Urology/Bulge/aneurysm in tunica?
QUESTION: Hi Dr. Leslie,
I am a 29 y/o M who has noticed a slowly growing circumferential bulge in the L sided of my shaft for the past several years. At first I thought it was a vein but it is flesh colored, not blue and much larger than my other veins. I have no pain there and I don't recall any penile injury. I have also had ED for several years, origin unknown (but physical element confirmed by decreased nocturnal tumescence), currently managed with Cialis.
Several months ago I went to a university urologist regarding the bulge. He conducted cavernosometry/cavernosography imaging to determine if there was a venous leak and found none, at the bulge site or elsewhere. He said without a leak there was no cause for surgery, but told me he had never seen a bulge like that in all his experience and so a prognosis was difficult.
I have attached some images with the hope that you have seen something like this before. My questions, if possible to answer, are 1) What is it? 2) How likely is it to keep growing? 3) At what point should I be concerned enough to return to the urologist?
It really seems like a rare problem. My online research shows it may be a tunica aneurysm, of which there are only a few case reports in older men or folks with connective tissue disorders. The bulge is most prominent during detumescence. Underneath the bulge feels firm, but my urologist tells me there are two layers of the tunica so perhaps there is an aneurysm in one of them?
Thank you so much for your help,
I have not seen a similar "bulge". If a university urologist was unable to give you a diagnosis after cavernosometry and cavernosography, then it is unoiikely I will be able to from here. My best advice is to get copies of the results and perhaps seek out one of the more experienced experts such as Dr. Larry Levine in Chicago who specialize in male issues like this. Actual tunica aneurysms are quite rare and unusual.
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QUESTION: Thank you for your advice Dr. Leslie, which I will probably follow, although I may try to find a urologist closer to where I live in Florida. Do you agree that there is no role for intervention (which I assume would be surgical) unless the "bulge" exhibits venous leak?
As I mentioned, the cavernosometry/cavernosography revealed no leak, and an ultrasound of the cavernosal arteries showed normal flow. I really just want to feel a bit of closure about the issue.
Thanks again for your time.
First, the bulge almost certainly has nothing to do with venous leak which is an effect of the spongy tissue underneath the tunica. The tunica is just a covering a little like the steel belts in your car tires.
The problem with the bulge is just that: a bulge! It means there may be a weakness in the shape or strength of the tunica and this may have an effect on erection rigidity. If it doesn't seem to matter at this point, enjoy.
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QUESTION: I see, thanks. Given that the DICC did not reveal any gross deformity at the bulge site, and that I haven't witnessed any buckling at the site, how likely do you think it is that this deformity has something to do with my ED? Though otherwise very healthy, I have two rare symptoms, ED in a young man and this bulge -- one would think they would have to be related.
Is it possible that it could be a aneurysm of the deep fascia instead of the tunica itself? Would this make any difference in management? When I press on the bulge during erection it feels hard underneath. I would think that if the tunica itself was herniating it would feel softer.
Obviously these are questions for my urologist, just curious what you think. Thank you again for your knowledge and advice.
My best guess is that the bulge probably has little if anything to do with your ED if the DICC was normal.
If there were a problem with the deep tissues, these would tend to be hidden by the tunica. There is no deep tissue structure to develop an aneurysm so to that degree your question is moot.
If the tunica was severely weakened and bulging, it would likely interfere with erection rigidity. A diagnostic ultrasound of the penis might be helpful in trying to clarify exactly what this is going on in this bulge.