PENIS (penis, PNA, JNA, BNA) — an unpaired outside men's generative organ.
The comparative anatomy
From vertebrata copulative body meets at viviparous and animal, for to-rykh internal fertilization is characteristic. In a class akulovy, napr, at a viviparous dog shark, the interiors of belly fins supported by a cartilaginous skeleton were transformed to copulative body.
In a class of bony fishes (zubaty, cyprinid and a gambusia) as copulative body serves the transformed proctal fin. From amphibians only at legless — the limbless amphibians are available copulative body in the form of a reverting wall of a foul place. At snakes and lizards copulative body are the sacculate protrusions lying under skin at the rear edge of a foul place. Turtles and crocodiles have an unpaired thickening of a wall of a foul place formed by cavernous fabric. This copulative body has a fillet for running off of a seed. The similar body on a structure is available in a class of birds — at goose, ostrich and a kiwi. At mammals structure of copulative body (penis) various. At oviparous (cloacal) the groove on P. of h turned into the canal beginning in an urinogenital sine and terminating at top of body. The item of h at these animals is directed back, is in a foul place and can move forward and be involved by special muscles. At ascigerous P. h is located near an anus, is surrounded by the general with it a sphincter and directed back, its end is doubled according to a double vagina of a female. At other mammal P. h is directed forward. Except cavernous and spongy bodies at marsupials, Pinnipedia, cetacea, wing-handed animals, separate predators, semi-monkeys and nek-ry monkeys in the forefront of body P.'s bone of h is located. In a skin fold around P.'s head of the p. (preputium penis) nek-ry animals have specific aromatic glands.
P. of h develops from the indifferent sexual hillock covered with an ectodermal epithelium. On the lower party of a hillock there are genital folds limiting an urethral plate. After overgrowing of an urinogenital sine (on the 7th week of embryonic development) at the back end of an urethral plate the urinogenital opening is formed. Cavernous bodies, and to the 10th week of pre-natal development — a head are formed of a mesenchyma of quickly growing sexual hillock in the beginning. By this time the going deep urethral plate turns into an urethral furrow. Genital folds grow towards each other and, beginning to grow together on the 12th week, turn an urethral furrow into an urethra (urethra). From a mesenchyma of genital folds around an urethra the spongy body of P. of h develops. At the same time the outside opening of an urethra gradually moves to P.'s head of h. At the edges of a head the fold of skin — a prepuce of P. of h expands. The internal leaf of a prepuce is soldered to skin of a head in the beginning, but by the end of pre-natal development between skin of a head and an internal leaf of a prepuce the crack is formed. By the time of P.'s birth of h it is completely created.
Anatomy and histology
Distinguish a body, a root and P.'s head of h (fig. 1). The body consists of two cavernous bodies (corpus cavernosum penis) and a spongy body (corpus spongiosum penis) concluding a spongy part of an urethra. The proximal ends of cavernous bodies called by P.'s legs of h begin on branches pubic and ischiums, forming a root. Rising to to a pubic symphysis (see), cavernous bodies of P. of h grow together. The distal ends of cavernous bodies are pointed and enter under a wreath of a head. The basis of cavernous bodies is made by the white formed by powerful bunches of collagenic fibers and reaching thickness of 1 — 3 mm. Branches of a white — a trabecula — limit the cells of cavernous bodies covered with an endothelium. To a lower surface of the coupled cavernous bodies prilezhit the spongy body similar to them on a structure. The back end of a spongy body is thickened and carries the name of a bulb of P. of the p. (bulbus penis), and front passes into P.'s head of the p. (glans penis), edges has an appearance of a cone-shaped curved plate. On the pointed top of a head opens urethra (see). Spongy and cavernous bodies are covered the general superficial and deep fastsiyama, atop to-rykh the skin having a large number of smooth muscle cells, thin with the translucent vessels, is located thanks to what in the weakened condition of body skin is collected in cross folds. Skin surrounds P.'s head of h with the fold called by a prepuce, the internal leaf a cut passes into skin of a head in the field of a wreath it, and on the ventral party forms a bridle of a prepuce. On an internal leaf of a prepuce there are its glands.
Blood supply is carried out by branches of an internal sexual artery (a. pudenda int.) — deep and dorsal arteries of P. of h (aa. profunda et dorsalis penis), artery of a bulb of P. of the p. (. bulbi penis) and urethral arteries. All arteries connect among themselves a deep and superficial anastomosis of various caliber. So, deep arteries anastomose the arc anastomosis passing in more thickly heads of P. of h. In the head there is an interlacing of the arteries tied by connecting fabric. In some cases one of large branches of a deep artery of P. of h replaces the absent urethral artery. Deep arteries of P. of h open in cells of cavernous bodies which represent peculiar expanded capillaries. Arteries of an urethra pass in the beginning into capillaries which gather in a peculiar veniplex of a mucous membrane of an urethra, and then in system of the cells of a spongy body representing peculiar veins. Venous outflow of h comes from P. through a deep dorsal vein of P. of the p. (v. dorsalis penis profunda), deep veins (vv. profundae penis) and a vein of a bulb of P. of the p. (v. bulbi penis) in veniplexes of a basin.
Lymph drainage. Roots limf, systems P. of h consist of three networks limf, the capillaries located in a white, fastion and skin of body. Vessels which form the textures in the corresponding parts of body passing into large vessels originate from networks limf. These vessels, having created in a krupnopetlisty texture on P.'s body of h, pass in more thickly fastion on its back and bear a lymph to superficial and deep inguinal limf, to nodes.
