Congenital conditions of the penis can be identified in a wide range of age groups but most often are diagnosed in infants or children. These conditions affect male genitalia and typically involve abnormal foreskin formation or internal anatomical differences. The differences usually prevent a successful newborn circumcision or put a boy at risk for circumcision complication if done as a newborn. Untreated conditions may have long-term consequences, including permanent penile deformity; risk for foreskin complications, such as infections; urinary difficulty; or sexual dysfunction.

Anatomy of the penis

At birth, an uncircumcised penis includes:

• Foreskin: This is a collar of skin that covers the tip, or glans, of the penis.

 

• Prepuce: The foreskin marks the border of the skin and mucosa. This tissue is similar to that of the labia minora, eyelids, anus and lips. The prepuce is an erogenous zone made of a complex network of nerves.

 

• Urethra: The urethra carries urine out of the body and allows semen to pass through during ejaculation.

 

• Meatus: The meatus is the hole where urine comes out.

 

• Penile shaft: The shaft is the base of the penis, where erectile tissues allow blood to fill for erections

 

Circumcision removes the foreskin entirely, typically in the interest of removing a need for future retraction care and cleaning.

Common penile anomalies

These are the most common penile conditions. The course of treatment depends on severity of presentation and type of anomaly.

 

Penile torsion: This causes the penis to twist, usually counterclockwise. Though it typically is not painful, it can cause urine to stream abnormally. Mild forms may not require correction, but severe forms may need surgery. The twist is usually related to skin and connective tissue tethering, but sometimes is related to the erectile tissues beneath as well.

 

Chordee: In this case, the penis has an asymmetry of the skin, connective tissues or erectile tissues, most commonly affecting the underside or ventral surface of the shaft. Chordee is congenital, while Peyronie disease typically develops later in life. Skin and connective tissue chordee often will cause redundant foreskin after newborn circumcisions, or risk too much skin being taken, causing erection curvature and/or pain. When chordee involves the erectile tissues, erection curvature is seen, which can be prohibitory or cause pain with future intercourse. Erection curvature is most commonly ventral or downward, but also can be sideways or lateral.

 

Buried: The penis is totally or partially concealed beneath the scrotum or excess fat/skin in the pubic area. The buried penis is usually the typical size and function, but you may not be able to see the head or shaft of a severely buried penis. These boys are at higher risk for getting the penis trapped in the scrotum or pubic fat, or having too much skin taken with a routine newborn circumcision.

 

Penoscrotal webbing: This occurs when some of the skin of the scrotum is attached to the shaft, and it can vary from mild to more severe forms. It is often associated with chordee and/or buried penis and can cause downward erection curvature. The condition also has been associated with inability of the foreskin to retract appropriately over time in boys for whom circumcision is deferred.

 

Hypospadias: This is when the urethral opening is located on the underside of the head or shaft instead of at the tip. It also refers to atypically shaped urinary openings. Hypospadias has a wide spectrum of findings, with some not needing a dedicated repair, but the more significant cases typically have problematic urinary stream deviation and/or notable erection curvature.

 

Circumcision for penile anomalies

 

Circumcision is a commonly performed procedure on newborns assigned male in the United States, however the rates of routine newborn circumcision have been declining as guidance from the American Association of Pediatrics has shifted. Circumcision may be done for medical, social or religious reasons, but in the case of congenital penile anomaly, it may be recommended to delay a circumcision. If there are minimal amounts of chordee, torsion or webbing, a circumcision may be performed. If the child is not referred until four to six weeks after birth, it is not safe to do a newborn circumcision. There also may be incidences where circumcision is contraindicated, particularly when there is concern for increased bleeding risk.

 

When to refer to a specialist for penile anomaly

Early detection is key to simpler and less complicated corrections, as well as improved patient and parent experiences. It is important to know the symptoms of a potentially serious condition as soon as possible to avoid long-term or permanent damage, loss of function or sexual dysfunction.

 

Symptoms of a serious condition related to penile anomalies may include:

• Hypospadias discovered during circumcision
• Inability to void urine, sometimes associated with more severe buried penis or webbing
• Injury to the glans, such as with a zipper, but can be a rarer newborn circumcision complication

 

Testing for serious penile conditions may include:

• Physical examination
• Blood tests
• Ultrasounds

 

Patients may need to have follow-up visits after surgery, sometimes during puberty.