When a bloke comes in to my medical office and his first words go along the lines of “This is a bit embarrassing Doc”, it generally means there is something wrong with his penis. I’m always amused at the various names assigned to the male appendage as generally the next line is “There is something wrong with my…” The fill in may be old fella, donger, doodle or plain old dick. After taking a history, it will generally then involve an order to drop your dacks and let’s have a Captain Cook. If this article is being read overseas or by someone with no knowledge of Aussie slang or rhyming slang, then the last line can be translated as an order by the doctor to the patient to remove his lower apparel so that visualisation of the male sexual organ can be obtained.

Now, I have examined quite a few dicks in my time as a GP and when I think of them it reminds me of that wonderful old joke – what’s old and wrinkly and hangs out your jocks? Your mum! Yes the penis has its fair share of lumps, bumps, spots, dots, wrinkles and creases. There are no two dicks the same. Just as fingerprints are used to identify individuals, penises could be used as a unique way of proving identity but it could create a bit of havoc at places like banks and airports. Importantly, most spots on the penis are harmless.

The skin of the penis is like skin anywhere else on your body. It can have all the various skin conditions that afflict the skin such as psoriasis, eczema, dermatitis and even skin cancer. Yes, cancer of the penis does occur but fortunately it is not very common – about one in 200-300,000. It generally presents as a non-healing sore and is commoner in uncircumcised males. Most blokes who come in who are worried about a spot on their dick are more worried about the possibility of a sexually transmitted infection (STI), and a lot of them have not had any untoward sexual contact. The commonest non-STI spots on the penis are:
– Normal sebaceous or oil glands: These are generally on the shaft and under the surface of the penis as well as on the scrotum or ball bag. They are small, whitish and uniform in size and shape and are more prominent when the skin is stretched. Hence they are more prominent when the penis is erect and hence may be noticed by the sexual partner. A concern may be expressed that they may represent genital warts but the appearance and distribution are quite different and your doctor should be quickly able to reassure you. Some of the glands may get blocked and some extra oily secretions may build up and make one more prominent than another. For trivia buffs, they are officially known as Fordyce’s spots.
– Infected sebaceous glands: The oil glands can get infected and then they will look like an infected pimple. It can be sometimes difficult to differentiate them from a herpes blister but generally a swab of the sore, which is sent to a pathology laboratory, will sort this important differential diagnosis out.
– Pearly Papules of the Penis: The PPP. These are small (1-2mm), uniform, dome shaped lumps that run around the edge (corona) of the knob (glans) of the penis in rows, which resemble a tiny string of pearls. They are more likely to be present in uncircumcised males in the 20 to 35 year age bracket for some unknown reason. It is estimated that 20% of males have them. They are neither infectious nor contagious and hence can be left alone.
– Little red spots called haemangiomas commonly occur on the ball bag (scrotal) skin.
When it comes to the sexually transmitted infections that present with lumps and bumps, the main conditions a doctor sees are genital warts, herpes and another viral infection called Molluscum Contagiosum. When I think of genital warts I think of the word irregular. They may be single or multiple and vary in shape and size. Some may be flat and others almost frond-like and can occur anywhere on the penis, pubic area and anus. The Human Papilloma Virus (HPV) causes them. A vaccination program in schools will hopefully greatly reduce the incidence of this disease, which can have dire consequences in females, making them prone to cervical cancer. Molluscum Contagiosum or MC as it is known is cropping up more and more in the sexual health area whereas before it was mainly confined to the skin of children. It is due to a poxvirus and has a characteristic feature of the lesions being what we term umbilicated or having a central core. Herpes Simplex infection, be it Type 1 (cold sores) or Type 2 (genital) presents with red painful sores, blisters or ulcers on the penis. A swab is generally taken and treatment instituted straight away. The main message is don’t be embarrassed and go and get anything new or different checked!

OUT OF SHAPE
Another area of complaint regarding the penis is the shape of it when it is erect. When erect, the penis should be fairly straight with a slight bow backwards. There is a condition called Peyronie’s Disease in which this bow is either exaggerated or in fact the penis bends sideways. This is not an uncommon condition although there are not a lot of visits to the GP to underline its importance. Most blokes and their partners probably silently put up with it. Clinically, it is estimated that it affects up to 3% of blokes, but it may be as high as 10% or more. The cause is unknown but it has a connection and similarities with a hand condition called Dupuytren’s Contracture in which the little finger and sometimes the ring finger progressively bends forwards into the palm.