The innervation (sensitive) is provided with branches of a sexual nerve (n. pudendus) and a back nerve of P. of h (item dorsalis penis) which innervates skin, cavernous bodies, a spongy body and a head. The vegetative innervation proceeds from the lower hypogastric texture (plexus hypogastricus inf.).
Dystrophic changes of P. of h are studied insufficiently, however fatty dystrophy of smooth muscle fibers of cavernous bodies and arterioles, and also atherosclerosis and calcification of arteries of P. of h are known.
The venous plethora of P. of h comes at heart failure, and also at priapism (see), characterized by a sharp venous hyperemia of cavernous bodies. At the same time in P.'s vessels of h the arising blood clots can be found for the second time. The arterial plethora develops at acute inflammatory processes, napr, a balanoposthitis (see. Balanitis, balanoposthitis ). As a result paraphimosis (see) and thromboembolisms of vessels of P. of h there can come his ischemia with the subsequent necrosis. P.'s hypostasis of h developing, e.g., because of heart failure is most expressed in the field of a prepuce. As a result of disturbance of a lymph drainage can develop elephantiasis (see).
The acute inflammation of P. of h has character of a balanitis or balanoposthitis more often. At superficial process find a limited inflammation with a dermahemia of a head of P. of the h and an internal leaf of a prepuce covered purulent separated. The epithelium in places is desquamated. As a result of a necrosis and rejection of epidermis there are erosive centers of bright red color of rounded shape. In some cases at erosive process there can come hypostasis of a prepuce, develop limfangiit also pakhovy lymphadenitis. At gangrenous defeat find deep erosion and ulcers with the expressed necrotic changes. An outcome of a balanitis and balanoposthitis, especially gangrenous, quite often happens phymosis (see) with development in a prepuce of coarse-fibered fibrous fabric.
P.'s gangrene of h (wet is more often) is characterized by formation of black or gray-brown sites of a necrosis. At gistol, a research on the periphery of necrotic masses find plentiful leukocytic infiltration, a plethora and thrombosis of many vessels.
Actinomycosis (see) proceeds with formation of hl. obr. on skin and P.'s head of h the granulomas and diffusion infiltrates which are exposed to fusion with formation of numerous it is long not healing fistulas; there can come P.'s gangrene of h. At gistol, a research find growths of granulyatsionny fabric, polymorphic on cellular structure, and druses of actinomycetes.
P.'s tuberculosis of h, as a rule, primary, at the same time a tubercular complex consists of primary affect in the form of a tubercular ulcer on P.'s head of h and lymphadenitis. Progressing of process can lead to destruction of skin of P. of h, a caseous necrosis inguinal limf, nodes, to miliary tuberculosis (see. Tuberculosis extra pulmonary ).
Primary period of syphilis is characterized by education on P. h a hard ulcer in the form of an erosion, an ulcer or, more rare, a lamellar thickening (see. Syphilis ). Histologically the hard ulcer represents diffusion, and in peripheral sites perivascular accumulation lymphoid and plasmocytes. At the same time in gistol, cuts, impregnirovanny silver, find numerous treponemas. In the subsequent granulyatsionny fabric ripens, and on site a hard ulcer the small hem is formed. In inguinal limf, nodes often there is a picture lymphadenitis (see), epithelioid and cellular granulomas with existence of colossal cells can come to light histologically. Manifestations of the secondary and tertiary periods of syphilis of P. of h are rare: in the secondary period they have usually the form of papules or flat condylomas, in tertiary — gummas or diffusion inflammatory infiltrates.
Methods of inspection
are generally used a usual wedge, methods (survey, a palpation) which allow to distinguish almost all diseases of P. of h. Palpation of infiltrative changes in more thickly tissues P. of h is sometimes facilitated at his palpation on metal cream puff entered into an urethra. At nek-ry patol. processes and P.'s diseases of h (ossification, a priapism, thrombosis of cavernous bodies) it is necessary rentgenol. research: a survey X-ray analysis, a kavernozografiya (it is carried out by a puncture of cavernous bodies and introduction to them of a contrast agent). Apply ultrasonic scanning less often (see. Ultrasonic diagnosis ), radio isotope research (see): the radio isotope penografiya characterizing a blood stream in cavernous bodies stsintigrafiya (see), giving an idea of circulator and anatomic changes in body. The diagnosis of a number of diseases of P. of the h macroscopically similar among themselves (an ulcer, tuberculosis, cancer, etc.), is confirmed by results of a biopsy.
Malformations are characterized by a big variety of anatomic and functional disturbances. Degree of their weight can be various. Malformations of P. of h can be divided into three groups: the isolated malformations only P. of the p. combined and the combined malformations.
The most frequent malformation in the first group is phymosis (see) — the expressed narrowing of an opening of a preputial bag interfering an exposure of a head of P. of h. The phymosis is physiological to two-year age, by this time usually there is a gradual rassasyvaniye of synechias between P.'s head of h and an internal leaf of a prepuce. An urination at a phymosis complicated, painful and extended on time. At the same time stream of urine thin, quite often discontinuous; urine fills a cavity of a prepuce. The phymosis often is followed by a balanitis or a balanoposthitis (see. Balanitis, balanoposthitis ).
