CHAPTER XLIir
DIAGNOSIS OF DISEASES OF THE PENIS
Conf/enital malioimalions. — Defective develop- ment of the lower wall of the urethra, or hypospadias, results in the urethra opening at some point on the under-surface of the penis. Three varieties are met with: {I) hypospadia glanclis, the meatus being situated at the junction of the glans and body, in the position usually occupied by the frtenum of the prepuce, which in these cases is slit below and covers the glans like a cowl ; (2) hypospadia penis, where the urethral opening is placed on the under surface of the body of the penis, which is usually stunted ; and (3) hypospadia perineaUs, or complete hypospadias, a condition in which the urethra opens m the perineum, associated with cleft scrotum and an imperfect development of the penis which re- sembles an hypertrophied clitoris. These patients are also known as pseudo-hermaphrodites. A cleft of the penis along the dorsum is known as epispadias ; when complete it is associated with extroversion of the blt\dder.
The prepuce.— If the prepuce cannot be drawn back over the glans with ease and without pain the patient has phimosis. If, when the prepuce is drawn back, the glans is curved downwards, the frtenum is too tight. If the prepuce, having been drawn back cannot be replaced over the glans, the condition is known as paraphimosis, and when the constriction of
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SURGICAL DIAGNOSIS [chap.
the prepuce is tight a roll of oedematous mucous membrane rises up behmd the congested glans, and still farther back the skin of the penis is swollen, while between these two swellings deep down in a sulcus is the tight margin of the prepuce. The pre- puce is often too long, but if it can be properly retracted this condition is not phimosis.
Phimosis may be congenital or acquired. The con- genital form is recognized by the history. It is due either to narrowness of the orifice preventing its , passing back easily over the glans, or, more com- ; monly, to adhesion of the prepuce to the glans. The : condition can easily be recognized by attemptmg to . draw back the prepuce. A very tight congenital phimosis may after a long time lead to great dila- tation of the prepuce. Acquired fUmosis may be caused by cedema, either inflammatory or part of a general dropsy, by solid oedema, by a hard chancre, by chronic balanitis causing adhesion of prepuce to glans, by cicatrices narrowing the orifice of the pre- puce, by growths, or by elephantiasis or great disten- sion of the scrotum by hydrocele, etc., dragging upon the sheath of the penis Any one of these condi- tions may be combined with congenital phimosis. Acquired phimosis is often met with in morbus cordis and chronic nephritis, gonorrhosa, chancre, primary syphilis, and after the healing of chancres of the prepuce. Solid 03dema or hypertrophy of the pre- puce may be caused by constitutional syphilis.
When under a congenitally tight foreskin a lump of stony hardness is to be felt, it is to be diagnosed as a prefutial calculus ; if a probe is passed beneath the prepuce it gives a grating sensation as it touches the stone. These calculi are not to be confoimded with the firm but yielding induration of a hard chancre, epithelioma, or gumma.
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Discharge from the prepuce may be caused by balano- postliitis, urethritis, soft sore, primary syphilis, epithe- lioma, or warts. When the prepuce can be withdrawn the diagnosis is simple {see below), but if there is phimosis care is required to arrive at a right con- clusion, and it may be necessary to slit up the prepuce to allow of an early and exact diagnosis. The orifice of the prepuce is to be well cleaned by syringing or careful wiping, and then the sur- geon should endeavour to expose the meatus urin- arius, and at the same time press forwards along the urethra : if pus is seen to flow from the urethra there is urethritis ; the pus should be examined for the gonococcus. A history of urethral discharge before the phimosis appeared, or of scalding paip along the urethra in micturition, or of chordee supports this conclusion, and if the meatus cannot be exposed the diagnosis may be made from these symptoms alone. If the discharge is sanious and not thick creamy pus, soft chancre is to be diagnosed ; the presence of chancres at the orifice of the prepuce, or the history of an ulcer before the phimosis, is strong corroboration of this diagnosis.
