Conditions of Male Genitalia Flashcards
4 Red Flags
ED - erection >4hrs (priapism)
Hematospermia (blood in semen) - sx lasting >1mo, palpable mass, hematuria, and/or obstructive sx
Urethral Discharge (STI or E coli) - w/pelvic pain, fever, chills, and/or urinary retention
Scrotal Pain - if acute onset, N&V, abdominal pain MUST rule out testicular torsion
Epispadias
Congenital malformation of urethral meatus w/opening on the dorsal surface of the penis. If flow is adequate, may not be a problem. Refer to urologist if needed.
Hypospadias
Congenital malformation of urethral meatus on ventral surface of penis. If needed, urethroplasty.
Balanitis, Posthitis, & Balanoposthitis
Balanitis: inflammation of glans penis
Posthitis: inflammation of the foreskin
Balanoposthitis: inflammation of both
Causes: infectious (candida, GC, Chlamydia, scabies, etc), non-infectious (contact dermatitis, psoriasis, etc), or more commonly, poor hygiene or diabetes.
May predispose to meateal stricture, phimosis, paraphimosis, and cancer
Balanitis xerotica obliterans (BXO)
lichen sclerosis of the penis - indurated, white area on glans from chronic inflammation. Precancerous.
Phimosis
Foreskin cannot be retracted from glans.
Physiologic: May not fully retract until 15yo, ~50% by 10yo.
Pathologic: Pain, constriction, blockage of meatus from adhesion.
-Risk factors for pathologic phimosis: frequent diaper rash, poor hygiene, condom catheter, DM
Paraphimosis
Foreskin remains in retracted condition & becomes inflamed. Reduced blood flow to glans can cause gangrene or necrosis.
Peyrionie’s Disease
Chronic inflammation of the tunica albuginea. Scarring of tunica albuginea (in corpus cavernosa) leads to plaques that can cause painful erection & dorsal curvature. Disorder of wound healing w/over expression of TGF-beta1. More common in caucasians. Up to 10% of ED pts have PD. Psychological affects are significant!
PE: *palpable plaque on dorsalsurface of the penis!
Genital Herpes
Common ulcerative STI cuased b HSV-2 or (10-30%) by HSV-1.
Primary infection: 4-7 days after exposure. Outbreak is more painful & prolonged than recurrent infection. Clusters of vesicles erupt & form superficial ulcers on an erythematous base. Loc. on prepuce, glans, shaft, anus, rectum, or thighs. Concomitant sx - urinary hesitancy, dysuria, constipation, sacral neuralgia, flu-like discomfort, fever. Scarring may occur. Virus sheds for ~3wks.
Recurrent infection: 80% of HSV-2 & 50% of HSV-1 recur. Less severe, sheds for shorter period (~3days), ~4x/year. Men have recurrence 20% more than women. Dx w/clinical eval of lesion, Tzanck test, and viral culture
Genital Warts (Condylomata Accuminanta)
Common STI from HPV. >70 types, ~90% caused by 6 & 11, which are low-risk for CA (16 & 18 are high risk). Usu. seen between 17-33yo, highly contagious - 60% risk of infection w/exposure. May be latent for months to years. Assoc. w/:OCs by female b/c of increased sex w/out barrier protection, multiple sex partners, early age of sexual activity.
Lesions painless; location, size, or itching may cause irritation. Range
Syphilitic Chancre
Solitary, painless or slightly tender ulcer, nun-exudative w/indurated edge. Contagious Treponema pallidum. Regional non-tender adenopathy. Serologic testing to dx.
Chancroid
Painful, shallow non-indurated ulcers w/irregular edges & red borders with gray or yellow purulent exudate. Infection of Haemophilus ducreyi. Regional tender adenopathy. May abscess. PCR testing to dx.
Squamous Cell Carcinoma of the Penis
More common in uncircumcised males w/poor local hygiene habits. HPV 16 & 18 may play a role. Fungating exophytic or ulcerative infiltrative types. Presents as a non-painful sore that won’t heal. Dx w/biopsy.
