8.3 Phimosis, Paraphymosis, Urethral Discharge, Genital Ulceration And Necrotizing

Question 1

Phimosis
General
Causes

Answer 1

• inability of foreskin to retract over glans
• not emergency
• age of 3 years is cut off for foreskin to retract (physiological)

Causes
- Balanitis
- trauma (retracting of foreskin as baby)
- dermatitis / posthitis (DM)
- lichen sclerosis

Question 2

Paraphimosis
Definition
Causes

Answer 2

• EMERGENCY

Def:
Foreskin is retracted behind glans and can not be reduced

• narrow foreskin forms tight band behind glans

⬇️ venous & lymphatic drain of glans -> swelling of inner prepuce and glans -> ⬇️ perfusion of glans with necrosis

Causes
- Iatrogenetic (catheterisation)
- incomplete phimosis: foreskin pulled back and left there with relative tight foreskin

Question 3

Urethral discharge
Causes

Answer 3

Causes:
- Urethritis (STD)
- Urethral cancer
- foreign bodies
- stones
- urethral strictures
- instrumentation (cystoscopy)
- chemical irritation
- systemic illness (Reiter’s)

Question 4

Causes of Urethritis

Answer 4

1. Gonococcal (GU)
- Neisseria gonorrhoea
- sym (females 70% asym)

2. Non-gonococcal (NGUC)
- Chlamydia trachomatis (50-60%)
- ureaplasma urealyticum (20%)
- mycoplasma genitalium
- trichomonas vaginalis
- most common STI
- asym
- spread easily

Reiter’s syn: Chlamydia trach
- can’t see, can’t pee, can’t climb a tree = conjunctivitis, urethritis, reactive arthritis

Question 5

Complications of urethritis

Answer 5

• urethral stricture (up to 20 years later)
• epididymitis
• infertility (obstruction)
• pelvic inflam disease (PID)

Systemic
- Periphepatitis
- arthritis
- dermatitis
- meningitis
- myopericarditis

Question 6

Genital ulcers causes

Answer 6

• syphilis
• HSV
• chancroid
• malignancies (penile cancer)
• premalignant conditions (carcinoma in sito, Lichen Schlerosis)
• lymphogranuloma venereum
• granuloma inguinale

Question 7

Syphilis
General
Types (x4)

Answer 7

• treponema pallidum
• stages of untreated infec: prim, sec, latent , tertiary infec
• Latent: early and late (late - infec in last 12m)
• incubation varies: 21 days / decades later

Primary
- at site of infection occured
- painless ulcer (firm, hard)
- endarteritis and vascular sclerosis
- clean base with raised edges
- oedema
- heals spontameously + scar
- non-tender rubbery inguinal lymph nodes

Secondary
- most contagious stage (8 weeks after)
- flu sym + skin rach (soles of feet + palms of hands; mucular->papular)
- generalised lymph nodes
- might have any inflam
- resolve spontaneous in 1 year

Latent
- no clinical signs
- can still be transmitted through blood
- can only test through blood

Tertiary
- gummatous phase anywhere in body
- 3-10 years after initial infec
- granulomas
- painless testicular swelling
- aoritis (aneurysms)
- neurosyphilis

Question 8

Herpes Simplex Virus

Answer 8

• LIFE LONG; never get rid of it
• Serotypes 1 & 2
• Mucosal membranes
• Genital leisons 2-20 days after infec (painful)
• tender inguinal lymph nodes
• flu-lik Sx
• dysuria
• pass to neonates during delivery

Question 9

Chancroid

Answer 9

• Haemophilus ducreyi
• Cofactor for HIV
• Erthematous papule 3-14 days after infec
• painful matted inguinal nodes (buboes)

Question 10

Lymphogranuloma venereum

Answer 10

• Chlamydia trachomatis
• tropical climates
• self-limiting ulcers
• later inguinal lymp nodes (2-6 weeks)

Question 11

Granuloma inguinale

Answer 11

• causes painless ulcers without any lymph node involvement
• can easily bleed
• Donovanosis (donovan bodies)
• calymmatobacterium granulomatis

Question 12

Necrotising fasciitis (Fornier’s gangrene)

Answer 12

• EMERGENCY
• Rapid, fulminating gangrene of genitalia
• Immunocom pt
• develops and spreads very rapidly (within hours)

Pathogenesis
- Source: GIT, GUT, skin
- Local inflam response -> ⬇️ O2 tension in tissues -> growth of anaerobes -> tissue necrosis
- polymicrobial infec
- ⬆️ mortality