Home >> Surgery-and-obstetrics >> Affections Of The Ear to Wounds Of Special Regions >> Diseases of the Sheath

Diseases of the Sheath and Penis

DISEASES OF THE SHEATH AND PENIS Tumours of the Sheath and Penis On the external surface of the sheath small warty growths often occur. They may be sub cutaneous and sharply defined (fibromata) or irregular in surface and sessile (papillomata). Frequently a considerable number of small black warts occur in clusters on the skin of the prepuce. Carcinoma, melanoma, and sarcoma are occasionally met with in this situation, but are somewhat rare. Enlargement due to botryo myces infection is of more common occurrence, and is in the majority of cases associated with scirrhous cord. The prepuce may be enor mously swollen or cederoatous from varying causes. Sclerostomes, purpura limmorrhagica, circulatory or renal disorders, traumatic injury, accumulation of smegma, lack of exercise—any of these conditions may be responsible. We have observed generalized fibrous thickening of the prepuce without evident cause. The parts hung midway to the hocks, were of the size of a football, and apart from their unsightly appearance interfered with progression and micturition. The prepuce was removed by operation, and owing to the adhesions present it was found necessary to remove three inches of the penis also. Recovery was complete in a month, and after the second day micturition became normal.

Tumour formation on the penis itself is by no means rare.

In the horse a growth is often met with, which upon cursory examination appears to be attached to the glans penis. In most cases, however, it will be found to arise from the lining of the prepuce, and has an irregular"cauliflower"surface. It breaks down easily upon palpation and is usually surrounded by a greyish stinking discharge and masses of de composing smegma. This growth is extremely likely to recur after removal and in a few months may attain its original size. It is liable to interfere with the free passage of urine, induces a condition of phymosis, and causes a considerable amount of discomfort and symp toms often resembling those of mild colic, the animal constantly assuming a position as though attempting to pass urine. These symp toms are aggravated by the presence of quantities of foetid smegma.

A similar growth sometimes occurs on the penis of the horse, usually near the orifice of the urethra. In addition to interference with micturition it also occasionally gives rise to a considerable degree of haemorrhage. The penis of the bull is also sometimes affected in a like manner, the growth usually occurring several inches behind the glans.

Carcinoma of the end of the penis is some times met with in the horse, particularly when of advanced age.

Early amputation is advisable.

In the dog infective granuloma may give rise to tumour formation on the penis.

Treatment. Warty growths on the external surface of the sheath may be removed by scissors or the scalpel if of small size, or by means of the ecraseur if at all large or if they are provided with a neck. Recurrence is, however, the rule, and it is advisable to dress the parts daily with sulphur iodide rubbed down with lard, removing the scab which forms every day before applying the ointment. Small fibromata may be squeezed out with the fingers after incising the skin.

Papillonaata occurring within the sheath must be removed surgically. The horse must be cast, the penis withdrawn and thoroughly cleansed together with the scrotum, and all discharge and smegma removed. The growth is best removed by the wire ecraseur, and the resulting wound should be well cauterized with the hot iron to check haemorrhage and to prevent further growth, an attempt which is, however, seldom successful. Similar growths occurring on the penis must be treated similarly, but when they involve the extremity of the glans close to the urethral opening and are recurrent, amputation of the penis usually becomes necessary sooner or later.

Growths occurring on the penis of the bull are more difficult to remove. The animal is thrown, and as soon as the penis can be pro truded, it is secured by a loop of tape and with drawn from the sheath by steady gentle traction. The growth is removed by means of a scalpel or scissors, and the haemorrhage controlled by pressure applied by means of a plug of wool soaked in adrenalin solution, or the part may be cauterized with nitrate of silver.

Granuloma of the penis occurring in the dog may be removed with scissors after pouring cocaine solution into the sheath. Haemorrhage is often severe, and should adrenalin prove in efficient, it may be necessary to put one or two stitches in the mucosa. The parts should be subsequently dressed at intervals with one of the silver proteids or albuminates.

