Urology/Chronic pain and numb on erection
I had a circumcision in 2010 for a minor foreskin problem that could have been fixed otherwise.
An awful lot of the skin was removed which left little room for expansion and combined with very swollen nocturnal erections I felt a lot of pressure was put on the penis and perineum.
A couple of weeks after the circumcision I started getting feelings of pins and needles in the glans and pressure in the perineum when flaccid (such that I was sitting on something like a hard bicycle saddle) and an altered penile shape (fatter but shorter in length) and numbness in the glans on erection.
This has been the case for the last 4 1/2 years.
I have to apply a make-shift bandage to the glans during the day to minimise irritation and I feel constant discomfort in this area. The glans is now virtually numb on erection but somehow I can still ejaculate with some effort - although I would say this is more of a necessity than something enjoyable and I would not describe the climax as an orgasm in the way I knew it before, even if technically it is.
The problem that is troubling me is the constant day-to-day feelings of pain and pressure in the glans and perineum (bicycle seat kind of sensation) which are distracting and uncomfortable enough to prevent me from working full-time and doing activities such as running, cycling or swimming.
I have had an ultrasound of the prostate and an MRI of the pelvis, neither of which came up with anything of note.
I take some pregabalin and amitriptyline at low doses which help to some extent although I am not keen to take high doses as I am sensitive to medication and don't want to feel drowsy or doped-up all the time.
My question is: are there any further investigations which may help find the cause of the problem? I am interested in whether a high definition 3T MRI would be appropriate for the perineum area and whether a cystoscopy would tell a doctor anything more than the condition of the inside of my tubes.
Thank you for reading and please let me know if you have encountered anything similar before or if you have any suggestions.
Richard, sorry you are having this problem. As you might imagine, for this type of problem it is not possible for me to make an exact diagnosis or give recommendations over the internet because of the inability to take a more complete history and do a physical examination. However, I shall try to help you.
I do not think the pressure in the perineum and glans penis are related to your circumcision. By far, the most common cause of these symptoms are an inflammation of the prostate gland, so called prostatitis. This is a disorder that I have commented on extensively on this web site. Fancy imaging studies are not needed to make the diagnosis. In case you have not read it before, to follow is a "macro" I have written on this problem that will explain the various types of prostatitis, the diagnosis and their treatment to you.
Symptoms that might occur with prostatitis include frequency of urination, slowing of the urinary stream, burning with voiding or ejaculation, burning in the penile tip unrelated to voiding, urethral discharge, sexual dysfunction (such as difficulty with erection), aching in the penis, testicles, and discomfort in the lower abdomen, low back, groin, rectum or perineum (the area between the scrotum and rectum – between the “wind and the rain”) and constipation. The passage of blood at the initiation or termination of urination or in the semen can also be noted. During sexual arousal the prostate gland & seminal vesicles manufacture fluid that account for the majority of the semen. The seminal vesicles are paired structures located behind the prostate gland that are also sensitive to sexual excitement. Sperm from the testicles (which account for only 1-2 % of the semen) travel up a series of tubes (epididymis and vas deferens) on each side to join the seminal vesicles forming the paired ejaculatory ducts. These structures empty into the prostatic portion of the urethra. At the time of ejaculation, fluid is discharged from the prostate gland and ejaculatory ducts into the urethra (urinary canal) forming the semen. The average semen volume is 2-6 cc. With the inception of ejaculation, the bladder neck closes and the semen is forced forward out the urethra by contraction of the pelvic muscles.
It is not uncommon for inflammation and/or infection to spread in a retrograde manner into the vas and epididymis. Even without such spread, prostatic discomfort is often referred into the testicle. Too frequent or too infrequent ejaculation, sexual arousal without ejaculation, withdraw at the time of ejaculation, aggressive bike or horse back riding, and excessive spicy foods, alcohol, and caffeine in the diet can predispose you to this. Sitting for long periods of time, especially in an automotive vehicle, can put undo pressure on the prostate and aggravate the condition. For the latter, it is best not to sit more than 2-3 hours at a time. Stop the vehicle periodically, take a short walk and go to the bathroom to urinate. A thick pad or piece of sponge rubber on your seat will also help to cushion the prostate. One should avoid any of the above that apply. Eliminating all of these factors that apply to you are just as important, if not more so, than taking medication! Ejaculation beyond the tolerance of the prostate to fill and empty may also cause discomfort. Likewise if one does so infrequently, fluid still builds up from thoughts, dreams, fantasies, etc. and has to be released periodically to decompress the gland and relieve the symptoms. For most men, ejaculation in moderation, perhaps 1-2 times a week, is reasonable. A daily warm bath for 10-15 minutes 1-2 times daily also lessens the discomfort. Attention to sexual activity and warm bathes should be utilized regardless of the type of prostatitis and whether or not medications are prescribed.
