Disorders of the penis, scrotum, and prostate Flashcards
objectives
Priapism definition
- a persistent penile erection that continues hours beyond, or is unrelated to, sexual stimulations and lasts greater than 4 hours
Types of Priapism
- Ischemic
- Non-ischemic
Ischemic Priapism
- low flow, veno-occlusive priapism. Painful!
- Decreased venous outflow = increased pressure = decreased arterial inflow
- Emergency!!! Can lead to fibrosis and ED
Non-ischemic Priapism
- high flow, arterial
- Increased arterial inflow without reduced venous outflow
- High inflow + high outflow
- Prolonged, non-painful partially rigid erection
- Non emergent – usually will resolve on it’s own
Ischemic Priapism presntes w/…
- low pH
- low O2
- high CO2
Non-Ischemic Priapism presntes w/…
- high O2
- low CO2
Priapism Risk factors
- Sickle cell trait and disease
- Malignant infiltration of corpora
- leukemia
- Medications
- ED meds
- testosterone
- trazadone
- Recent spinal cord injury
- Cocaine
Priapism Evaluation
- Differentiate between ischemic and nonischemic
- History – meds, prior episodes, erectile function, cancer, trauma, drugs, etc
- Physical Exam
- Labs – CBC, drug screen, sickle cell
- Cavernosal blood gas
- Ultrasound
Priapism Tx
- Corporal aspiration and irrigation
- Phenylephrine can be administered during corporal aspiration
- Manage sickle cell – IV fluids, pain control, oxygen
- Surgical: Shunts – distal or proximal
- If persistent – consider penile prosthesis
Priapism Penile shunts Tx
- Goal
- relieve erection
- restore consistent flow of oxygenatied blood
- eliminate hypoxia
- can be distal or proximal
Peyronie’s Disease definition
- inelastic scar (plaque) in tunica albuginea of corpora cavernosa.
- Cause is unknown
- could be trauma
- Cause is unknown
Peyronie’s Disease characteristics
- An inflammatory process occurs which results in a fibrous plaque developing on the penis, usually on the dorsum, which in turn causes an curvature of the penis.
- Acute phrase – inflammation, deformity, pain
- Chronic phase – after 6-18 months pain resolves, plaque stabilizes
Peyronie’s Disease Hx
- Painful erection
- an unnaturally shorten penis during erection
- ED and painful sex
- Usually occurs in middle aged to elderly men
Peyronie’s Disease Physical Exam
- note penile plaques
- degree of curvature
- ultrasound to visualize location and degree of calcification
Peyronie’s Disease Tx
- NSAIDS
- Vitamin E
- Colchicine
- topical verapamil
- shock wave treatments
- intralesional plaque injections
- surgery (prosthesis)
Balanitis Definition
- inflammation of the glans penis
Balanitis risk factors
- diabetes
- poor hygiene
- antibiotic use
Balanitis long term effects
- phimosis
- lichen sclerosis/balanitis
- xerotica obliterans
- meatal stenosis
Balanitis Hx
- rash
- pain
- pruritis
- foul odor
Balanitis Physical Exam
- erythema
- ulceration
- fissures
- scaling
- edema
- discharge
- phimosis
Balanitis Tx
- Can obtain cultures and check for DM and HIV
- Retract foreskin and soak with warm water
- Candida: clotrimazole, fluconazole cream
- Bacterial (Foul odor): antibiotics
- Hydrocortisone cream
- Combination – clotrimazole – betamethasone cream
- Circumcision
Penile Cancer definition
- Typically squamous cell carcinoma
- slow growing and usually not infiltrative until far advanced
Penile Cancer Epidemiology
- rare
- appox 2300 cases in 2018
- Rare in circumcised male
Penile cancer Characteristics
- Sharply demarcated
- erythematous plaque on the glans or foreskin
Penile cancer Hx
- Usually uncircumcised male with poor hygiene
- past HPV infection
- U/V radiation exposure
- increasing age
- immunodeficiency state
Usually uncircumcised male with poor hygiene, past HPV infection, U/V radiation exposure, increasing age, immunodeficiency state physical exam
- Usually uncircumcised male with poor hygiene
- past HPV infection, U/V radiation exposure
- increasing age
- immunodeficiency state
Penile cancer tx
- Depending on the stage of the cancer
- Local resection
- Local chemo
- 5-Fluorouracil cream
- laser treatment
- surgery is the mainstay of invasive carcinoma, penectomy
Phimosis
- Tightening of the foreskin that prevents the retraction of the prepuce over the glans of the penis
Phimosis types
- Congenital
- leave it alone, usually gets better with age
- Symptomatic
- circumcision
Paraphimosis
- Inflammation or infection of a forcibly retracted foreskin
- Manually reduce
- Surgical techniques
- Emergent!!