Carcinoma and kindred growths of the penis of the horse necessitate amputation of that organ.

Amputation of the Penis The chief difficulty to be contended with is the tendency of the divided urethra to close up as the surface of section of the penis heals.

Several methods of operating have been devised by which this obstacle may be over come, but even with favourable conditions, the operation is not always successful at the first attempt. The fact that the stump of the penis is withdrawn for some distance within the sheath and is completely hidden from view, is distinctly unfavourable to healing, and as the penis must be grappled for and forcibly with drawn by the hand on each subsequent occasion for purposes of inspection or dressing, con siderable difficulty is experienced in maintaining sutures in position.

Whichever method of operation is adopted it is necessary to cast the horse, and for this purpose sidelines are preferable to hobbles. The penis is withdrawn and thoroughly cleansed with warm water and soap together with the surrounding areas. Chloroform must then be administered and a catheter passed and left in position. A length of indiarubber tubing is next tied around the penis well above the seat of amputation, the ends being left sufficiently long to ensure a good hold. This being held by an assistant prevents the organ being with drawn into the sheath and also acts as a tour niquet. If preferred, a loop of tape may be employed in place of the rubber tubing. There are three methods of operating in general use: (i.) The penis may be cut through in one stroke, in which case the catheter will not be employed; or the corpora cavernosa may be first divided, after which the urethra is dissected out and severed about a quarter of an inch beyond the stump of the penis. The catheter must then be withdrawn. In either case, the next step is to slit the urethra longitudinally for half an inch along its upper surface. Into the cavity thus produced the point of a conical"budding"iron is introduced at a dull red heat and main tained in position for two or three seconds. A funnel-shaped opening is thus produced which tends to become larger after a few days, by which time the urethra will be found to have become firmly adherent at the lower edges. The tourniquet is then relaxed slightly and the bleeding vessels, of which the dorsal artery is the most important, may be ligatured, sub jected to torsion, or sealed by applying the point of a red-hot budding-iron to each.

This method of operating, although somewhat crude and barbarous, has given good results in our hands, and has the further advantage that after-treatment is reduced to a minimum. We have in some cases stitched a short female gum catheter into position and left it in situ for the first few days, but it is not absolutely necessary. As a rule soreness prevents the horse from making an effort to stale, and we now adopt the plan of emptying the bladder twice daily for the first few days after operation by pressure of the hand through the rectum. In some cases, however, the horse continues to stale in a normal manner from the time of operation without assistance.

It sometimes happens, when a large growth exists on the penis, that the organ cannot be with drawn from the sheath. It may then be brought through an incision made in the side of the pre puce which may be sutured after the operation has been completed and the penis replaced.

(ii.) Just behind the intended seat of am putation a triangular piece of skin with the apex pointing backwards is removed from over the urethra. The base of the triangle should be about inch in width, whilst the length from base to apex should be If inches. The portion of urethra underlying this area is then carefully dissected free and divided at the lower margin of the wound after removing the catheter. A sharp bistoury is then inserted into the urethra, which is divided longitudinally throughout the entire length of the portion exposed. With a small needle and fine silk the edges of the urethral flap are sutured to the skin along all three sides of the triangle. The stitches must be inserted fairly closely. An elastic ligature is then wound tightly around the penis about inch below the base of the triangle, and a little below this again the end of the penis is amputated with a scalpel.

The portion below the ligature being out off from the circulation, sloughs off entire in about ten days. The operation area becomes swollen during this time, usually several of the stitches give way and active granulation takes place. Healing should be complete in two months. After-treatment consists in keeping the parts clean by occasional injection of warm antiseptic solutions into the sheath. The chief guide must be the ability of the horse to micturate. If the bladder become distended and cannot be emptied by pressure per rectum, the penis must be withdrawn and examined, and as a last resort a catheter passed a short distance. Catheters thus employed, either temporarily or left in position, must be provided with a terminal orifice in addition to the usual laterally situated openings.

