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.
