The other morning, I had to take care of three penises before lunch. That was an unusual concentration of penis problems so I decided to share them with you.
The first was a thirty-year-old man with a “drip” or discharge from his penis. Of the three penis complaints, his was the most common for us to deal with in the emergency department and, as a result, the easiest. For about a day he had been having a thick, green discharge from the end of his penis with some burning when he urinated. He admitted to having unprotected intercourse with someone he was sure had passed this little present on to him. This sort of discharge is usually caused by gonorrhea so I treated him for that as well as chlamydia, because they so often travel around together. He was advised to notify all of his sexual contacts and a report was sent to public health.
Penis number two was a twenty-year-old who came in saying he caught the end of his penis in his zipper. This had caused a little cut that would not stop bleeding. Sure enough, he had a little cut and it was still oozing but it was clear he was lying about how he got it. An uncircumcised man who catches the end of his penis in his zipper will almost always catch the end of the foreskin. Most of the time, this just causes a painful pinch but it can cause a small laceration. The end of the foreskin can also get caught in the zipper so deeply that the patient is unable to get it out. I have seen more than one man come in with the zipper, cut free from the old pants, caught on the end of his penis and tucked down into the pants he was then wearing. We have little tricks to get the foreskin out of the zipper without doing any more damage and such a patient is always quite appreciative once he is extricated.
It was immediately clear that this man had not caught his penis in his zipper at all. His laceration was in the frenulum of his penis. This is a thin connection between the bottom of the glans (head) and shaft. It is down underneath the foreskin and very protected from any errant zipper. The frenulum is frequently damaged from too exuberant sex, which is most certainly what happened to this man, though he persistently denied it.
There are several tricks for getting a pesky little cut like this to stop bleeding. Most will stop with just some good pressure. When this doesn’t work, the next thing I try is a little injection of local anesthesia with epinephrine (adrenaline.) This causes constriction of the blood vessels, which helps stop the bleeding. If that doesn’t work, I put one or two little stitches into the cut. That always fixes the problem. This guy didn’t need the stitches and went off happy that his penis was no longer bleeding. Makes me wonder if he thought we still believed his zipper story or not.
Penis number three is saved for the last because his was the most unusual and difficult to care for of the three. He was a seventy-year-old who was unable to pee. His doctor recently told him he was passing a kidney stone. In the past, he had a kidney stone stuck in the end of his penis and he had to go to the emergency department to have it pulled out. He said he could now feel a stone half way down the shaft of his penis and that that was probably the reason he couldn’t pass urine.
Evaluating his penis was difficult because he had a small penis and was quite obese. The shaft of his penis was almost covered by the fat of his mons pubis (hair-covered skin above the penis.)
The most straight-forward way to fix a penis plugged by a stone is to pass a Foley catheter through the penis and into the bladder. The catheter pushes the stone back into the bladder so the patient can pee. Then, the patient can then follow up with his urologist to have the stone removed.
A while after I asked the nurse to pass the catheter, she came back saying she was unable to do so. The patient had phimosis, which is a scarring of the foreskin so it cannot be retracted off the glans. With a combination of the patient’s obesity, small penis and phimosis, there was no way the nurse could get to the opening of the urethra to pass the catheter into it.
This kind of situation is a urological emergency. The patient is unable to void and he needs to empty his bladder. However, because I was working in a small-town emergency department with no urologist on call, I had to do something. One option I had was to poke a needle through the patient’s lower abdominal wall and pass a catheter straight into his bladder from there. The other option I had was to do a dorsal slit of the patient’s foreskin. This was more aggressive effort to gain access to the opening into the urethra, and it was the approach I decided to take.
First, I used a local anesthetic to numb up his entire penis. I then cut back through the foreskin, trying to expose the glans and find the opening to the urethra. This ended up being much more difficult than I expected it to be. It had been so long since his glans had seen the light of day that the foreskin was scarred down completely to the underlying glans. I had to insert a forceps a little way, make a small slit in the foreskin, then repeat, all the time controlling the bleeding and making sure not to cut anything but the foreskin. Eventually, I was able to identify the urethra and, with quite a bit of difficulty, get a little catheter passed up into the patient’s bladder. His relief was immediate.
By this time, I was convinced that his scarred down foreskin was the real cause of his inability to void. However, to be sure, I sent him for an ultrasound of his penis and bladder. No stone was detected which confirmed my diagnosis.
The patient went home with the catheter in place and a referral to a urologist. He will need to have a circumcision to fix his problem for good.