Both conditions involve scar tissue developing in the ligaments of the penis or the hand. The scar tissue slowly but progressively contracts or shortens and with respect to the penis this contracture may bend the penis so much so that it makes sexual penetration almost impossible. It can be painful and may lead to erectile problems because the blood can’t get past the bend. The penis can look completely normal when not erect but sometimes the thickened hard lump under the skin, called a plaque, can be felt. The big problem is what to do about it. Various remedies have been tried including potions and lotions, injections and even surgery. As a general rule in medicine, when a lot of remedies exist for any condition, it means that there isn’t a cure.

It tends to be a condition that predominately affects blokes in the middle to later years, the 40-75 age bracket, although I have had a couple of younger blokes in their 30s. No one really knows what causes it, but as there is scar tissue involved it probably has something to do with an over-active healing process with some sort of trauma to the penis being the instigator. There is a family link and it also has connections with diseases which may affect blood supply going to the penis such as diabetes, high blood pressure and cholesterol as well as lifestyle issues such as grog and fags. Another good reason to have alcohol free days and give up the fags!

So what can be done about it? Firstly, understanding that it is a relatively common but unheralded condition is important, as well as knowing that the lump you can feel in the penis is not a cancerous lump. Reassurance may be all that is required. If there is no pain or discomfort involved and satisfactory intercourse (from both sides) is occurring then no treatment is needed. Will it get any worse? It may, but it may not, and in my experience, the may nots seem more prevalent. Basically the options are surgery, which works but it has a major problem in that shortening of the penis occurs, versus another group of various treatment modalities, which have various responses, but with limited proven effectiveness. This group includes oral and topical therapies such as Vitamin E and the blood pressure drug Verapamil (Isoptin).

Injections have also been tried and perhaps offer a potential benefit. Studies are underway using a drug called Xiaflex or collagenase which is a scar dissolving drug. It has been found to be useful in the hand equivalent condition of Dupuytren’s contracture. Verapamil has also been injected with good responses, as to the immune, anti-viral drug, Interferon. There are also stretching devices called traction devices or penis extenders, which have been shown to straighten out the penis with the added benefit of lengthening it. However, it is like having your dick stretched out on a rack under your pants all day for quite a long time before results are seen. I’m not sure about that one. Surgery and injections are in the realm of a urological surgeon or Urologist so you would need a referral from your GP to head down those paths. The decision to go ahead with surgery is a major one and will depend on the severity of symptoms, whether or not the condition is stable and the realisation that the penis will be straighter (perhaps not perfectly straight) but more than likely, shorter than what you were given.

THE FORESKIN
You can’t talk about the penis without talking about the hoody or foreskin. The first issue is that you may or may not have one. If you don’t have one then you don’t have a problem. Circumcision rates were in the 80% range back in the 1950s. This is probably a reflection of society at the time, and especially the large number of males having gone through the World Wars. Circumcision was considered a public health intervention as it was thought to reduce the incidence of sexually transmitted infections. It continued for a time as the male off spring were circumcised to keep them like dad. Certainly the incidence and prevalence of circumcision has reduced over the years with the number of males without foreskins being now in the order of 15%. I know when I was at school at Marcellin in the mid 70s it was probably about 50/50 as one of the criteria for picking the soccer sides at lunch time was circumcised versus uncircumcised and about half went one way and the other half the other way. The only problem was that the uncircumcised blokes were generally from overseas parentage and hence were bloody good soccer players! A recent study has confirmed the value of circumcision as a strategy in HIV prevention in Third World countries but then extrapolating this to our society is an issue for debate.
The main problem that occurs with the foreskin is that the opening can narrow down and become tight and not allow the head or knob of the penis to push through, trapping urine and increasing the risk of infection and scarring, which further makes the narrowing worse. It can also make having erections painful. The narrowing is called a phimosis. An infection of the foreskin and knob of the penis may then occur and is called balanitis. The phimosis or narrowing can be treated with cortisone creams and infections may require a topical antibiotic and sometimes an oral one as well. Fungi can also get under the foreskin and require specific creams. If the narrowing persists and the foreskin can’t be retracted properly then a circumcision may need to be contemplated. I’ve seen blokes almost do their own handiwork with respect to this procedure by doing the dreaded zipper injury – ouch!
When it comes to lumps and bumps ‘down there’, there is also the issue of the testicles. I will leave the issue of testicular problems to my next ManSpace article, as it is an important area to cover in depth. In the mean time, stay happy and healthy… And go Hawks!

Dr Bernie Crimmins