To malformations of the first group also disturbances of a structure of cavernous bodies and a prepuce, inborn absence of P. of h, a transposition P. of h — its arrangement behind a scrotum and fixing belong to the lower or nizhnezadny surface of pubic bones. P.'s doubling h (difalliya) is seldom observed; and full doubling is characterized by existence of usual number of cavernous bodies and an urethra in each body. At a difalliya one of P. of h can be underdeveloped and in this case the internal opening of an urethra can be located out of a zone of a sphincter of a bladder that is shown by an incontience of urine. At incomplete doubling two heads of P. of h and two openings of an urethra are located on one P.'s body of h. Huge P. of h (megalopenis) can reach the sizes, at to-rykh the sexual intercourse is impossible. Small P. of h (micropenis) is manifestation of the hypogenitalism connected with inborn disturbances of endocrine system (see. Hypogonadism ).
Sometimes there is P.'s rotation h around a longitudinal axis on 90 — 180 °, the edge is not followed by any disturbances. The hidden P. of h — lack of own integument of P. of h, at Krom the cavernous bodies and an urethra having a normal structure and the sizes or which are moderately lagging behind in development are located under skin in the field of a pubic symphysis, seldom scrotums or crotches.
Inborn pathology of a prepuce: its total absence, a short bridle owing to what there is an excessive tension, an excess of a head of P. of h and is created an obstacle to the shift of a prepuce, is complicated by a balanitis or a balanoposthitis, an anguish (gap) of a bridle which is followed by bleeding.
Malformations of P. of h and urethra belong to combined, at to-rykh inborn anatomic disturbances are limited to limits cavernous and spongy ph. the full and partial doubling of an urethra which is followed by an underdevelopment of a spongy body; segmented stenoses or an obliteration of an urethra, its inborn (front) diverticulum with an underdevelopment of the respective site of cavernous bodies; stenosis and ectopia of an outside opening of an urethra; paraurethra lny courses (fistulas) and P.'s cysts of h. These patol, some urologists carry states to malformations of an urethra (see).
Such malformations of P. of h which are combined with malformations of other bodies belong to combined urinogenital system (see) and on the wedge, to value have minor character. Their correction is possible or reasonable after elimination of the main inborn pathology or is single-step with it. Not fusion of an urethra on an extent belongs to such malformations; as a result of a nesmykaniye of caudal departments of genital folds not fusion of a ventral surface of P. of h is noted — arises hypospadias (see). At this P. h is bent, lags behind in growth, his Cavernous bodies are underdeveloped, the spongy body is absent, the urination occurs often on female type.
Disturbance of a smykaniye of a mesodermal plate in front in combination with an allotopia of pair primary sexual hillock and delay of its merge leads to emergence of an ekstrofiya of a bladder (see. Bladder ), at less Expressed disturbance of process of a mesodermal bookmark — to epispadiya (see). At this P. h is deformed, short, will tighten to the Lobby: to an abdominal wall; the opening of the Urethra is localized on its dorsal surface; the full incontience of urine is observed.
Treatment of malformations — operational; the choice of a method of an operative measure is in most cases individual. The most frequent operation at a phymosis — a dirkumtsiziya (circular circumcision). At inborn absence of P. of h its recovery is applied — phalloplasty (see), and at a transposition — moving to normal situation. Sometimes at P.'s doubling removal of underdeveloped body is necessary h. At the combined and combined malformations of P. of h the plan and volume of an operative measure depend on weight patol, changes.
the Damages (closed and opened) — rather rare species of pathology of P. of h. In peace time the following closed P.'s damages by h meet: bruise, gap, dislocation, infringement.
Among open damages distinguish the cut, chipped, bitten wounds, P.'s scalping of h — in peace time, gunshot wounds — in wartime (tsvetn. fig. 1, and and; fig. 2, and and b).
A bruise — the easiest damage rate of P. of h if there is no rupture of a white and cavernous ph. It arises at blow by a firm subject of neeregirovanny P. of h and is characterized by puffiness, hypodermic hematoma (see), edge owing to friability of its hypodermic cellulose can reach the big sizes, extending on scrotum (see). Treatment: a bed rest, rest that is reached by carrying suspenzoriya (see), locally in the first 3 — 4 days cold, then warmly. At emergence of signs of infection of a hematoma appoint antibacterial therapy.
Rupture of cavernous bodies (so-called change of P. of h) occurs at impact of the injuring force on P. the h who is in a condition of an erection, most often at its bending during the violent or rough sexual intercourse. The rupture of cavernous bodies is followed by a characteristic crunch, sharp pain, the termination of an erection then big puffiness and an extensive hypodermic hematoma quickly develops, the integument becomes crimson and cyanotic. In rare instances when at the same time there is a rupture of an urethra, the urethremorrhagia and disturbance of an urination appears. The hematoma (urohematoma) is inclined to distribution on a scrotum, a crotch, lower parts of a stomach.
Treatment operational: exposure and sewing up of defect of a white and cavernous bodies of P. of h; at a simultaneous rupture of an urethra — removal of urine by an epicystostomy (see Vesicotomy) with the one-stage or delayed recovery of an integrity of an urethra, drainage of a hematoma and an uric zatek (see). In the postoperative period — a bed rest, locally cold, reception of bromides (for prevention of erections), haemo static and antibacterial therapy. Sometimes after a rupture of cavernous bodies disturbance of an erection owing to development in them cicatricial fabric is possible that demands purpose of long resorptional therapy.
Dislocation of a penis arises for the same reasons, as the rupture of cavernous bodies, at the same time occurs a rupture of the sheaves fixing P. of h to pubic bones, and his root is displaced in a scrotum, under skin of a pubic symphysis, a hip or a crotch. Quite often at the same time there is a separation (as if scalping) skin of a body of P. of h from a head.