(iii.) This method aims at more rapid healing; but the result is by no means so certain, as swelling of the penis following operation is liable to tear out the sutures.

The integument covering the dorsal surface of the penis is divided transversely through half its circumference at a point about 1 inches below the intended line of amputation. This is then raised and dissected free as far back as the latter point. The remaining skin is divided transversely on a level with the base of the flap thus formed. The corpora cavernosa are then cut through at the same level, but the corpus spongiosum is left an inch longer. The urethra is dissected out and hmmorrhage is controlled by torsion or ligature of the vessels.

The flap of skin dissected free from the dorsal surface of the penis is now turned down over the stump. At the level of the urethra an elliptical hole is cut and through this the urethra is passed. The edges of the flap are then sutured to the edges of the skin surround ing the severed stump, whilst the urethra is divided longitudinally on either side and the flaps are sutured to the edges of the elliptical opening.

In the dog amputation may be performed either through or behind the os penis. Reported cases indicate that stricture of the urethra is more common when the operation has been effected by sawing through the bone.

Another method is to apply a ligature im mediately behind the os penis and amputate the penis. The skin of the prepuce covering the urethra is then divided longitudinally for inch, the urethra opened similarly behind the ligature and its edges united by fine sutures to the edges of the skin. An artificial opening is thus established and the danger of stricture occurring is considerably diminished.

Phimosis This term indicates that condition in which the penis is incapable of being protruded from the sheath. Phimosis is in some instances congenital and due to constriction of the preputial orifice. Thus it is met with in puppies occasionally. In newly-born foals the penis becomes in rare instances folded back wards upon itself, and the young animal is thereby rendered incapable of micturition un less the condition be recognized and remedied. Cases of phimosis occurring in adult life may arise from neglect, injury, or from the pres ence of new growths either in the sheath or penis.

From neglect, accumulations of smegma become deposited in the folds of the prepuce; from the irritation thus produced swelling of the sheath occurs and inability to protrude the penis results. The urethral fossa then becomes filled with secretions, pressure upon the free end of the urethra results, and the animal experiences great difficulty in passing urine.

Injury to the sheath includes kicks, blows from the whip, and wounds which cause swelling. (Edema of the sheath following castration or arising from purpura, lack of exercise or the presence of sclerostomes in the body, may also produce the condition.

We have observed phimosis following am putation of the penis from adhesion between the stump and the sides of the prepuce. Cicatricial contraction resulted in the drawing in of the sides of the sheath and stricture of the urethra.

New growths occurring on the penis, as carcinomata or large papillomata, may render the organ so large that protrusion becomes impossible. A similar condition of the pre puce produces the same effect. Botryomycosis sometimes extends to the sheath and may greatly restrict the size of the opening.

Treatment. This must be varied according to the cause of the condition. Inability to protrude the penis in the foal is usually remedied by straightening out the organ with the finger and applying a little vaseline.

The treatment of phimosis arising from neglect obviously lies in thoroughly cleansing the prepuce.

In cases where cedema is excessive, puncture at various points with a needle, followed by exercise, often gives relief.

New growths and enlargements arising from scirrhous cord must be removed surgically.

Congenital phimosis in adults, due to undue smallness of the preputial orifice, may be treated by incising the floor of the sheath and sub sequently uniting the upper and lower layers of skin of each side by sutures. Sometimes a V-shaped piece of skin may be removed with advantage or an artificial opening may be made in the floor of the sheath.

Paraphimosis This term indicates the condition when the penis cannot be retracted into the prepuce. The causes may be too small an opening in the sheath, a swollen penis, or paralysis of that organ.

