4 - Penis Flashcards
Penis
Anatomy slides 7,8
What is balantitis and balanoposthitis?
Inflammation of the glans penis and/or foreskin
Common cause of balanitis and balanopsthitis?
Usually candida albicans
- poor hygiene
- complication of phimosis
What is phimosis?
Contracted foreskin cannot retract over glans
- can develop smegma, calculi and SCC under foreskin
Presentation of phimosis?
Pain or tenderness of foreskin
Chronic “yeast infections”
Tx for phimosis?
- Broad spectrum abx
- Circumcision
What is paraphimosis?
Retracted foreskin is trapped behind glans penis
- tourniquet effect
- painful swelling of the glans
- necrosis
MEDICAL EMERGENCY
Tx for paraphimosis?
Manual reduction (1st line)
Immediate urology referral if 1st line fails
- incision under local anesthesia
So you did a manual reduction (never making eye contact) now what?
All paraphimosis pts require urological referral for circumcision to prevent further recurrence
MC congenital malformation of the penis?
Abnormal location of the urethral meatus:
- Hypospadias - ventral meatus (penis, scrotum, perineum)
- epispadias - meatus opens on dorsal aspect of penis
Hypospadiasis characteristics?
- More common
- associated w feminization
- excellent prognosis with repair
Tx for hypospadias?
No circumcision (used as a graft)
Repair <18mo (usually 6mo)
Epispadias characteristics
- Rare
- Urinary incontinence is common
- Dorsal curvature of penis is common
- Poorer prognosis
What is chordee?
Abnormal congenital ventral curvature of the penis
- short urethra and or fibrous tissue around the corpus spongiosum
- commonly associated w hypospadias
What is peyronie’s disease?
Fibrous d/o of tunica albuginea, curvature, deformity, pain
- acquired malformation
Middle aged men
Causes of peyronie’s?
Probably minor penile trauma
- inflammation of corpora cavernosa -> d/o collagen disposition
PE for peyronie’s disease?
Plaque involving the tunica albuginea that is:
- Palpable
- Dense
- Fibrous
- dorsal midline (usually)
Peyronie’s diesase is associated with what condition?
Dupuytren contracture
Tx for peyronie’s disease?
10% spontaneously improve
Medical therapies
- collagenase clostridial histolyticum inj
- CCB or interferon
Surgery (if compromised sexual function)
Priapism is?
Erection >4hrs
- not associated w sexual arousal or desire
Causes of priaprism?
Idiopathic (60%)
- leukemia
- SCD
- pelvic tumors
- penile trauma
- spinal cord trauma
- meds
Types of priapism?
Non-ischemic
Ischemic
- both need urology consult
Non-ischemic priapism?
- High flow priapism
- Arteriovenous shunging -> unregulated high blood flow
- perineal or spinal cord trauma
- may not require tx
- ED usually spared
Ischemic priapism?
- Low flow-> venous congestion and arterial inflow cessation -> ischemic injury to corpora cavernosa
- painful erection
Tx for ischemic priapism?
Emergent treatment to prevent erectile function loss
- large needle blood aspiration
- adrenergic meds (phenylephrine)
How common is penile cancer?
Its not
<1%
Risk factors for penile cancer?
Uncircumcised - poor hygiene Phimosis - 7-10% increase HPV infection
Usually seen in 6th decade
Types of penile cancer?
SCC - 98%
- seen on glans
Bowen disease (SCC in situ) - red plaque on shaft
Erythroplasia of queyrat
- velvety red lesion w ulcerations on glans
- bowen disease of glans
Penile cancer ddx?
Biopsy - manditory to r/o
- syphilis
- chancroid
- condylomata
Scrotal pain, swelling and masses?
Pic on slide 36 shows the different types
Scrotal anatomy?
40, 41, 43
How is the scrotum evaluated?
Palpate testes between fingertips of both hands
Palpate for any suspicious masses
Transillumination -solid vs cystic lesion
MCC urology referral is for?