Pearly Penile Papules
Soft papular angiofibromas around the corona. Benign hair-like projections (more like sprinkles). Usu. on uncircumcised males. Can be removed, are likely to return.
Contact dermatitis
Eczematous rash (red & pruritic) may develop in response to latex or other agent.
Risk Factors for Erectile Dysfunction
- Drugs: anti-depressants, NSAIDs, sbstance abuse esp. narcotics.
- Neurogenic disorders: spinal cord & brain injuries, nerve disorders; stroke, Parkinson’s, Alzheimer’s, MS)
- Cavernosal disorders
- Psychogenic Causes: performance anxiety, stress, mental health disorders (depression, schizophrenia, panic disorder, anxiety, personality disorder)
- Aging: linear increase from age 40 to 70 w/lower T & higher E
- Kidney failure
- Diabetes (affects vascular & NS)
- Smoking (arterial narrowing)
- Alcoholism
- Saddle injury (long bike rides)
Impotency/ED
Inability to attain or sustain enough erection to perform sexual activity & ejaculation. Very common, increased w/age. Need hx to determine pattern of ED (ie does erection occur at night? ED only w/partner? Etc).
PE: cardiovascular, neurological, and mental status w/GAD7 or PHQ-9
Work up: UA, CMP, hormone testing
Priapism
Prolonged painful erection lasting >4hrs! (EMERGENCY: ischemia, necrosis). Idiopathic: prolonged sexual excitement. Secondary: drugs, alcohol, cocaine, sickle cell dz, DM, CML, penile trauma, black widow spider bite.
Low-flow: veno-occlusive, most-common. Penis painful & tender, little intracorporal blood, compartment syndrome w/metabolic changes & increased pressure leading to hypoxia & acidosis.
High-flow: increased arterial inflow w/out increased outflow resistance. Non-tender penis!
Dx: color doppler US, assessment of corporeal blood gasses
Any hard swelling of the testes is…
Considered testicular cancer until proven otherwise! Especially in the young. Swelling may be due to trauma, inflammatory conditions, neoplasms, etc.
Hematocele
Blood-filled swelling su from trauma, may be tender initially but generally not painful. Does not transilluminate b/c blood is dark.
Hydrocele
non-tender serous fluid filled mass. Fluid btwn tunica layers. Acute: most common hydrocele btwn 2-5yo. Usu result of inflammation of epididymis or testis. Chronic: Middle age men from inflammation/injury. Usu not painful and typically doesn’t require tx. Does transilluminate. Scrotal US to confirm.
Varicocele
Incompetent venous valves -> dilation of pampiniform plexus. “Bag of worms” appearance & feel along spermatic cord. Worse w/valsalva & standing. Nontender, though may have a “dragging” sensation. May be an indication, if new or worsening in an older man of: tumor or mass occluding L renal or testicular vein if on L side; occlusion of vena cava if on R side. May result in infertility from increased temperature in scrotum. Dx w/angiography
Sebaceous cysts
Firm, cutaneous nodules
Scrotal Edema
From CHF, nephrotic syndrome, ascites, parasites, filaraisis, tumor cells blocking lymphatics
Indirect inguinal hernia
May extend into scrotum. Large compressible scrotal mass that won’t tranilluminate & can’t palpate upper edge. May hear bowel sounds. Risk of bowel strangulation.
Testicular Torsion
EMERGENCY - assume this until proven otherwise! Must be de-torsed within 6 hours. Severe scrotal pain after trauma, intensive exercise, or spontaneously during sleep. Usu 10-25yo. Most who develop torsion have “bell clapper” anatomy wherein testicle freely rotates.
Sx: sudden acute unilateral, constant pain w/possible N/V. Swollen, tender, erythematous scrotum (difficult to discern structures). Affected testicle higher, epididymis m/b anterior, reactive hydrocele possible. Pain may radiate to abdomen (acute abdomen). Elevation of scrotum does not relieve pain (negative Prehn’s sign). Cremaster reflex absent.
UA is normal, color doppler is 99% specific, 85% sensitive.