Treatment operational: redeem normal situation P. of h, connect the broken-off sheaves, straighten and sew skin of a body of P. of h with a wreath of a head.
The penis captivus is observed during the pulling by its thread, a rope, a cord, putting on on it ring-shaped objects that at children's age can be result of prank, and at adults — the investigation onanism (see), attempts of creation of an obstacle at an incontience of urine, for maintenance of an erection or as a result of a mental disease. The main symptom — P.'s puffiness of h distalny places of infringement, at considerable and long infringement — necrotic changes up to gangrene. At the sharp puffiness hiding the place of infringement character of a ring helps to define it and P.'s X-ray analysis of h.
Treatment — removal of the restraining subject. At insignificant puffiness of P. of h it is possible to make an attempt of removal of the restraining ring-shaped subject of Hartmann. Items of h, since the distal end, hardly tighten a narrow tape or thread, imposing it is turbinal towards the place of infringement that reduces hypostasis. Having brought turns of a tape or thread to the restraining ring-shaped subject, the end it is brought under a ring by means of a stupid needle, and then, taking up a tape or thread in the opposite direction, displace a ring towards the distal end (fig. 2) and deleted. At sharp puffiness an operative measure is usually necessary: in the beginning distalny and proksimalny places of infringement cut the restrained fabrics, under it bring the probe, on Krom by means of the picked-up tool cross a ring. After that sometimes it is necessary to excise nekrotizirovanny fabrics.
Cut wounds — the most Frequent type of open damages of P. of h in peace time. They can be put in an attack of jealousy, mentally sick or is accidental. Superficial wound proceeds easily, wound of cavernous bodies is followed by severe bleeding.
Treatment operational: primary surgical treatment of wounds (see), bandaging of blood vessels (see), suture on the damaged fabrics. In view of plentiful blood supply and high reparative abilities of tissues P. of h to lay down. tactics shall be the most organ-preserving. At P.'s amputation h perhaps anatomic and functional recovery of body with the help microsurgery (see).
Chipped and bite wounds which are usually characterized by a small zone of damage of fabrics and insignificant bleeding demand only roughing-out of a wound and sewing up of defect. At simultaneous injury of an urethra are necessary removal of urine by an epicystostomy, primary or delayed urethroplasty.
The traumatic scalping which is followed by extensive crush of skin of P. of h, imbibitsiy blood and a big hematoma demands closing of the bared cavernous bodies with the skin taken from a scrotum, a hip, a stomach. During the first stage of operation P. of h, deprived of an integument, place under skin of suprapubic area or an inner surface of a hip and impose urethral fistula in a crotch for removal of urine. Further release P. of h, finding a skin rag of the sufficient sizes, edges to-rogo are sewed among themselves and with P.'s head of h, thereby finally closing all skin defects. Recover an integrity of an urethra later.
Burns and freezing injuries of a penis meet seldom. Their treatment is carried out by the general principles (see. Burns , Freezing injury ), at big defects of skin its change from other body parts in order to avoid development of the rough hems deforming P. of h and breaking its functions is shown.
Gunshot wounds of a penis in the period of the Great Patriotic War of 1941 — 1945 made 14% of total quantity of wounds of bodies of urinogenital system; from them wound without injury of an urethra — 73%, with injury of an urethra — 19,4%, P.'s amputation h — 7,6%.
Among P.'s wounds h distinguish the tangents which are limited to damage only of skin; tangents with disturbance of an integrity of a white of one or both cavernous bodies; nonperforating wounds, at to-rykh a hurting shell gets stuck in one or both cavernous bodies; through wounds with injury of one or both cavernous bodies; P.'s amputation h.
The first and pre-medical help consists in imposing of an aseptic bandage, a temporary stop of bleeding a compressing bandage, administration of anesthetics.
If necessary replace a bandage with PMP or impose it if it was not made earlier, enter anesthetics, antitetanic anatoksinony it is reasonable to enter a soft catheter into an urethra, and then of h to apply a bandage P.
In MSB only economical primary surgical treatment is admissible: a stop of bleeding, irrigation of a wound, economical excision of the died fabrics, infiltration of surrounding fabrics antibiotics. At avulsive wounds the rags of skin which are hanging down at the edges do not exsect, and cover with them defect and put several directing stitches. At extensive injuries of skin of P. of h make excision of the smashed its lifeless sites, stop bleeding, and a wound leave open for healing second intention. At injury of cavernous bodies of P. of h put catgut stitches with capture of a white in transverse direction, avoiding underrunning of large arteries that prevents a zapustevaniye of cells of cavernous bodies. P.'s amputation at destructions of both cavernous bodies is made h only after establishment of a line of demarcation of gangrene. In all cases of damage of P. of the h having the nature of almost full amputation, sewing together of its ends is obligatory. In the presence of the combined damage of P. of h and an urethra impose suprapubic vesical fistula (see. Bladder ).
During the rendering specialized medical aid make closing of big defects with way skin plastics (see), reconstructive operations, eliminate fistulas and the arisen complications.
The principles of assistance in GO are identical described above.
Distinguish P.'s diseases of h which are followed by indurative changes (Peyroni's disease, krauroz), a priapism, infringement of a head of P. of h (paraphimosis), germ and fungus diseases of skin of P. of h, inflammatory diseases (the balanitis or a balanoposthitis, a cavernitis, herpes praeputialis, an erysipelatous inflammation, limfangiit, thrombophlebitis, etc.), venereal diseases, and also benign and malignant tumors.