The preputial orifice may be constricted from the time of birth, as is often the case in puppies and young dogs in which the glans penis pro trudes either during defmeation or some other posture or during coition, and is unable to be again withdrawn through the narrow opening. In other cases, when the penis is quite normal in size, the long hairs attached to the end of the prepuce become adherent to the penis during erection, and upon the organ again becoming quiescent these are drawn into the sheath. The skin around the opening then becomes inverted and reduces the size of the opening to such an extent that the glans cannot be retracted. This occurs in the dog, bull, and occasionally in the boar.

The penis, being thus exposed to the air and its venous outflow more or less strangulated, swells and becomes very painful and congested. The glans takes on a dark purple or livid appear ance, and after a time droplets of serum exude from it. After a varying period, if relief be not afforded, necrosis may set in. The surface is first affected, and the covering of the penis is rubbed off by friction of the body and bedding, leaving a raw oozing surface beneath. Recovery may, however, ensue even at this stage if the penis can be replaced in the sheath; and experi ence goes to prove that in the dog the organ may even be exposed for a week without death of the deeper structures, whilst in the horse the condition often lasts for ten or fourteen days with appearances simulating necrosis, and yet complete reduction may ultimately ensue.

In the horse occasionally, but more frequently in the bull, cases are met with in which the penis becomes injured during copulation. The symptoms are swelling and inflammatory changes in the body of the penis a few inches behind the glans. Not infrequently the organ is more or less bent at this point, and it protrudes for some little distance from the sheath. It is a common condition in Jersey and other small breeds, and also in young bulls of any class which are allowed to run with a herd of large cows, and results from repeated unsuccessful attempts at copulation and from striking the penis against the buttocks of the cow.

Paralysis of the penis is a rare condition, but it may occasionally result from local injury, from sclerosis of the lumbar portion of the cord, or in conjunction with paraplegia.

Paraphimosis is also associated with certain diseases, as purpura, influenza (rarely), but not infrequently occurs as a sequel to castration in the horse.

Prognosis. This is favourable in cases where true paralysis does not exist. Loss of power traceable to the retractor penis usually termin ates in injury to the organ from blows from the patient's hind feet or from contact with the ground whilst the animal is lying, and amputa tion is usually necessary.

Injuries resulting from copulation usually recover with proper attention, although bulls thus affected are sometimes incapable of serving afterwards. In some cases the end of the penis is no longer capable of erection.

Paraphimosis in' the horse is often very persistent, but the majority of cases recover eventually. It is unwise to perform amputa tion until all sensation has disappeared and the penis is cold to the touch. A fortnight is often required to effect reduction.

Treatment. In dogs pressure upon the swollen glans usually brings about diminution of its size, when the prepuce can be straightened out and drawn over it. Should this be im possible, the lower edge of the prepuce may be nicked with a bistoury, when reposition will be greatly facilitated.

Injury occurring during copulation in the bull may be treated by frequent warm fomenta tions and the application of lead liniment. Any attempt at replacing the glans is futile whilst the swelling exists in the body of the penis. Recovery usually occurs in from five days to a fortnight.

Paralysis of the penis may be treated by massage and stimulating liniments applied to the skin between the anus and scrotum, hypo dermic injections of strychnine, and by the use of a triangular suspensory bandage with which to sling the penis. Paraphimosis following castration or occurring as a complication of influenza or purpura is relieved by local scarifica tion, and in some cases by slinging, though this is not advisable in purpura, as sloughing may occur. Astringent lotions, such as lead and alum lotion, may be beneficial, whilst in some cases cold swabs are of assistance.

When the prepuce is chronically thickened or indurated a form of paraphimosis may persist in which the glans assumes the shape and size of a turnip. Circulation is, however, but little interfered with, whilst micturition is normal. The prepuce may be removed after applying a series of ligatures overlapping each other right around its circumference. It is seldom necessary to amputate the penis, as this soon assumes normal proportions after removal of the prepuce. R. H. S.

urethra, prepuce, horse, skin and usually