DDX: trauma, orchitis, epididymitis, torsion of appendix testis (blue dot discoloration)
Torsion of testicular appendix
(vestigial structure in upper pole of testis) Boys 7-14yo. SSX: subacute onset of pain in upper pole of testis. Cremasteric reflex present. “Blue Dot” sign - discoloration seen under skin.
Testicular tumor
Painless unless large or hemorrhage is present. Otherwise may be painful
Testicular trauma
Obvious hx. Swelling, hematocele or hydrocele may develop.
Mumps orchitis
(Paramyxovirus) 20% of post-pubescent boys onset 1-2 wks following parotitis. Unilateral or BL scrotal pain, erythema & swelling. Abdominal pain, NV. May result in testicular atrophy. Sterility rare, hormonal fxn in tact.
Spermatocele
Small painless cyst on the superior, posterior pole of the testicle (on vas deferens), may follow epididymitis. Benign, contains dead spermatozoa. Dx w/US or aspiration.
Acute Epididymitis
If involving testes = epididymo-orchitis.
If infectious: ascending LUT infection, UTI from choliform bacilli (children & men over 35), STIs (GC/CT teens-35)
Non-infectious: urine reflux/chemical irritation into ejaculatory ducts from heavy lifting, local trauma, prostate problems, or urethral stricture.
Risk Factors: sexually active, infrequent urination, UT malformation.
SSX: Painful, swollen epidydymis. Pain may radiate to abdomen. Hydrocele can develop. Overlying skin may look like an orange. Skin is movable (if fixed -> abscess). M/b febrile, Discharge (ascending infxn), urinary frequency, dysuria. Toxic appearance/sepsis rare.
PE: TENDER, swollen epid., scrotum indurated & erythematous. Elevating testicle eases pain. Normal cremaster reflex.
DX: Pyuria on UA. Urine culture, NAAT testing for GC/CT. Scrotal ultrasound to r/o torsion in those
Chronic epididymitis
Inflammation w/no infection. Enlarged, thickened, non-tender epididymis. Occurs after repeated acute epididymitis, may find incidentally on exam.
Cryptorchidism
Failure of testicles to descend into scrotum during infancy (usu. by 3-12 mo). High risk of infertility or testicular CA later in life (2.5-20x)
Categories: true, incomplete, ectopic testis, hypermobile/ retractile.
PE: gloved hand, warm room, palpate for testes. If unpalpable, have pt squat or valsalva & repeat palpation (distinguishes retractile from undescended).
TX: Orchioplexy
True cryptorchidism
Testis remains in abdominal cavity from mechanical obstruction or hormonal abnormality.
Incomplete
Testis in inguinal canal, obstructed by mechanical means
Ectopic Testis
Lies outside the usual course of descent
Hypermobile or Retractile testis
May lie in scrotum at times & then retract up into the inginal canal. Hormonal function usu. normal.
Testicular CA
*Most common solid CA in males 15-34yo.
40% Seminomas, 60% non-seminomas (26% mixed, 24% Embryonal, 5% teratoma, yolk sac & choriocarcinoma rare.)
Risk Factors: Cryptorchidism, exogenous estrogen exposure, trauma, gonadal dysgensis, Kleinfelter syndrome, low birth wt, environmental toxins, BPA, FHx, high animal product diet, marijuana (for nonseminomas), tobacco use. Rare in black & Asian populations.
SSX: painless testicular nodule, usu smooth enlargement, firm & nontender. Increases in sz over time, m/b dull ache, sensation of heaviness. Doesn’t transilluminate. Often found on self exam.
Work Up: Scrotal US, pelvic CT. Increased alpha-fetoprotein, HCG, LDH (esp LDH1). 5 year survival of seminoma is > 80% w/o tx.
Prostate Palpation & normal qualities
Peripheral zone is the aspect felt. 2/3 of CA arise there, the other 1/3 in the transitional zone (often causing urinary problems). 4 cm in length & width (1 finger to either side of median sulcus). Normal consistency is like tip of the nose. Usu symmetrical & non-tender.
Palpation - hypertrophy of prostate
Median sulcus obliterated, much of the prostate not palpable.