Phimosis vs. Paraphimosis image
Testicular Torsion definition
- Twisting of the spermatic cord and testicle to the point of reducing blood flow to the testicle
Testicular Torsion characteristics
- Usually seen in adolescent males, without history of injury, but can occur at any age.
- History of cryptorchidism
- Usually presents in 10-20y/o
Testicular Torsion Hx
- Patients usually present with a acute onset of testicular pain without swelling
- Nausea
- vomiting
- tachycardia
Testicular Torsion Physical Exam
- high riding testicle
- horizontal lie of testicle
- absent cremasteric reflex
- Doppler U/S to check for decreased blood flow.
Testicular Torsion Tx
- This condition is a surgical emergency and urological consultation is mandatory
- Can attempt manual detorsion
- Most remain viable when detorsed within six hours
Epididymitis definition
- Inflammation of the epididymitis at the posterior border of the testes
Epididymitis characteristics
- Presents with unilateral pain, slow onset
- Younger than 35 years of age = STD (gonorrhea/chlamydia)
- Older than 35 y/o = urinary tract infection bacteria (e.coli)
Epididymitis Hx
- testicular pain
- gradual onset of pain that progresses
- Possible pain in the groin
- possible urethral discharge
- fever
- Feels better with scrotal elevation
Epididymitis work-up
- H+P
- std testing
- urine culture
- can do scrotal US
Epididymitis Tx
- Scrotal elevation
- analgesics
- NSAIDs
- antibiotics
- **High fever/high pain = admit for IV antibiotcs
Orchitis definition
- Very similar to epididymitis
- Infection of the testes
- primary
- secondary
Orchitis characteristics
- May be due to…
- bacteria from the GU tract
- systemic disease
- viral illness
- mumps
- Usually not seen in males under 10
Orchitis Hx
- Local infection etiology is noted
- Systemic spread is more problematic
- Mumps orchitis occurs within 3-4 days of the onset of Mumps
Orchitis physical exam
- fever
- the testicle is swollen, painful, with small hemorrhages in the tunica albuginea.
Orchitis Tx
- Antibiotic treatment for bacterial infections
- otherwise symptomatic treatment is indicated
Hydrocele definition
- A collection of fluid between the layers of the tunica vaginalis.
- Can be due to…
- idiopathic
- local injury
- reactive to infection
- lymph obstruction
- testicular tumor
- effect of radiation therapy.
Hydrocele characteristics
- Usually seen in men over 40
- frequently undetermined etiology
- Felt to be a soft behind the testicle
- can be very large
- U/S being the most valuable test to identify fluid
Hydrocele Hx and physical exam
- soft
- nontender fullness
- scrotum will transilluminate
Hydrocele Tx
- Usually no treatment is necessary but surgical correction is an option for pain, cosmetics, or due to size of the collection of fluid
Varicocele definition
- Enlarged dilated veins of the pampiniform plexus
Varicocele characteristics
- Found in males between 15 and 35 years of age
- Felt as a fullness in the left scrotum
- Infertility is sometimes noted in males with varicocele
Varicocele Hx
- asymptomatic
- sometimes dull/achey scrotal pain
- worse as the day goes on
Varicocele Physical Exam
- Palpation reveals a “bag of worms” in the scrotum which tend to disappear when the patient lies down
- More prominent when standing
Varicocele Tx
- conservative
- Surgical ligation or sclerosing of the veins are treatment options
Spermatocele / Epididymal Cyst Definition
- benign cystic accumulation of sperm that arises from the head of the epididymis
- Usually smaller than 1cm
Spermatocele / Epididymal Cyst characteristics
- incidentally found on 30% of men who get scrotal ultrasounds
Spermatocele / Epididymal Cyst Hx
- asymptomatic
- usually patients come in when they feel a lump
- pain if large
Spermatocele / Epididymal Cyst Physical Exam
- soft, smooth, well circumscribed lesion
- typically at head of epididymis, posterior and superior to the testicle
- Will also transilluminate
Spermatocele / Epididymal Cyst Tx
- conservative
- surgical excision
Prostatitis Definition
- Inflammation of the prostate
- either from bacterial or unknown causes
- Bacterial prostatitis is usually due to E.coli.