There are several types of prostatitis. Sometimes prostatitis can be due to an infection of the gland with bacteria. Typically, pus cells and bacteria are found in the prostatic fluid. The infection usually requires an initial 4 week course of an appropriate antibiotic (the commonest prescribed are the fluoroquinolones, but tetracyclines, sulfas and other agents can also work).
Abacterial prostatitis has several varieties. In one, the prostatic fluid demonstrates pus cells but no bacteria. In the other, there are neither pus cells nor bacteria in the fluid, just the symptoms. In all types of prostatitis, the urinalysis generally is normal unless the infection spreads into the bladder. Abacterial prostatitis is an elusive entity that has been called by a variety of names including nonbacterial prostatitis, prostadynia, pelvic congestion syndrome and most recently pelvic myoneuropathy. The latter name was coined by Dr. David Wise of Stanford. He believes that this may represent up to 95% of all cases of prostatitis. This variant may be an expression of interstitial cystitis and possibly is due to autoimmune or neurogenic factors. Dr. Wise suggests that the primary cause of the symptoms involves pelvic muscle spasm, nerve trigger points and some degree of anxiety (either the cause or result of the symptoms). His therapy involves the use of anti-depressents (we have used Elavil for years in refractory patients), relaxation techniques, trigger point physiotherapy, and biofeedback. Some others recommend Yoga & meditation as being useful. Although he may well prove to be correct, I generally recommend an initial course of antibacterial therapy for patients who clinically have symptomatic prostatitis of any variety. The majority of patients (even those with nonbacterial prostatitis) seem to respond favorably. It has been know for decades that many patients with the abacterial variety of prostatitis do well with antibiotics but the reason has been vague. Some theorized that they may harbor bacteria in the tissues of the prostate that are not being picked up in cultures (possibly walled off loci of infection). For more information on Dr. Wise's studies check out:
In my experience, symptoms usually responds to the general measures mentioned in the initial paragraph. Medications that sometimes help include the over-the-counter natural supplement saw palmetto 320 mgm daily and alpha-blockers (such as Flomax, Hytrin, Cardura & Uroxatral). The latter require a prescription from you physician if he thinks it is indicated. More recently, a naturally occurring flavinoid with anti-oxidant and anti-inflammatory properties (such as quercetin) has been used in prostatitis. It's success is yet to be confirmed.
Prostatitis may also be classified as acute (severe), subacute (mild), or asymptomatic. It may also occur as a single episode, be recurrent or chronic. In chronic bacterial prostatitis, long term low dose antibacterial therapy often works well in suppressing symptoms. In refractory cases, culture of the prostatic fluid or semen often will disclose the offending bacteria. If found, sensitivity studies can identify which antibiotics are most likely to eliminate that particular germ. One should be off of all antibiotics for 7-10 days before the culture is taken. Otherwise, if there is residual antibiotics in your system, this may prevent bacteria from growing in culture.
In other cases refractory to treatment, there is another condition that can produce similar symptoms. This disorder is ejaculatory duct obstruction. Usually the doctor will find the seminal vesicles to be very swollen on rectal examination. The patient will notice either absence or a markedly diminished semen volume. The diagnosis is made by doing a transrectal ultrasound of the prostate and seminal vesicles.
Therefore, if symptoms persist, consultation with a urologist should be scheduled. In cases with recurrent prostatitis or hematuria, it often is necessary to study the urinary tract more completely. Predisposing factors to prostatitis such as a urethral stricture (narrowing) and other disorders can then be evaluated.
The numbness in the penis is best evaluated by a urologist, neurologist or both. Good luck.
I do not think you numbness is due to the circumcision. However, I neglected to mention some common etiologies of the numbness you are experiencing. A frequent cause occurs in bike (and occasionally horse back) riders. This is due to excessive pressure on the sensory nerves that run through the perineum. In men who use penile extenders or jelquing exercises they often develop this numbness. In these cases, stopping the causal activity generally resolves the problem although it often takes months for healing to occur. Other than these practices, numbness can be due to a a variety of neurologic conditions which is why I suggested a neurology consultation. Good luck.