatively. It is not known how frequently this condition will be seen or how often it will lead to sexual problems. However, it is significant since it is a condition that may be confounded with other types of erectile failures. Furthermore, it seems possible that the problem can be corrected with a simple surgical procedure. Respectfully, J. Ebbeh
1. Haddad, F. S.: Penile strangulation by human hair. Report of three cases and review of the literature. Urol. Int., 37: 375, 1982. 2. Dakin, W. B.: Urological Oddities. Los Angeles, 1948. 3. Guillimeau, J.: The Nursing of Children. London, 1612. LACKING TUMESCENCE OF GLANS DURING PENILE ERECTION To the Editor. During normal penile erection blood flow through the glans penis is increasing, resulting in tumescence and color change. I The importance of this reaction to sexual performance is not quite clear but it is known that some patients may maintain normal coital activity after amputation of the glans penis. Lacking tumescence of the glans during an otherwise normal erection was the complaint of 3 of 300 patients with various types of erectile insufficiency. These patients were able to have coitus and were told not to worry about this minor abnormality. When patient 4 presented with a similar complaint we decided to evaluate the condition. The patient was a 22-year-old student who had had erections with normal rigidity and tumescence of the glans until he was 15 years old when he was in a car accident and suffered a serious concussion. Since the accident he had not experienced tumescence of the glans during erection. It could not be established whether the patient had injured the penis during the accident. He was able to have coitus but he was ashamed of the appearance of the erect penis. An ultrasonic Doppler examination revealed a penile blood pressure index of 0.9, increasing to 1.2 after 5 minutes of penile ischemia. 2 The pulse curves from the left dorsal artery and both deep arteries appeared normal, while the curve from the right dorsal artery was abnormal before as well as after intracavernous injection of papaverine. An artificial erection could be obtained with infusion of 150 ml. per minute and maintained with 50 ml. per minute. 3 Full rigidity of the cavernous bodies was obtained by intracavernous injection of 20 mg. papaverine." During the artificial and the papaverine-provoked erection the glans penis remained flaccid and the patient stated that these erections were similar to his usual erections. The sensitivity of the glans was normal. Consequently, it seems as though the blood supply to the glans penis was insufficient, while the blood supply to the cavernous bodies seemed to be normal. After some considerations and because the patient
RE: PENILE DENUDATION INJURIES AFTER CIRCUMCISION J. R. Sotolongo, Jr., S. Hoffman and M. E. Gribetz
J. Urol., 133: 102-103, 1985 To the Editor. I write strictly in regard to the complication of neonatal circumcision and in reference to case 1 in the study. I concur with the management of this case as one way to manage the problem. Often, however, it also is advantageous to place 4 quadrant sutures and to approximate better an edge of the ventral foreskin to the edge of the remaining shaft skin. My disagreement with the study is that this is not a regeneration of the penile shaft skin. The denudation of the shaft skin in neonatal circumcision occurs usually as a result of failure to break down completely the ventral foreskin adhesions to the glans penis. Breakdown must be complete so that the entire corona is visualized. What usually remains after denudation of the penile shaft skin is the ventral foreskin, as demonstrated in part A of the figure in the article. It is my impression that part B of the figure shows that this skin is penile shaft skin and the evident healed suture line at the base of the penis. This is an example of what is termed "the hidden penis syndrome or pseudomicrophallus syndrome". When confronted with this complication my experience has been that it is important to recognize that usually the ventral foreskin is still adherent to the glans penis and that this allows the corrective repair of the complication without the need of a skin graft.
1220
Respectfully, PaulSmey Section of Pediatric Urology University of Texas Branch at Galveston Galveston, Texas 77550-2776