Inflammatory diseases of a penis are the most widespread.
A balanitis or a balanoposthitis — an inflammatory disease of skin of a head and internal leaf of a prepuce of various etiology. The wedge, a current can be acute and chronic, and morfol, changes are various — from a simple inflammation to gangrenous forms (see the Balanitis, a balanoposthitis).
Cavernitis — the inflammation of cavernous bodies of P. of h usually secondary origin proceeding sharply or chronically (see. Cavernitis ).
Herpes praeputialis on an etiology and morfol, a picture does not differ from herpes of other localizations (see. Herpes ). On an internal leaf of a prepuce, is more rare on a head, even less often on P.'s body of h there are small transparent bubbles which then burst with formation of surface erosions. A current with a frequent recurrence. Treatment generally local (trays, powders, etc.). Ointments and emulsions with antibiotics and corticosteroids are effective (Linimentum Synthomycini, prednizolonovy ointment, Oxycortum, etc.).
The erysipelatous inflammation usually extends from the next bodies and seldom happens isolated, only on P. of h (see. Ugly face ). Symptoms — fervescence, a hyperemia, puffiness of skin of P. of h, sometimes develops P.'s gangrene of h. Treatment — sulfanamide drugs and antibiotics, including locally, at considerable puffiness of P. of h — early cuts of skin in order to avoid its necrosis, at the developed gangrene — excision of necrotic fabrics.
Limfangiit quite often accompanies acute inflammatory process on a head and a prepuce, and also in an urethra. Inflamed limf, vessels (see. Limfangiit ) are probed on dorsal and side surfaces of P. of h in the form of dense gyrose painful tyazhy which extend to a symphysis, and increased painful inguinal limf, nodes. P.'s skin of h over inflamed limf, vessels is hyperemic and edematous; at sharp hypostasis of a prepuce there is a phymosis. Spayaniye inflamed limf of a vessel with skin, formation of infiltrate, and then a softening indicate suppuration; transition to P.'s phlegmon of h is possible. Treatment — antibacterial therapy, topical administration in an acute stage of cold, then is warm, at formation of an abscess — its opening.
Thrombophlebitis meets seldom, is shown by emergence of a dense painful tyazh on a dorsal surface of P. of h on the course of superficial veins. A wedge, a picture same as at P.'s limfangiita of h, sometimes there are severe pains, owing to disturbance of venous outflow emergence patol, erections is possible. Treatment — locally warmly, anticoagulants (see. Thrombophlebitis ).
Phlegmon develops as a complication of inflammatory diseases or P.'s damages by h and an urethra as a result of suppuration of a hematoma or an uric zatek. General serious condition, high temperature, puffiness and P.'s hyperemia of h. Treatment is operational, open and drain purulent cavities, at the same time carry out intensive antibacterial care (see. Phlegmon ).
P.'s gangrene of h can be primary and secondary. Primary gangrene meets seldom, generally at young age. Activators — most often a hemolitic streptococcus, staphylococcus, quite often anaerobic bacteria, fuzospirokheta. The smallest damages of an integument of P. of h can be infection atriums. Quite often P.'s gangrene of h is combined with so-called idiopathic gangrene of a scrotum (see. Fournier gangrene ). Secondary gangrene develops at inflammatory diseases and P.'s damages by h. In the beginning reddening and a dermatalgia of P. of h is noted, then body temperature increases, the general state worsens, symptoms of intoxication accrue. Against the background of a hyperemia spots with the wrong outlines appear black'. In 2 — 3 days from the beginning of a disease the line of demarcation forms, and rejection of necrotic sites of skin and hypodermic cellulose begins. The general state improves, body temperature is normalized. Process of a granulation and epithelization of skin defects takes 4 — 6 weeks. Treatment — intensive antibacterial and disintoxication therapy (see), early cuts with removal of necrotic fabrics. At extensive defects of an integument of P. of h further make plastics with movement of a piece of leather from other areas that prevents cicatricial deformation of body.
Germ and fungus diseases of skin of P. of h arise most often along with damage of skin of a scrotum. A wedge, manifestations, the diagnosis, treatment and their forecast are identical (see. Scrotum ).
P.'s defeats arise also at venereal diseases h — syphilis (see), soft chancre (see), a venereal granuloma (see. Granuloma venereal ), an inguinal lymphogranulomatosis (see. Lymphogranulomatosis pakhovy ).
A paraphimosis — infringement of a head of P. of h in the narrowed opening of a prepuce. The reasons are various (an onanism, a violent exposure of a head of P. of h, etc.). In early terms after infringement reposition of a head works well rather easily, in late terms it is necessary to cut the restraining ring (see. Paraphimosis ).
A priapism — resistant patol, the erection which is not connected with sexual excitement. Its etiology is various. Treatment conservative and operational (see. Priapism ).
I ndurat io penis plastica (Peyroni's disease) — a disease with the obscure etiology, at Krom patol, leads the process which is localized preferential in a white and a partition of cavernous bodies of P. of h to its deformation at an erection (see. Induratio penis plastica ).
Krauroz — rather rare disease which is characterized by the progressing wrinkling of an internal leaf of a prepuce and skin of a head of P. of h with loss of elasticity of their surface and a peculiar change of pigmentation (blanching) very similar to change of pigmentation at a leukoplakia. At patients the severe itch is noted. In late stages of a disease owing to consolidation and irritation of fabrics cracks and grazes are formed; development of a tumor is possible. Symptomatic treatment.
Benign and malignant tumors of P. of h can have an epithelial and not epithelial origin.