When the swelling of the prepuce is not uniform and a distinct induration is felt at one part only, and there are several indolent buboes in the groiiu, it is primary syphilis ; should the patient show the signs of secondary syphilis, the diagnosis is at once certain. In every case the discharge must be care- fully examined for the Spironema pallidum (see p. 622). If, in a man over 30 years of age, there is a chronic progressive enlargement of the end of the penis, discharging a bloody watery fluid, and a red granular or fungating growth is seen inside the prepuce, or even ulcerating or fimgating through it, it will be recognized as epithelioma,
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SURGICAL DIAGNOSIS
[chap.
esjjecially if tlie inguinal glands are infiltrated. A similar swelling with a thin discharge, in a young man, with a bright, florid, granular appearance ot the growth, without any thickening of the base, would be ivarts. When the discharge is purulent in character, and is found not to flow from the urethra, and there is no localized induration of the prepuce, the condition is halano-fosthilis . Where the inflamed prepuce can be drawn back the mucous surface is seen to be smeared with discharge, and presenting bright-red excoriated patches without any induration or ulceration.
Ulcers on the penis. — The following ulcers are met with on the penis : Herpes.
Simple fissure. - Soft chancre.
Hunterian or hard chancre (primary syphilis).
Mixed chancre.
Gummatous ulcer.
Epithelioma. The first question that must be answered in a case of ulcer of the penis is, Is the lesion a hard chancre ? In many cases it quite clearly is not ; whilst in others the signs of secondary syphilis- enlarged glands, a rash, sore throat, etc.— may be present and prove conclusively that it is. But, fortunately, it is possible to-day to make a cer- tain diagnosis in most cases by demonstrating the presence or absence of the Spironema ■pallidum in the sore.
For details of laboratory methods of examining for the spironema, works on pathology or bacteri- ology must be consulted, but the following method needs no special apparatus; and, in view of the importance of the recognition of syphilis in its
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CHANCRE
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initial stage, we liave thought it well to describe it here before proceeding to the general investigation of ulcers ot the penis.
The surface of the chancre may be scraped, or, better, a fine pipette is driven into the sore. The fluid which passes into the pipette is allowed to settle, and a drop of the serum which separates from the corpuscles is allowed to fall upon a slide. This is mixed with a drop of distilled water and a drop of 1-per-cent. solution of Congo red or of Chinese ink. A film is made with another slide in the usual way and allowed to dry. When examined with a A-inch immersion lens the spironemas are seen as white spirals in a dark field. Their length is about twice the diameter of a red .corpuscle, the spirals, eight to twelve in number, are tightly coiled, and the ends are pointed.
In any ulcer of the penis the surgeon should note the age of the patient, the previous history as regards venereal disease and sexual intercourse, the initial stage of the sore— whether a crop of vesicles, a pustule, an induration, a crack, or a wart — and the number of the ulcers. The sore must be examined to determine the amount of idceration, the presence or absence of induration of its base and edge, and the amount of discharge. The glands in the groin must also be carefidly examined and any enlargement, harden- ing, or fixation of them to the fascia or skin care- fully noted.
- If the sore is quite superficial, not extending through the mucous lining of the prepuce, is of recent ongm, not indurated, and is attended with much itching and smarting, it is probably herpes prEeputialis. If the patient has suffered from similar attacks,' and the affection is known to have begun in a group of tiny vesicles on a bright-red base, this
624
SUKGICAL DIAGNOSIS [chap_
diagnosis is certain. The inguinal glands may be slightly enlarged in this condition.
A linear crack at the orifice of the foreskin, noticed immediately after connexion, which does not deepen or widen, and quickly heals up, is a simple fissure ; this may be multiple and recurrent when there is phimosis ; it is not infrequently seen at the frsenum when that band is tight.
If an acute ulcer develops within a few days after exposure to possible infection, wears a punched- out appearance, with sharply cut edge, an excavated spongy base, without surrounding or subjacent in- duration, it is a soft or non-infecting chancre. This diagnosis is confirmed if the sore is known to have commenced as a pustule, if the ulcer is multiple, and fresh ulcers form from time to time where cracks or erosions are in contact with the abundant purulent j discharge, if there is inflammatory enlargement of ; an inguinal gland, and if the spironema cannot be fomid. The detection of the causal organisms of ! soft sore is always difficult. Sloughing fhagedcena and serf iginous ulceration may attack a soft chancre, but in many of such cases there is evidence of pre- vious constitutional syphilis. All soft chancres leave depressed cicatrices.