Mass on scrotum
They must decide if lesion is w/in testicle, related to epididymis or cord
Masses arising from w/in testes are?
Usually malignant
- so there is that…
What testicular masses are usually benign?
Epididymis and spermatic cord are usually benign
Describe testicular malignancies?
Lesion that is:
- Painless
- Firm
- Solid
- W/in substance of testicle
- Does not transilluminate
Testicular mass “when in doubt?”
Image
- US preferred
Safe reliable method to relieve anxiety of the pt
List of scrotal/testicular masses
Hydrocele Varicocele Epididymal cyst Spermatocele Hernia Testicular cancer
What is a hydrocele?
Collection of fluid between the 2 layers (parietal and visceral) of tunica vaginalis
Causes of hydrocele?
2/2
- congenital cause (patient process vaginalis)
- infection (epididymitis)
- trauma/testicular torsion
- tumors (cancer)
Describe hydrocele?
Young (usually 1st yr of life)
Painful (if large)
Heaviness in scrotum
Transilluminates
Tx for hydrocele
Watchful waiting
Surgery
- excision of hydrocele sac
With hydrocele?
DO NOT ASPIRATE
What is epididymal cyst?
Cyst occuring at the caput of the epididymus
- <2cm
- distinct from testicle
Benign
What is a spermatocele?
Benign cystic accumulation that arises from the head of the epididymis
> 2cm
Symptoms of spermatocele?
Asymptomatic
- non tender on exam
If large, may feel “heavy”
Where do you palpate a spermatocele?
Palpable on exam
- near upper pole of the testicle
Tx for spermatocele?
Watchful waiting
Surgery (if symptomatic)
What is a varicocele?
Abnormal dilation of the pampiniform plexus of the spermatic veins
- bag of worms
Varicocele is most commonly found?
On the L
Varicocele presentation?
Dull ache Size - increase when upright - decrease when supine Pain worsens w activity
Varicocele a big deal?
May cause infertitlity
- increase scrotal temp -> germ cell apoptosis
- testicular atrophy
PE for varicocele?
Bag of worms
increase W valsalva
decrease when supine
Left side
+/- US (its a clinical dx)
Grades of varicoceles?
1: small - palp only w valsalva
2: moderate - nonvisible on inspection but palp on standing
3: large - visible on gross inspection
Further eval needed (varicocele)
- Unilateral right sided
- Lesion remains dilated when supine
- Occur abruptly (obstruction)
- Enlarge rapidly
R sided sudden varicocele may be?
Retroperitoneal malignancy
Get a CT scan
Tx for varicocele
Initially -> symptomatic management
- reassurance and watchful waiting
- scrotal support
- activity mod
- NSAID
W infertility/pain
Surgery
- ligation of gonadal vein via inguinal canal, laparoscopy or microsurgery
Types of hernias?
Indirect: congenital patient process vaginalis
Direct: arises from protrusion of abdominal viscera -> weakness of the posterior wall of inguinal canal (acquired)
Pics 67-69
Which type of hernia may extend into the scrotum and goes through the deep or internal inguinal ring into inguinal canal?
Indirect (congenital)
Diagnosis of hernia?
Palpable bulge (esp w valsalva)
US or CT
If there is any doubt wheteher a mass is w/in or outside testicle?
Get a scrotal US
urologic consult
It could be cancer to dont fuck around
MC neoplasm in men 15-35?
Testicular cancer
How is testicular cancer diagnosed?
Orchiectomy
- damn, that escalated quickly
What type of cancer is testicular cancer?
90-95% are germ cell tumors
- arise from spermatogenic cells w/in seminiferous tubules
Risk factors for testicular cancer?
- Cryptorchidism
- Testicular trauma/torsion
- Infection-related testicular atrophy
- Chemical exposure/pollutants
S/s of testicular cancer
- Painless enlargement of testes
- sense of heaviness
- palpable mass
- hydrocele (10%)
Labs for testicular cancer
Elevated
- hCG
- AFP (alpha fetoprotein)
- (LDH) lactate dehydrogenase
Advanced disease
- CBC
- LFT (liver mets)
Imaging for testicular cancer?