Benign tumors of an epithelial origin, or papilloma, divide into two groups: tumors of a virus and not virus etiology.
Viral papillomas, or sharp-pointed condylomas, P. of h meet often. Are localized on a head and an inner surface of a prepuce (fig. 3). Sharp-pointed condylomas of a kontagiozna, extend sexually. Their virus etiology is proved in experiences with subinoculation of tumors by means of an acellular filtrate. At infection sexually the incubation interval can last from 1 to 9 month. The existence of viral papilloma of P. of h is longer, the more it approaches on gistol, to a structure typical skin papilloma with a hyperkeratosis (see Papilloma, a papillomatosis).
Manifestations — warty, are more often multiple growths of a sharp-pointed form, I remind-htsiye by the form a cauliflower or mulberry berry. In the started cases when viral papillomas of P. of h give magnificent exophytic growth (so-called tumors of Bushke — Levenshteyna), or at the beginning malignancy the diagnosis can be complicated and is based on data of a biopsy.
Treatment operational: excision (it is desirable by electroscission) papillomas within healthy fabrics with the subsequent gistol, a research; at extensive defeat of a prepuce — a tsirkumtsiziya.
P.'s papillomas of h not virus etiology meet much less often. They develop as a result of stagnation of a smegma on a head or an internal leaf of a prepuce near a neck of a head, have the fungoid form and the wide basis (fig. 4). The biopsy is important for the diagnosis. Treatment operational: at papilloma of a head of P. of h — a resection of a head, at papilloma of a prepuce — a tsirkumtsiziya.
Benign tumors of not epithelial origin (fibroma, a lipoma, a hemangioma, a lymphangioma) meet extremely seldom. On morfol, to signs and a wedge, to manifestations they do not differ from similar tumors of other localization. Treatment operational — excision within healthy fabrics. Removal of benign tumors of cavernous bodies of P. of h can be complicated by P.'s deformation h.
Malignant tumors of an epithelial origin. P.'s cancer of h in a number of the countries of Asia, Africa, Latin America where it is high on the list among cancer of various localization at men is most widespread. Rather seldom occurs in the countries of Europe and North America (apprx. 1% among other localizations of cancer at men).
P.'s cancer of h usually arises at young age (in most cases in 20 — 40 years), is localized only in a preputial bag (on a head, in a neck of a head, on an internal leaf of a prepuce). At most of patients (60 — 80%) arises at an inborn phymosis. Persons, the Crimea the tsirkumtsiziya in the first days of life is made, usually do not develop P.'s cancer of h; if this operation is executed at the age of 4 — 14 years, P.'s cancer of h meets, but is rare. These data confirm an oncogenous role of congestive contents of a preputial bag. Oncogenous properties of a smegma (see) are shown in animal experiments of L. I. Charkviani and V. D. Todua, Plaut, Kohn-Speyer (And. Plaut, A. S. Kohn-Speyer), H. R. Pratt-Thomas et al. With influence same etiol, a factor connect developing of such precancerous diseases of P. of h as a leukoplakia (see) and an eritro-plaziya (see Keyr an eritroplaziya), and also the h who is extremely seldom meeting on P.'s head. skin horn (see). A leukoplakia (whitish sites of skin, sometimes with cracks and ulcerations) and an eritroplaziya (a bright red plaque with a velvety surface) are localized on P.'s head of h and are formed usually at a phymosis (tsvetn. fig. 1). Carry also benign tumors of an epithelial origin, Bowen's disease to precancerous diseases of P. of h (see. Bowen disease ).
Distinguish two forms of cancer of P. of h — exophytic and endophytic (see Cancer). At an exophytic form the tumor develops fungoid or papillary (in the form of a cauliflower); at the second — a tumor in the form of deep infiltrate or an ulcer (tsvetn. fig. 2 and 3). In the beginning the symptomatology is poorly expressed since a tumor it is most often long develops under the narrowed prepuce. Only after accession of the inflammatory phenomena (purulent discharges from a preputial bag, puffiness and a hyperemia of a prepuce, sometimes with education on it purulent fistulas) the wedge, manifestations become more accurate, and a tumor seen or probed. Metastasises arise most often in regional (inguinal, ileal) limf, nodes. However in connection with frequent accession to P.'s cancer of h inflammatory process increase regional limf, nodes approximately in half of cases has an inflammatory origin. The remote metastasises (in lungs, a liver) are rare.
According to classification of the International anticarcinogenic union (see. The international system of clinical classification of cancer) distinguish four stages of cancer of P. of h: Tkh — a tumor to dia, no more than 2 cm without infiltration of the subject fabrics, T2 — a tumor to dia, from 2 to 5 pieces with insignificant infiltration, T3 — a tumor to dia, more than 5 cm or any size with the deep infiltration taking an urethra, T4 — the tumor burgeoning in the next fabrics and bodies. The state limf, nodes is estimated as follows: N0 — limf, nodes are not palpated, Nx — are palpated displaced limf, nodes on the one hand, by N2 — displaced limf, nodes are palpated on both sides, N3 — are palpated nesme-shchayemy limf, nodes; There is no M0 — signs of the remote metastasises, Mkh — are available the remote metastasises.
The diagnosis in early stages is complicated because cancer often develops under the narrowed prepuce. The tumor can be probed in the form of a dense node. The main role in cancer detection of P. of h belongs to a biopsy. Recognition of regional metastasises of cancer of P. of h is based on data of a palpation (dense melkobugristy limf, nodes), tsitol, researches of punctate limf, a node, a limfografiya though rentgenol, the picture at a limfografiya often does not allow to differentiate inflammatory changes in limf, nodes from metastasises of cancer.
