PRACTICAL CONSIDERATIONS : THE PENIS. i973 



At birth the prepuce is normally adherent to the glans, its moderate retraction 

 barely exposing the meatus. Continued retraction everts the lips of the meatus and 

 then separates the epithelial adhesions between glans and prepuce, ultimately exposing 

 a congested surface and causing punctate hemorrhages. 



This separation should normally take place during infancy or early childhood, 

 either spontaneously as a result of erections and of the growth of the organ or because 

 of gradual mechanical retraction by nurse or mother. When it fails to do this, th'e 

 condition oi phimosis — inability to retract the prepuce — follows, and is due partly to the 

 persistent adhesions and partly to a frequently associated narrowing of the preputial 

 orifice. 



Both these factors may be the result of disease, and acquired phimosis may occur 

 at any time of life and follow any form of inflammation of the skin covering the glans 

 {^balanitis ) , of the inner surface and cellular tissue of the prepuce {posthitis), or of 

 both {balano-posthitis) , the last named being the most common. Following phimosis 

 there may be, (a) as a result of retention of secretion and of urine in the subpreputial 

 space, balanitic or herpetic ulceration, or the development of papillomata (venereal 

 warts) ; (^) as a result of obstruction to the flow of urine and the consequent strain- 

 ing, vesical irritability, dilatation of the bladder, ureters, and kidneys, hemorrhoids, 

 and hernia (62 per cent, of cases of congenital phimosis) (Kempe, quoted by Jacob- 

 son) ; {c) as a result of nerve irritation (the region having an unusually rich nerve- 

 supply), spastic palsies, reflex joint pains and muscular spasm (simulated coxalgia), 

 or even general convulsions. 



These complications are most apt to occur in infants and very young children, 

 and their frequency has been exaggerated. 



As a result of phimosis, even when the preputial orifice is ample, there may be 

 a contracted or ' ' pin-point' ' meatus, which may give rise to the same train of symp- 

 toms and will require to be di\'ided {jneatotomy) by a linear incision directed towards 

 the frenum, and kept open during the process of healing. 



Circumcision, whether done for phimosis or to meet other indications, requires 

 for its successful performance attention to the following anatomical points : {a) the 

 laxity of the skin, permitting it easily to be drawn so far in front of the glans that 

 when it is severed at that point so much may be removed that the remainder retracts 

 quite to the root of the organ, which is left denuded ; {b) the close attachment of the 

 inner or mucous layer of the prepuce to the corona, so that the length of the portion 

 of that layer that is allowed to remain will determine the distance of the operati\'e 

 scar (at the muco-cutaneous junction) from the meatus ; if this stump is not exces- 

 sive, it will thus effectually prevent the mortifying but not infrequent accident of re- 

 formation of a phimosis after a circumcision ; (r) the loose, abundant cellular tissue 

 and rich vascular supply in the frenal region, which, together with the dependent 

 position of the part, may determine an excess of exudate that will result in an objec- 

 tionable fibrous mass in that region if full hsemostasis is not secured or if any redun- 

 dant tissvie is left there. 



When a relatively small preputial orifice is drawn behind the corona it causes 

 marked constriction at that point, especially if it is not only small but also inelastic as 

 a result of chronic inflammation. If the constriction remains unrelieved, paraphimo- 

 sis results ; the glans becomes distinctly enlarged, increasing the constriction, purplish 

 in color, and glossy. It is often partially concealed by a thick collar of shiny, oedem- 

 atous skin, behind which there is a deep, excoriated sulcus, and back of this sulcus 

 there is usually a second oedematous band less marked than the one lying immediately 

 behind the coronary sulcus. The penis seems to have a distinct upward kink or bend 

 just behind the glans. This appearance is due to the deep notch caused bv the 

 margin of the retroverted orifice of the prepuce and to the oedematous swelling 

 which is particularly marked about the position of the frenum. In some cases, where 

 the tense, inelastic edge of the orifice exerts a more than usual amount of constriction, 

 circulation is markedly interfered with, and ulceration and even sloughing involving 

 both the foreskin and the head of the penis may take place. This complication would 

 undoubtedly be more frequent were it not for the rich blood-supply to the glans 

 and the anastomosis between its vessels and those of the corpora cavernosa. The 

 ulceration usually involves the foreskin only. 



