Chapter 39: Disorders of the Male Genitourinary System

Question 1

Explain the physiology of penile erection and relate it to erectile dysfunction and priapism.

Answer 1

Erectile Dysfunction:

Inability to achieve and maintain erection sufficient to permit satisfactory sexual
intercourse

Causes:
Psychogenic
Organic – most common
Both

Psychogenic:

• performance anxiety
• emotional issues with partner
• depression

Organic:
Neurogenic
=Stroke, spinal cord injury, surgery
Vascular
=Hypertension, smoking, DM, irradiation
Hormonal
=Decreased androgen levels
Drug-induced
=Antihypertensives, nicotine, alcohol, 	antidepressants, antipsychotics, B-blockers
Aging

TREATMENT:
Psychosexual Counselling
Medication
Androgen replacement (when deficiency is confirmed)
Oral Phosphodiesterase type 5 inhibitors (viagra)
Intracavernous
Vacuum constriction devices
Prosthesis (short term)
Vascular surgery

PRIAPISM
-Involuntary, prolonged, painful erection d/t impaired blood flow in corpus cavernosa resulting in failure of detumescence

Risk factors:
Sickle cell disease, neoplasms
Primary: IDIOPATHIC
Secondary:
Hematological, neurological, renal
Medications

Question 2

Describe the usual causes of penile inflammation and infection

Answer 2

Due to trauma, irritation, infection
Candida albicans, bacteria
Often related to STIs

Manifestations:

• Erythema, edema of glans and prepuce
• Malodorous discharge

Blanitis xerotica obliterans (often UKE)
-Sclerosing atrophy of the foreskin: precancerous state

Question 3

Define the term testicular torsion and the importance of efficient diagnosis and treatment.

Answer 3

Testicular Torsion:
Twisting of the spermatic cord suspending testes

Extravaginal: more common fetus/neonate

Intravaginal:
Common in teenager d/t testicular growth
Obstructs venous drainage first, then arterial
Edema, pain, nausea

Often second testes affected… or will be
Surgery: fixate testes or orchiedectomy

Treatment includes surgical detorsion and orchiectomy. Orchiectomy is carried out when the testis is deemed nonviable after surgical detorsion. Testicular salvage rates are directly related to the duration of torsion

Question 4

State the causes, physical manifestations, and complications of cryptorchidism.

Answer 4

Failure of one or both testicles to move down inguinal canal into scrotal sac by 7-9 months gestation

Risk factors:
Prematurity, small birth weight, genetic if term-baby

Causes: Idiopathic, genetic, hormonal

Manifestation:The major manifestation of cryptorchidism is the absence of one or both of the testes in the scrotum. The testis either is not palpable or can be felt external to the inguinal ring

Spontaneously descends by 3 mo. but rarely after 4 mo.
Abnormal testicular pathology by 6-12 months

Complications:
Infertility, testicular torsion, malignancy (high rate), psychological

Treatment
Surgery and follow-up screening

Question 5

List common causes and manifestations of acute prostatitis.

Answer 5

Causes:
Spontaneous
Instrumentation
Secondary 
HIV
DM
Urethral strictures

1. Acute bacterial
2. Chronic bacterial

3.Chronic prostatitis/pelvic pain syndrome
Most common/least understood
Inflammatory but not bacterial, or non-inflammatory

The inflammatory type was previously referred to as nonbacterial prostatitis, and the noninflammatory type as prostatodynia. A large group of men with prostatitis have pain along the penis, testicles, and scrotum; painful ejaculation; low back pain; rectal pain radiating to the inner thighs; urinary symptoms; decreased libido; and impotence, but they have no bacteria in the urinary system.

4. Asymptomatic inflammatory prostatitis
   - Men with asymptomatic inflammatory prostatitis have no subjective symptoms and are detected incidentally on biopsy or examination of prostatic fluid

E. coli most common pathogen
Manifestations:
Similar to pyelonephritis
Fever, malaise
Dysuria, frequency
Pelvic aching pain (rectum, perineum)
Malodorous cloudy urine
Rectal exam: swollen, tender, warm, thick discharge

Question 6

Describe the urologic manifestations and treatment of benign prostatic hyperplasia.

Answer 6

Non-malignant enlargement of prostate d/t imbalance between cell proliferation & apoptosis
Common >60 years old
Related to
proliferation of prostate cells
Alpha 2 adrenergic receptors overeact
Detrusor instability & impaired bladder contractility (recent thoughts)

MANIFESTATION:
Prostate enlargement compresses urethra causing
Weak stream, urgency, dysuria, nocturia, overflow incontinence
Bladder distension causes destructive changes in bladder wall causing
Hydroureter, hydronephrosis, herniations, sacs
infections

Pharmacologic
Alpha adrenergic blockers 
Alpha reductase inhibitors block androgens
Herbal therapies
Surgery
Removal of enlargement 
Transurethral prostatic resection (TUPR)
Suprapubic, perineal
Laser vaporization, microwave, needle ablation

Question 7

List the methods in the diagnosis and treatment of prostatic cancer.

Answer 7

2nd most frequently diagnosed cancer in men
Incident increases >50 years of age
Etiology (unclear)
Familial connection
Increased dietary fats may alter hormonal balance

Asymptomatic
Metastasis to lung reflects lymphatic spread
Migration to bladder not until later
Bone pain (vertebral, rib, pelvis) often first sign d/t metastasis

DIAGNOSIS:
Digital exam via rectum
Transrectal ultrasound
Prostatic Specific Antigen (PSA)  ??
Treatment
Surgery
Radical Prostatectomy
Radiation
Hormonal therapy to reduce testosterone levels