Palpation - rubbery prostate
BPH
Palpation - Boggy prostate
Congested: infrequent ejaculation or chronic infection
Palpation - Indurated prostate
Nodules: infection w/ or w/out stones
Palpation - Hard prostate
Consider tumor in absence of WBCs & infection. Suspicious lesion may not be raised. Distinct edge, abrupt change in consistency.
Palpation - tender prostate
Prostatitis
“Voiding” sx
Suggest narrowing of prostatis urethra: decreased force of stream, hesitancey, intermittency (start & stop), straining to void, splitting stream, post void dribbling.
Bladder & “storage” sx
From chronic obstruction of prostatic urethra: urgency, frequency, incontinence, nocturia.
PSA
Prostate-specific antigen: a protein made by prostate epithelial cells.
Causes of increased PSA
DRE (blood draw should be done before this exam), Ejaculation, Recent sexual activity, BPH ( in 30-35% of cases), Cystitis, Acute/Chronic prostatitis (falls once treated), Prostate biopsy, Exercise involving perineal pressure, Prostate Cancer (in 25-92% of cases, but PSA velocity & Free:bound PSA ratio might be better indicators).
Causes of lowered PSA
Finasteride (Proscar), Saw palmetto, Radical prostatectomy, Withdrawl of anti-androgen drugs, Regular prostatic massage, Green tea.
Benign Prostatic Hyperplasia (BPH)
Hyperplasia of prostatic stromal & epithelial cells in transitional zone resulting in large, fairly discrete nodules in periurethral region. 50% of men 51-60 yo & >80% over 80yo.
Cause: DHT (dihydrotestosterone synthesized by 5alpha-reductase) stimulates prostate cells to grow. More androgen receptors in transitional zone = greater affect there.
Hx: AUA Symptom Score questionnaire to quantify extent of sx.
SSX: Progressive urniary frequency, urgency, nocturia, urinary hesitancy, decreased forceo f stream, initial & terminal dribbling, overflow incontinence.
Complications: urine stasis can lead to UTI -> pyelonephritis, & urolithiasis. Hydronephrosis from urine back flow. Ruptured veins, hematuria, vasovagal syncope, hemorrhoids, hernias from straining. Sudden urinary retention (requires catheter!)
PE: DRE - enlarged, rubbery, smooth, symmetric, loss of median furrow, non-tender. Abdominal exam may show distended bladder.
Lab: Increased BUN & serum creatinine if kidneys involved. UA & urine culture to r/o infectious cause. PSA moderately increased (*draw before DRE).
Procedures: Uroflwmetry for flow rate & residual volume. M/b transrectal US or prostate biopsy to r/o CA.
**CA & BPH can coexist!
Prostatitis (general definition & presentation)
Inflammation of the prostate. Infectious or non-infectious. Presents variably as irritated/obstructed urinary sx & perineal pain.
Acute Bacterial Prostatitis
Acute symptomatic infxn of prostate characterized by pathogen in urine culture & generalized sx of acute inflammation.
Pathogens: E. Coli, Klebsiella, Proteus, Pseudamonas, Enterobacter, Chlamydia.
Infections ascends the urethra to distal prostate, more common in young men & immunocompromised.
SSx: Sudden onset spiking fever, chills, malaise, arthralgia, myalgia, Lower urinary tract sx (dysuria, nocturia, urgency & frequency), m/b urinary retention, low back/perineal/rectal pain.
PE: GENTLE DRE *exquisitely tender prostate & can cause systemic infection. Swollen, firm, warm. Possible d/c after.
Labs: CBC leukocytosis w/left shift, UA shows WBCs, bacteria, m/b hematuria, Culture of prostatic secretions shows increased bacteria, elected CRP, *transient increase in PSA which returns to normal in ~2 wks.
Chronic Bacterial Prostatitis
~5% of acute cases become chronic, only ~5-10% are infectious.
SSX: Recurrent UTIs, fatigue, chronic pain (perineal, lower abdominal, testicular, penile), sexual dysfunction, ejaculatory pain, milky urethral d/c
PE: Moderate tenderness, boggy, enlarged soft prostate.