The differential diagnosis is carried out with syphilis (see), a venereal ulcer (see), tuberculosis (see), an actinomycosis (see), elephantiasis (see), and also with nek-ry tropical and skin diseases, one of the centers to-rykh can be localized on P.'s skin of h.
Treatment shall be combined. The choice of a method of treatment depends generally on a stage of cancer.
In stages of T1 — T2 is possible radiation therapy or chemotherapy or organ-preserving operations, the look to-rykh depends on localization of a tumor — circular circumcision, a resection of a head, P.'s scalping of h (Sapozhkov's operation). In a stage of T3 the peotomy within healthy fabrics, in a stage of T4 — emasculation or palliative radiation therapy is necessary (or chemotherapy).
In initial stages of cancer of P. of h apply chemotherapy, napr, Bleomycinum as independently, and in combination with other antineoplastic means and radiation therapy.
At regional metastasises in a stage of Nx-2 in 2 — 3 weeks after operation for a tumor carry out a bilateral inguinofemoral limfadenektomiya (see. Dyukena operation ). Specialized institutions sometimes apply an expanded regional limfadenektomiya: simultaneous removal of a fatty tissue with inguinal and ileal limf, nodes and a fatty tissue and limf, nodes on the course of ileal vessels.
Radiation therapy is method of the choice for treatment of all early and localized forms of tumors of P. of h. Contraindications — infiltration of cavernous bodies, germination of a tumor in an urethra, disintegration of a tumor in the presence of an infection, a recurrence after radiation therapy. Treatment consists of two stages: the first is directed to elimination of a tumor, the second — to treatment of metastasises in inguinal limf, nodes. For radiation therapy of primary tumor can be used short-distance roentgenotherapy (see), remote gamma therapy (see) and radioactive drugs (ssh.), applied by an application and interstitial method. Before radiation therapy elimination of a phymosis — a section of a prepuce in the place, free from a tumor, or performance of a tsirkumtsi-ziya, preferably an electroknife is necessary. The short-distance roentgenotherapy is shown at superficial tumors with a diameter no more than 2 cm in a total focal dose — 5000 is glad (50 Gr) in the conditions of simple fractionation during 4 weeks.
Apply also interstitial implementation of the needles, pins or grains containing natural or artificial radioactive drugs to treatment of limited defeats of P. of h, in a dose 30 — 40 hour is glad/; the total dose makes to 5000 is glad (50 Gr), a radiation time — within the 200th hour.
The application method is applied at more common forms of cancer with involvement in process of a head, a coronary furrow and a prepuce. Production of the applicator in the form of the cylinder with wall thickness of 2 — 3 cm consisting of two divided half is preferable. Drugs place so that on the centerline the total dose 5000 was created is glad (50 Gr), and a dose on the surface of skin 6000 is glad (60 Gr). Treatment by an application method continues within 7 — 8 days on 8 — 10 hours a day. Remote megavoltny therapy is recommended as an independent method of treatment, and at the combined treatment. In the conditions of simple fractionation the week dose on primary tumor and inguinal limf, makes nodes 1000 — 1200 is glad (10 — 12 Gr), a total focal dose at radiation therapy as an independent method of treatment — to 6000 is glad (60 Gr), at the combined treatment — 4000 — 4500 is glad (40 — 45 Gr).
The forecast depends on a stage of a disease, existence or lack of regional metastasises. At the combined treatment life expectancy of St. 5 years is noted more than at 60% of patients.
Prevention of cancer of P. of h consists in the prevention of stagnation of a smegma that is reached by a daily toilet of generative organs. Early detection and treatment hron, inflammatory diseases of skin of P. of h is of great importance.
Not epithelial malignant tumors meet seldom. They are divided into three groups: vascular, pigmental and connective tissue.
Vascular tumors — endotheliomas (see) — are observed more often than others. They come from an endothelium of cavernous bodies, are shown by consolidation in a cavernous body, a priapism. Treatment — P.'s amputation h, postoperative radiation therapy.
Pigmental tumors (melanoma) from primary center quickly extend to cavernous bodies, in regional limf, nodes, in the remote bodies (see. Melanoma ). The treatment combined: P.'s amputation h, a limfadenektomiya with before - and postoperative radiation therapy.
Connective tissue tumors — fibrosarcoma (see), myosarcoma (see) — are shown in the form of a dense node in a cavernous body, pains, a priapism. Current rather slow. The treatment combined: a peotomy, before - and postoperative radiation therapy, an inguinofemoral limfadenektomiya. The forecast depends on a type of a malignant tumor and its stage. At nek-ry tumors (a melanoma, a myosarcoma) the forecast is more serious, than at P.'s cancer of h
At operative measures on P. h usually apply local anesthesia (see Anesthesia local), more rare inhalation anesthesia (see).
The most frequent operation on P. of h — circular circumcision, or a tsirkumtsiziya, to-ruyu produce hl. obr. concerning a phymosis (see), sometimes at hron, a balanoposthitis, P.'s tumors of p. which are localized on a prepuce. The section of the restraining ring of a prepuce is applied at paraphimosis (see). At hypospadias (see) before plastics of defect of an urethra make P.'s straightening h
Frenulotomiya (a section of a bridle of a prepuce) carry out at an inborn short bridle. It is cut in the middle in transverse direction on depth of 0,5 — 0,7 cm. Edge of the formed wound connect along P. the p. 2 — 3 noose sutures thanks to what the line of seams accepts lengthwise direction and there is a lengthening of a bridle. The bandage in the form of the gauze roller is fixed to a wound, tying over it the ends of ligatures.
