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renal failure. In addition, chronic, severe strictures may lead to urethral fistulas and periurethral abscesses.Concept 2: Phimosis & Paraphimosis (Q# 20, Study Guide, p. 130): Phimosis and paraphimosis are disorders in which the foreskin (prepuce) is “too tight” to be moved easily over the glans penis. Phimosis is a condition in which the foreskin cannot be retracted back over the glans, whereas paraphimosis is the opposite: the foreskin is retracted and cannot be moved forward (reduced) to cover the glans. Both conditions can cause penile pathologic conditions. The inability to retract the foreskin is normal in infancy and is caused by congenital adhesions. During the first 3 years of life these adhesions separate naturally with penile erections and are not an indication for circumcision. Although most cases occur in uncircumcised males, stenosis and resultant phimosis can occur in males with excessive skin remaining after circumcision. Phimosis can occur at any age and is caused most commonly by poor hygiene and chronic infection. Concept 3: Peyronie Disease (Q# 6, Study Guide, p. 129): Peyronie disease (bent nail syndrome) is a fibrotic condition of the tunica albuginea of the penis resulting in varying degrees
of curvature and sexual dysfunction. Peyronie disease develops slowly and is characterized by tough, fibrous thickening of the fascia in the erectile tissue of the corpora cavernosa. A dense fibrous plaque is usually palpable on the dorsum of the penile shaft. The problem usually affects middle-age men and is associated with painful erection, painful intercourse (for both partners), and poor erection distal to the involved area. In some cases, impotence or unsatisfactory penetration occurs. There is no pain when the penis is flaccid. Although the exact cause is unknown, a local vasculitis-like inflammatory reaction occurs and decreased tissue oxygenation results in fibrosis and calcification. Peyronie disease is associated with Dupuytren contracture (a flexion deformity of the fingers or toes caused by shortening or fibrosis of the palmar or plantar fascia), diabetes, tendency to develop keloids, and in rare cases, use of beta-blocker medications. There is no definitive treatment for Peyronie disease.Concept 4: Priapism (Q# 4, Study Guide, p. 129): Priapism is an uncommon condition of prolonged penile erection. It is usually painful and is not associated with sexual arousal. Priapismis idiopathic in 60% of cases; the remaining 40% of cases are associated with spinal cord trauma,sickle cell disease, leukemia, pelvic tumors or infections, or penile trauma. Priapism also has been associated with cocaine use. Intracavernous injection therapy for impotence seems to be themost common cause. Prolonged sexual stimulation often is associated with initial development of the idiopathic type. The two corpora cavernosa within the erect penis are filled with blood andare tender to palpation; neither the corpus spongiosum nor the glans is engorged. The vascular congestion is thought to be associated with venous obstruction. If the erection remains over a period of days, edema and fibrosis develop, leading to erectile dysfunction (impotence). Priapismis a urologic emergency. Treatment within hours is effective and prevents impotence.