Labs: Post-massage urine culture & sensitivity, EPS culture, semen culture. UA may show incidental bacteriuria. >10 leukocytes/HPF in EPS
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CPPS)
Poorly understood somatic syndrome w/biopsychosocial effects at any age peaking 35-45yo. Criteria: No objective cause to explain the sx, sx relate to anatomical area around the prostate, refractory to tx.
SSx: Pain in pelvic region >3mo, *disability out of proportion to PE/labs, dysuria, urgency, low back/perineal pain referred to tip of penis, sense of rectal fullness after unsuccessful defecation, sexual dysfunction, *post-ejaculation pain, decreased libido, m/b hematospermia, fatigue, stress, m/b concurrent IBS or chronic fatigue syndrome.
PE: DRE- mildly tender, boggy, m/b enlarged, tenderness of pelvic floor & sidewalls, check for hernia, testicular masses, hemorrhoids.
Lab: UA, urine C&S, EPS cell count & culture, CBC. R/o Chlamydia & gonorrhea. Urine cytology if hematuria.
Procedures: TRUS, abdominal CT, uroflowmetry, IVP, cystoscopy
DDX: CaP, obstructive uropathy, bladder CA, urethritis, neurogenic bladder.
Tip: *Let these pts know that you believe their pain.
Asx Inflammatory Prostatitis
Found incidentally - no sx but WBCs found in prostate secretions of biopsy.
Prostate CA (general )
*Most common male CA in men >50yo, over 75% dx’d in men over 65yo. 1 in 5 black men, 1 in 6 white men. Most men die with it instead of from it, but there are some aggressive & fast growing forms.
Prostate CA Risk Factors
Increasing Age, Ethnicity (African-Americal 35% higher incidence with larger tumors, more mets, and more frequent recurrence with 2x the mortality rate of white men) and less incidence in Asian men than white men, family hx (primary relatives), Hormones (increased androgen exposure), Diet (high fat, low fiber, alcohol, coffee), Obesity, Vasectomy m/b, Occupational exposure (farmers, mechanics, plumbers, welders, rubber & battery manufacturers), Smoking m/b, Meds (statins, NSAIDs)
Prostate CA SSx
Early: None. Slowly progressive sexual dysfunction, incontinence, irritative or obstructive sx depending on tumor’s location.
Late: Bladder outlet obstruction, urethral obstruction, hematuria, pyuria, metastasis to pelvis, ribs, vertebrae (may cause bone pain as bone is the most common site of metastasis), tumor enlargement may compress cord -> neuropathy, unintended wt loss
Prostate CA PE & Labs
PE: DRE - variable size, asymmetrical, non-tender. Firm, stony hard, irregular nodule is pathognomonic.
Labs: with PSA 4-10ng/ml likelihood of CA is 25%, if >10, likelihood of CA is >50%.
PSA velocity - with 3 measures over 18-24mo an increase of >0.75ng/ml/year or higher when PSA is 4-10ng/ml is suspicious for CA.
Free:Total PSA ratio -
Prostate CA DX & DDX
- Transrectal US w/biopsy for grading w/Gleason score
- Axial CT or MRI for staging based on tumor size, node spread, and mets.
DDx: Colorectal CA, bladder CA, Paget’s dz, other causes of increased PSA, indurated prostate from TURP, needle biopsy, or prostatic calculi.
Compare: Prostatitis, BHP, and Carcinoma for Size
Variable, variable - enlarged, and variable
Compare: Prostatitis, BHP, and Carcinoma for Consistency
Boggy/irregular, Rubbery or firm, and stony hard/irregular
Compare: Prostatitis, BHP, and Carcinoma for Symmetry
Usu symmetric, usu symmetric but may feel irregular, and usu symmetric.
Compare: Prostatitis, BHP, and Carcinoma for Tenderness
Present, Absent, Absent
Compare: Prostatitis, BHP, and Carcinoma for Secretions
Diagnostic, not helpful, not helpful
Compare: Prostatitis, BHP, and Carcinoma for PSA
Usually increased in all three!
