All that such papillomatous growths require is complete excision or extirpation (i. e. destruction), with cauterization of their bases and subsequent local cleanliness. They are not infrequently referred to as venereal warts, which, in effect, they usually are. The other benign tumors of the penis are rare. Occasionally some dermoid cyst or small fatty or fibrous growth may be seen. Sarcoma of the penis is also rare, while epithelioma is not uncommon, constituting the ordinary cancer of the penis.
Epithelioma in this region has its origin around some portion of the mucous surface of the glans, spreading in time to the prepuce, more or less involving the entire organ, while by its rich lymphatic supply involvement of the inguinal and other nodes happens early, whereby the situation is sadly complicated. Epithelial cancer here evinces the same local tendencies toward extension and destructive ulceration as elsewhere, made more rapid by exposure to surface irritation. Its base is indurated, even if sometimes everted; it grows irregularly, but destroys everything with which it comes in contact.
Epithelioma of the penis should be recognized and extirpated early to offer any prospect of success. It is usually as unpromising a condition as epithelioma of the tongue, because of the early lymphatic involvement. A lesion of limited area may justify local excision, but a distinctly marked lesion can only be successfully treated by amputation, at least of the anterior portion of the organ, perhaps of the entire structure of the penis, and thus ensure complete eradication.
Amputation of the penis is easily effected with a circular sweep of the knife, or by an abrupt cross-section, there being but little choice of method, the intent being only to save sufficient of the organ so that cleanliness during and after the act of urination may be maintained. When any portion of the pendulous organ is preserved the margin of the divided skin should be attached to that of the urethra by a series, say, of four sutures, placed at equal intervals, after hemorrhage, which will be somewhat difficult of control, both from the larger vessels and from the cavernosa, has been subdued. It may require buried sutures through the divided cavernosa in order to permit of such control.
If, however, it seem necessary to remove the organ close to the pubis it will probably be found more desirable to make a more complete dissection, taking out the corpora cavernosa entirely, and then making a median incision in the perineum, dissecting out the urethra, bringing it out through the wound, shortening it to the proper extent, and fastening its termination to the skin margin, thus making, as it were, a vulvar outlet, which will not interfere with urinary control, but will permit urination to be satisfactorily accomplished, though only in the sitting posture. This is usually known as Demarquay’s operation.
CIRCUMCISION.
In children this requires a general anesthetic; in adults it can almost always be satisfactorily performed under local cocaine anesthesia; the intent being to remove the redundant foreskin. A circular incision is necessary, which may be made with knife or scissors. The parts being prepared for operation, the prepuce is drawn forward, being caught either with forceps or fingers of an assistant, and the little circular amputation is made just in front of the corona of the glans. The first incision extends through the skin, after which there remains a cuff of mucous membrane, which is sometimes adherent to the glans, as in children, or may be infiltrated with exudate, as by a concealed chancroid or chancre beneath. Ordinarily this cuff is split in the middle line of the dorsum and removed in halves, in order to avoid any possible injury to the glans itself. The cut is made somewhat obliquely from above downward and forward, the intent being to divide it at the frenum, sufficiently far from the meatus in order to not distort the latter by subsequent cicatricial contraction. These tissues are sometimes inordinately vascular, and bleeding points need to be quite carefully secured. In one case known to me an infant bled to death from an unsecured vessel near the frenum, the operator having neglected it at the time and having left the patient. In a clean case, the vessels having been secured, a running suture of fine catgut should unite the cut edges of the mucosa and of the skin. It is not necessary to apply sutures in a venereally infected case, for raw surfaces will also become infected, and would be best protected by immediate cauterization, in which case primary union would be prevented.
The little procedure may be modified in various ways to meet individual needs. After its performance there will occur considerable local swelling and edema, which can be best kept under subjection by a dressing moistened with cold saturated boric acid solution or its equivalent. If the sutures have been too tightly applied there may be a species of paraphimosis, with too much constriction, which would require their division.
THE URETHRA.
In [Chapter XII], on Gonorrhea, were described the usual specific forms of urethritis, with their complications and results. To this chapter the reader is referred for all data regarding gonorrhea as it involves this passage-way, with its complications. Such lesions as ulcers may persist for some time, while the papillomatous outgrowths, polypi, etc., connected with gonorrhea and gleet, which are not discoverable from without, are now easily examined and estimated with the endoscope. Specific ulcers of the syphilitic type, and virulent ulcers even of the chancroidal type, also occur, usually within the first inch of the urethra, causing more or less discharge, with local soreness, and leading, unless promptly recognized, to cicatricial stricture formation.