Vascularization Lymphatic Drainage and Nerve Supply of the Penis

The vascular supply of penile erectile tissues is provided by paired branches of the internal pudendal artery, either by the perineal artery (which supplies corpus spon-giosum) or the cavernosal artery (which supplies corpora cavernosa). The dorsal artery of the penis, another terminal branch of the internal pudendal artery, supplies the skin, Buck's fascia, tunica albuginea and corpus spongiosum and is located deep to Buck's fascia. The arteries give off circumflex branches to the corpus spongiosum and corpora cavernosa. Branches of the external pudendal arteries which are branches of the proximal femoral arteries also supply the penile skin.

The venous drainage is provided by the dorsal veins of the penis. The superficial dorsal vein, which runs across the dermis of the penile shaft, drains the skin and foreskin. It empties into one of the external pudendal veins. The deep dorsal vein, which may be single or multiple, is located in Buck's fascia and drains the corpora cavernosa, glans, and corpus spongiosum via circumflex veins, before entering the internal pudendal veins and ultimately the prostatic and pelvic venous plexus. The cavernous veins travel along the dorsum of the urethral bulb under the crus of the penis to drain into the internal pudendal system. The crural veins arise from the dorsolateral surface of the penis and drain into the internal pudendal veins. This pattern of venous vascularization is important since it explains why the majority of penile secondary tumors originate in the prostate, bladder, and rectum and the preferential involvement of corpora cavernosa by metastatic disease.4

Lymphatics from the penis drain directly into the inguinal lymph nodes. A superficial system drains the skin and a deeper lymphatic system drains the corpora and the glans penis. The sentinel node (or nodes) is expected to be found at the inner superior quadrant of the inguinal region. This sentinel node is the purported first lymph node affected by metastatic disease.5 Inguinal lymph nodes then drain into pelvic nodes. Drainage of penile lymphatics directly into pelvic nodes is an exceedingly rare phenomenon. Very infrequently there is a prepubic lymph node.6 Pelvic (iliac) nodes drain into paraaortic lymph nodes and from thereon into other systemic lymph nodes. The pattern of lymphatic drainage explains the sequence of sentinel node - inguinal nodes -pelvic nodes that is followed during regional and systemic spread.7 Identification and evaluation of sentinel lymph nodes status in penile cancer patients with clinically nonpalpable lymph nodes (cN0), a procedure which nowadays is performed using radioisotopes, permits the more rational implementation of radical groin dissections.8

The pudendal nerve (S2-4) is the major somatic and sensory nerve supply to the penis. After emerging through Alcock's canal, the pudendal nerve gives off a dorsal branch which runs along as the dorsal nerve of the penis. The nerve is deep to Buck's fascia and lateral to the dorsal arteries. The pudendal nerve then divides into the inferior rectal and perineal branches. The perineal nerve supplies motor function to the bulbospongiosus muscle and innervates the corpus spongiosum. The cavernous nerves course along with the cavernous artery and vein along the prostatic capsule as part of the prostatic neurovascular bundle.

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