The plastics of skin is made at elephantiasis and P.'s damages by h.
Phalloplasty (see) — complete or partial recovery of P. of h — is applied at its inborn absence, an underdevelopment or after P.'s amputation h. H make operations on P. also at priapism (see) — a section of cavernous bodies and removal of clots, a safeno-cavernous and spongiokavernozny anastomosis; a fibroplastic induration of P. of h (Peyroni's disease) — excision of the sclerosed fabric (see Induratio penis plastica). At impotence (see) according to special indications h implant plates from synthetics into fabrics P.
The resection of a head of P. of h is shown at a high-quality new growth or cancer in a stage of Tkh — T2 with its localization only on a head. An electroknife make a section, otstupya not less than 1 cm from edge of a tumor, and excise it the uniform block.
In the I stage of cancer of P. of h P.'s scalping can be applied h (Sapozhkov's operation). Circular section at a root P. of h cut skin with hypodermic cellulose to a white of cavernous bodies and, having taken skin for edges clips, turning out it as a stocking, pull together from cavernous bodies to P.'s head of h. In a neck of a head of P. of h skin is cut a circular section and deleted. The bared cavernous bodies of P. of h place in a hypodermic tunnel on the centerline of a front surface of a scrotum, removing P.'s head of h outside through a skin section in the bottom of a scrotum. Edges of the lower skin scrototomy tsirkulyarno connect noose sutures to P.'s head of h; an upper skin section at the root G1. take in h tightly. In 1 — 2 month carry out the second stage of operation: two longitudinal parallel cuts find a rag from skin of a scrotum and release P. of h. The ventral surface of P. of h is closed edges of the skin rag found from a scrotum, connecting them among themselves noose sutures. Defect of skin of a scrotum is taken in in lengthwise direction.
At a stage of T3 of cancer of P. of h make full or partial amputation of P. of h depending on prevalence of a tumor. The section of skin and hypodermic cellulose do tsirkulyarno, otstupya on 1 cm from a tumor and on 1 piece distalny alleged crossing of cavernous bodies. A proximal part of skin of P. of h is shifted to his root, cross an urethra and a spongy body at the level of a skin section, and cavernous bodies of P. of h — on 1 cm proksimalny. Large vessels tie up, stumps of cavernous bodies stitch P-shaped or Z-shaped catgut seams. After a hemostasis connect edges of skin and an urethra noose catgut sutures.
At partial amputation of P. of h concerning cancer excision of hypodermic cellulose on its extent since in it there pass ways of regional innidiation is desirable. In the first days of the postoperative period establish a constant urethral catheter. In case of full amputation of P. h impose a perineal ureterostoma (see. Butonyer ).
At P.'s cancer of h passing to a scrotum and its bodies (a stage of T4) emasculation can be executed (full removal of P. of h and a scrotum with its bodies). Skin is cut two cross sections of a kpereda from a root P. of h and a kzada from a root of a scrotum, and then connect them two slits. Seed cords cross and tie up as at castrations (see), and P. of h — as at its full amputation. Impose a perineal ureterostoma, on a cut in the first days enter a constant catheter into a bladder. The wound is sewn up tightly: the forefront of a wound — in transverse direction, back — in longitudinal therefore the line of seams gets the T-shaped form.
Bibliography: Gerke P. Ya. Private embryology of the person, page 106, Riga, 1957; About y x e r M. I. Surgical and beam cancer therapy of a penis, Kiev, 1965; The Clinical onkourologiya, under the editorship of E. B. Marinbakh, page 284, M., 1975; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 7, page 427, M., 1964; The Multivolume management’ on surgery, under the editorship of B. V. Petrovsky, t. 9, page 46, M., 1959; Experience of the Soviet medicine in the Great Patriotic War of 1941 — 1945, t. 13, page 268, 286, M., 1955; Petten B. M. Embryology of the person, the lane with English, page 585, M., 1959; The Guide to clinical urology, under the editorship of A. Ya. Pytel, page 403, M., 1970; Sinelnikov R. D. Atlas of anthropotomy, t. 2, page 112, etc., M., 1973; Frighten - N and A. I N. The long-term results of beam cancer therapy of a penis, in book: Vopr. wedge, radio-gramophones., under the editorship of M. N. Pobedinsky, etc., page 83, JI., 1960; Strukov A. I. and Serov V. V. Pathological anatomy, page 430, M., 1979; At with t and m of e of N to about E. M. Rak of a penis, M., 1964, bibliogr.; Froome-to and A. P N. Military injury of urinogenital system, M., 1944; Chukhriyenko D. P. and Lyulko A. V. The atlas of operations on bodies of urinogenital system, M., 1972; Shabad A. JI. Tumors of a penis, Alma-Ata, 1967; Shmalgauzen I. I. Bases of a comparative anatomy of vertebrate animals, page 385, M., 1947; Gray H. Gray’s anatomy, L., 1973; P 1 an u t A. Kohn-Speyer A. C. The carcinogenic action of smegma, Science, v. 105, p.391, 1947; Pratt-Thomas H. R. a. o. The carcinogenic effect of human smegma, Cancer, v. 9, p. 671, 1956; Radiotherapy in modern clinical practice, ed. by H. F. Ho-pe-Stone, p. 301, L., 1976.
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