Prostatitis characteristics
- Patient may complain of …
- chills and fever
- malaise
- myalgia
- arthralgia
- frequency and urgency of urination
- urethral discharge.
Prostatitis Hx
- Acute symptoms same as characteristics
- chronic history of achy perineum and rectal pain.
Prostatitis Physical Exam
- Confirmatory pain on palpation
- a rectal exam positive for a swollen, tender, warm prostate with scattered soft areas
- Generally avoid prostate massage or aggressive prostate exam
Prostatitis Tx
- After urinalysis, urine culture, treatment with appropriate antibiotics.
- Chronic prostatitis requires long term antibiotics and other symptomatic treatment.
- Bactrim x 4 weeks
- Fluoroquinolones x4 weeks
- High fever/sepsis? Admit for IV abx
Benign Prostatic Hypertrophy (BPH) Definition
- Age related, nonmalignant enlargement of the prostate gland.
- Transitional zone
BPH signs/symptoms
- Frequency
- urgency
- nocturia
- hesitancy
- feeling of incomplete bladder emptying
- straining to void
- weak stream
- post void dribbling
BPH Dx
- DRE
- Consider….
- UA
- urine culture
- BMP to assess kidney function
- PSA
- Ultrasound
- prostate volume
- PSS
- severity scores
- Flow rate, post void residual urine volume, pressure-flow studies
BPH meds Tx
- Alpha-adrenergic receptor blockers (Tamsulosin)
- Decrease resistance at bladder neck, prostate, urethra
- 5-alpha reductase inhibitors (finasteride)
- Reduce prostate volume, months to work
- blocks the conversion of testosterone to DHT,
- Phosphodiesterase-5 enzyme inhibitors
- Daily tadalafil
BPH other Tx
- Transurethral resection of prostate tissue (TURP)
- Simple prostatectomy
- Laser treatments
- Implanted devices to relief obstruction (Urolift)*
- Prostatic stents
Inability to retract the foreskin from the glans penis due to inflammation or infection is often an indication for circumcision. What condition describes this?
Phimosis
Anatomic portion of the prostate that becomes hyperplastic with BPH is.,?
Transition zone
A 38 year old male presents with abrupt onset of myalgia and low back pain/perineal pain. Patient reports frequency, urgency, and dysuria. UA reveals pyuria. Urine culture is positive for gram negative bacteria. What is the initial therapeutic approach?
Bactrim or FQ for four week
A 20 year old college football player presents with a chief complaint of a dull ache in his scrotum after prolonged standing on the sideline. It gets worse with activity and is relieved by lying down. Dilated veins in the left scrotum are observed on inspection and both testicles are palpable and without masses. What is most likely diagnosis?
Varicocele
A 72 year old man presents to the office with a chief complaint of progressive worsening of nocturia, weak stream, and straining to void for the last few years. What is the most reasonable initial therapeutic approach for this patient?
Trial of tamsulosin
A 32 year old male presents with a complaint of increased urinary frequency and pelvic pain. He states that he has been feeling poorly for the past 4 days with intermittent fever, chills, and persistent malaise. Physical exam revealed temperature of 101F. Genital examination is normal except a gentle DRE reveals an enlarged, tender prostate. What is the most likely diagnosis?
Acute bacterial prostatitis
