7: Peno-Scrotal Disease Flashcards
What are the various causes of erectile dysfunction
- vascular
- neurological: diabetes, CVA, spinal injury
- venogenic/cavernosal
- hormonal
- medication: anti-depressants, beta-blockers
- psychogenic
Why is erectile dysfunction important
- sensitive marker of early vascular disease
- important for GPs to address CVS risk factors
- can potentially mitigate risk of MI, CVA
What are the 2 broad categories of erectile dysfunction and how can they be differentiated
Organic & psychological
1. Speed of onset: gradual = organic, sudden = psychological
2. Presence of early morning erections
What investigations are done in erectile dysfunction
- address vascular risk factors e.g. BP, lipids, glucose, smoking status
- early morning testosterone
- prolactin, LH, FSH
What is involved in the management of erectile dysfunction
- psychosexual counselling
- PDE5 inhibitors (sildenafil) but contraindicated if requires nitrates for ischaemic heart disease
- treat low testosterone
- intraurethral PG pellets or topical gel
- vacuum tumescence device
- penile prosthesis inflatable or malleable
What is phimosis and what are the different types
Tight foreskin ( prepuce is not fully retractable)
- physiological phimosis
- pathological phimosis
What is physiological phimosis
Majority of babies have a non-retraction foreskin which gradually reduces with time
What is pathological phimosis and what is the consequence of this
scarring of the foreskin opening leading to symptoms and non-retractability of the prepuce
- usually due to balanitis xerotica obliterans (BXO)
- repeated infections leads to repeated scarring and tightening
- can cause difficulty passing urine, pain, cracking when the penis is erect
What is the treatment of phimosis
Topical steroids or circumcision
What is paraphimosis and why is it an emergency
When the foreskin becomes trapped behind the corona of the glans penis and is an urological emergency
- timely recognition is important and reduction due to the risk of glans necrosis
What is the cause of paraphimosis and how is it managed
Failure to replace foreskin in patients needing care, after catheterisation or self-neglect
- firm compression for 20 mins until swelling reduces prior to pulling back the foreskin
- very rarely patient may need a penile block +/- dorsal slit
What is Fournier’s gangrene
Polymicrobial necrotising fasciitis of the perineal, perianal or genital areas
What are the risk factors of Fournier’s gangrene (4)
- poorly controlled diabetes
- alcoholism
- obesity
- indwelling catheter
What is Peyronie’s disease
Non cancerous conditions resulting from fibrous scar tissue that develops on the penis and causes curved, painful erections
- similar to dupuytren’s contracture in hand
- penile curvature correction surgery can be offered
What are key causes of scrotal lumps
- hydrocoele
- varicocele
- epididymal cyst
- testicular cancer
- inguinal hernia
- testicular torsion
How do you distinguish scrotal lumps
- Can you get above it?
- no = inguinal hernia
- yes = next question
- Can you feel the testes?
- no = hydrocoele
- yes = next question
- Is it separate to the testicle?
- yes = epididymal cyst or varicocele
- no = testicular tumour
What is a hydrocoele
Collection of fluid within the tunica vaginalis that surrounds the testes
- usually painless and present with a soft scrotal swelling
What are the examination findings of hydrocoele
- testicle is not always palpable within the hydrocoele
- soft, fluctuating and may be large
- irreducible and has no bowel sounds (differentiate from hernia)
- transilluminated by shining torch through the skin
What is a varicocoele
Veins in pampiniform plexus become swollen
- common affecting 15% men
What might varicocele cause (2)
- impaired fertility due to temperature disruption in affected testicle
- testicular atrophy which reduces size and function in testicle
What side do most varicoceles affect and why
Left due to increased resistance in the left testicular vein which drains into the left renal vein
- can indicate an obstruction of the left testicular vein caused by a RCC
How might varicocele present
- throbbing/dull pain or discomfort, worse on standing
- dragging sensation
- sub fertility or infertility
What is the management of varicocele
Consider embolisation for pain, testicular atrophy or infertility
What are the examination findings of epididymal cysts
- soft, round lump
- typically at top of testicle
- separate from testicle
- may be able to transilluminate large cysts appearing separate from the testicle
- consider surgery to excise if large and symptomatic
what is the most important initial management for a patient presenting with obstructive urinary calculi and signs of infection
nephrostomy tube to decompress + IV abx
what is the most important initial investigation for varicocele
adult patients with a hydrocele require an ultrasound to exclude underlying causes such as a tumour
what is the most appropriate management for testicular torsion
Emergency bilateral orchidopexy
what are medical indications for circumcision
- phimosis
- recurrent balanitis
- balanitis xerotica obliterans
- paraphimosis
why are the testes and epididymis not affected by Fournier’s Gangrene
fasica act as barriers and prevent entry of infection to these areas
- dartos fascia of testes
- Colle’s fascia of perineum
- Scarpa fascia of anterior abdominal wall