Scrotal US
CT/PET after orchiectomy for staging
Treatment for testicular cancer?
Radical orchiectomy
- further tx depending on what path says
Prognosis for testicular cancer?
Stage I-III : 5 yr = 95-100
Bulky retroperitoneal malignancy or advanced = 55-80%
Secondary testicular tumors are?
Rare
Lymphoma (usually)
USPSTF says
No testicular self exam
- i say what you do in the privacy of your own home is your own business
Age prevalence of testicular torsion?
Neonates - MC
Post-puberty 60%
Men >21 40%
Presentation of testicular torsion?
Sudden onset of pain
- several hours after activity/trauma
- after cremasteric contraction during REM sleep (well damn)
Pain, N/V
PE for testicular torsion?
Classic sign:
- high riding testes w long axis oriented transversely
Early: profound swelling
Late: after 12hr reactive hydrocele and scrotal erythema
Exquisite tenderness
Absent cremasteric reflex
Neg phren sign
Testicular torsion is MC associated w?
Bell clapper deformity
Test of choice for testicular torsion?
Doppler US
- if you dont have it just do the surgery
Tx for testicular torsion?
Surgery - life limb or eyesight
Removal or orchipexy
Manual detorsion?
Its a thing but should you?
Either way, its call “open book” R - counterclockwise and L - clockwise
30-70% success
You did the open book and it worked what now?
Still surgery
MCC of scrotal pain in adults
Epididymitis and epididymo-orchits
Epididymitis and epididymo-orchits are usually caused by?
Infection (2 types)
STI
- Men <40
- urethritis
- N gonorrea/chlamydia
Non-STI
- older men
- UTI and prostatitis
- Gram-neg rods
Acute presentation of Epididymitis and epididymo-orchits?
Follows physical strain (heavy lifting), trauma, or sex
Fever
Exquisite tenderness and swelling of epididymis, testicle and or scrotum
Irritative voiding symptoms
PE for Epididymitis and epididymo-orchits?
Induration
Swelling
TTP (exquisite)
+ phren sign
Epididymo-orchitis also have testicular swelling and pain w scrotal wall erythema and may have reactive hydrocele
What does phren sign differentiate?
Phren sign relieves pain w epididymitis
Does not relieve pain w testicular torsion
Diagnostic tests for Epididymitis and epididymo-orchits?
Diagnosed by PE
Also get:
- CBC
- UA
- Urine culture
- Gram stain of urethral discharge
- US (Equivocal exam)
Tx for Epididymitis and epididymo-orchits?
STI
- ceftriaxone + doxycycline
- treat the partner
Non-sexually transmitted form
- ciprofloxacin/levofloxacin
- eval urinary tract
Viral/non-infectious
- symptomatic care
Everybody:
- bed rest
- scrotal elevation
Direct blow or straddle type injury to the testicles can cause?
Hematocele
Rupture
Surgery referral
Blue dot sign?
Torsion of appendix testis
infarction/necrosis
Torsion of appendix testis presentation?
Similar to testicular torsion (more gradual)
Blue dot sign
+ US
Tx for torsion of appendix testis?
Conservative tx
- rest
- scrotal elevation
- analgesics
Referred testicular pain?
Stones Uti Pyelonephritis Low back pain AAA Post surgical (herniorrhaphy)
What does mumps do to the testicles?
Orchitis
- fever, Parotitis usually precede orchitis
What os fournir’s gangrene?
Necrotizing fasciitis of perineum and scrotal skin
- Diabetics
Fournier’s gangrene tx?
Urgent surgical debridement
What is PVPS?
Post-vasectomy pain syndrome
- chronic pain following vasectomy
- painful granuloma palpable at site of vas
- foreign body reaction
Blessedly uncommon
How is chronic orchalgia diagnosed?
Diagnosis of exclusion
Id like to give a big shout out to all the sidewalks
For keeping me off the streets