If an ulcer has a smooth glistening base, a romid sloping edge, thin watery discharge, and a sharply defined, firm, elastic induration around it which blanches on gentle pressure, it is a hard chancre. If the sore consists of a raised, flat, well-defijied. elastic induration, either with or without ulceration, it is probably a hard chancre. The clearly defined, not very vascular induration is the special mark of the initial lesion of syphilis; it may vary from a small papule or thin paper-like plate m the deeper layer of the skin, to a wide, very dense mass, with
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CHANCRE
625
extensive ulceration. Additional evidence is all'orded by noticing that the induration appeared from three to six weeks after infection (although there may have been a sore before), by the detection of multiple indolent buboes in both groins about the second week after the appearance of the induration, and by the appearance of the secondary eruptions and sore throat, etc. Although most commonly single, mul- tiple chancres do occur. A chancre leaves a scarcely noticeable scar on heahng. C'onfirmatioii of the diagnosis rests upon the detection of the sj)ironcma (see p. 622), and, after the lapse of a week or two from the first appearance of the chancre, a positive Wassermann reaction.
If an ulcer has at first the character of a soft sore, and later on specific induration occurs, it is a mixed chancre, and constitutional syphilis will follow. The surgeon cannot assure a patient of his freedom from syphilis unless a period of at least six weeks from the date of exposure to infection has elapsed without the development of a specific induration ; the occurrence of a soft chancre in no way protects from or renders unlikely the subsequent development of a hard chancre.
If the ulcer is deeply excavated with under- mined edge, and a tough or soft tenacious slough adheres to the base, and this has resulted from the softening down of a chronic induration of the penis in a man whose serum gives a positive Wassermann reaction, or who shows other signs of syphilis, it is a gummatous ulcer. There will not be glandular enlargement ; the sore will yield to antisyphilitic treatment and leave a very depressed scar.
If the ulcer is chronic, and steadily progressive in spite of treatment, with a warty irrcgidar hard
626
SURGICAL DIAGNOSIS [chap.
base, nodular everted edges, a foul watery or sauious discharge, and an infiltrating enlargement of one or more inguinal glands, it is epithelioma.
Phagedaena is the name given to an acute gan- grenous, rapidly spreading inflammation of the penis, resulting, in persons with a low resistance, from a streptococcal infection superimposed upon a specific ulcer.
Gangrene of the penis may arise in the course of specific fevers, or from paraphimosis, phimosis with concealed chancre, or sloughing phagedsena.
Tumours oi the penis may be grouped into the superficial and the deep. The surgeon should notice the mode of attachment or fixation of the tumour to the adjacent parts, and the history or signs of constitutional disease.
If the tumour is a sessile or pedunculated out- growth from the skin or mucous membrane, mth no surrounding indm-ation, and with a branched irregular surface, florid and moist where covered by the fore- skin, dry and hard where exposed, it is a papilloma or wart. These little growths are generally multiple, and usually follow urethritis or balanitis ; they may attain a large size, and then, if exposed to friction, may ulcerate superficially. A horn may be found on either the prepuce or the glans penis.
A flat sessile outgrowth of slight thickness and moderate induration, with a milk-white eroded surface, is a mucous patch.
If the tumour infiltrates the tissue of the penis as well as grows from its surface, havmg a firm irregular outline, and a granular or warty surface, it is epithelioma. The patient is generally over 30. As a rule the growth quickly ulcerates, and spread to. the inguinal glands occurs early. Cancer may grow out of sight imder a tight prepuce, or by its
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balk prevent retraction of the prepuce, and it may spread along the deep structures of the penis.
A firm or boggy induration in the prepuce or deep in the corpora cavernosa, which shows a ten- dency to adhere to the skin and to soften down, is a gumma ; other evidence of syphilis and the efEects of specific treatment confirm the diagnosis.
Very chronic indurations, which do not soften down, are movable under the skin, and situated apparently in the sheath of the corpora cavernosa, are gouty indurations ; at least they are not gummata, they occur quite mdependently of syphilis, and are often associated with gout. Indurations of the penis are also found lingering for many months after injury to the part ; they are sometimes spoken of as throm ■ bosis. Inflammation may spread from the urethra and lead to intense and obstinate induration of the corpora cavernosa. All deep indurations of the penis cause chordee.
Scirrlius of the penis has been described ; it will be recognized by its stony hardness, steady growth, and infection of the glands. Melanotic tumours also occur on the penis. A mucous cyst of the urethra may project from the urinary meatus.
Cieali-iccs on the peuis.— The mitial lesion of syphilis docs not leave a permanent scar ; soft chancre leaves a depressed scar which may after a time wear out; gummatous ulcers leave permanent depressed, thin, ill-nourished scars, often having much pigment in them. The extensive scars of phagedasna and of serpiginous ulceration are most common in the subjects of syphilis.
Diseases of the urethra are considered in Char>
YT.VTTT ^uci^.