disorders of the penis/testes Flashcards
1
Q
what is balanitis?
A
Inflammation of the glans penis
2
Q
what is balanoposthitis?
A
inflammation of the glans penis WITH Involvement of the foreskin and prepuce
3
Q
who is most likely to get balanitis/balanoposthitis? why?
A
Uncircumcised men with poor personal hygiene most affected
Maceration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema
4
Q
symptoms of balanitis (4)
A
- Penile discharge
- Pain or difficulty with retraction of foreskin
- Itching, tenderness of the glans
- Difficulty urinating or controlling urine stream (very severe cases)
5
Q
PE of balanitis (4)
A
- Erythema and edema of glans and/or foreskin
- Discharge
- Ulceration and/or plaques
- Adhesions & phimosis (uncommon)
6
Q
what four organisms can cause balanitis ?
A
Candida (most commonly associated with diabetes)
Group B and group A beta-hemolytic strep
Gardnerella vaginalis
Trichomonas
7
Q
txt for balanitis
A
wash!
maybe topical antifungals if you think its candida
8
Q
what is phimosis? what are the two types?
A
Inability to retract the foreskin
Physiologic & Pathologic
9
Q
what is physiologic phimosis?
A
congenital
by 3yo, foreskin should retract easily (usually resolves with age)
10
Q
what is pathological phimosis?
A
previously retractable
older age groups by chronic inflammation or scarring
11
Q
txt for phimosis
A
topical steroids
Urology referral: circumcision
12
Q
what is paraphimosis? who gets this? (3 groups)
A
Entrapment of a retracted foreskin behind the coronal sulcus
- *only occurs in uncircumcised males
- children whose foreskins have been forcefully retracted or who forget to reduce their foreskin after voiding or bathing
- Adolescents or adults who present with paraphimosis in the setting of vigorous sexual activity
- Men with chronic balanoposthitis
13
Q
how does paraphimosis present? (3)
A
-Red, painful, and swollen glans penis
-Edematous, proximally retracted foreskin
forming a circumferential constricting band
-Penile shaft proximal to the constricting band is typically soft
14
Q
paraphimosis is dangerous or not?
A
a urologic EMERGENCY!
15
Q
4 initial txts for paraphimosis
A
- Ice packs-
- Glans compression
- Granulated sugar
- Hyalouronidase injection
16
Q
most common initial maneuver to correct paraphimosis?
A
Penile block, lube & attempt at reduction
- manual compression of the distal glans penis to decrease edema
- then reduction of the glans back through the proximal constricting band of foreskin
17
Q
what is the dundee technique for paraphimosis?
A
-Ring/penile block
-Multiple punctures of the edematous foreskin with 26ga needle
-Gentle pressure expresses edema fluid
(Allowing reduction of the prepuce)
18
Q
what is hypospadias?
A
-Ectopic urethral opening on the ventral aspect of the penis or scrotum (urethra opening not where it should be)
-Anywhere along the median raphe of the perineum
(usually congenital)
19
Q
what can hypospadias be associated with?
A
chordee (ventral curve of the penis)
20
Q
when would you do surgical intervention for hypospadias?
A
4-18months
21
Q
what do you need to be aware of with surgical intervention of hypospadias?
A
genital awareness occurs at about age 18 mo
correction after this can be associated with significant psychological morbidity
abnormal behavior, guilt, and gender identity confusion
22
Q
do you circumcise someone with hypospadias?
A
NO! foreskin used for corrective surgery
23
Q
what is epispadias?
A
Failure of complete development of urethra & external genitalia. usually associated with exstrophy (organs forming on the outside of the body)
24
Q
what does epispadias look like? (3)
A
- Phallus is short and broad
with upward curvature (dorsal chordee) - Glans lies open and flat like a spade
dorsal component of the foreskin is absent - Urethral meatus is located on the dorsal penile shaft
anywhere from base to proximal glans
25
txt of epispadias
surgery
26
what is peyroine's disease?
Abnormal curvature of the penis when erect
| -Idiopathic fibrotic plaques on the corpora cavernosa & tunica albuginea
27
what can peyroine's disease cause?
Can cause painful erections, coital difficulty (erectile dysfunction- from buckling of shaft or lack of rigidity) and dyspareunia
28
txt for peyroine's disease
In younger men, can resolve spontaneously
| if not, Surgery
29
what is priapism?
a persistent,* usually painful, erection of the penis
- unrelated to sexual stimulation or desire
* usually > 4hrs
30
is priapism an emergency?
YES may lead to permanent erectile dysfunction and penile necrosis if untreated
31
what is the most common variant of priapism seen?
ischemic- "compartment syndrome of the penis"
| - requires emergent txt
32
what variant of priapism is rare?
non-ischemic: often painless, not urgent
33
what causes priapism?
Cavernosal smooth muscle dysfunction most frequently caused by vasoactive medications or nerve dysfunction
34
what meds can cause priapism? (5)
1. ED agents: sildafenil
2. Antihypertensives: α-blockers, hydralazine
3. Antidepressants: fluoxetine, sertraline, citalopram, trazodone
4. Antipsychotics: phenothiazines, atypicals
5. Illicit drugs: cocaine, Ecstacy
35
hematologic causes of priapism (3)
Sickle cell disease
Leukemia
Myeloma
36
CNS causes of priapism (4)
CVA
Ischemic/traumatic cord injury
Compressive cord lesion
Nerve root lesion
37
how does priapism present? (timing and PE)
timing: shortly after onset of symptoms because of pain
PE: rigid penile shaft but soft glans
+ “peisis sign,”
38
how is non-ischemic priapism presentation different?
timing: may present after several hours or even days
PE: a partial erection, but the entire penis, including the glans, will be firm
39
what is the "peisis sign"?
partial or complete resolution of the erection during perineal compression
40
3 part txt of priapism
1. call urology
2. doppler US
3. Meds
41
meds for priapism? how does it work? (kinda weeds)
PO or SC terbutaline
(ß2-adrenergic agonist, is thought to increase venous outflow from the engorged corpora through relaxation of venous sinusoidal smooth muscle)
42
3 intervention txt options for priapism
1. Corporal aspiration & saline irrigation
2. Intracavernosal injection
α-blockers (dilute phenylephrine, epinephrine)
3. Urologic surgical intervention
cavernosum-spongiosum shunt
43
what is cryptochordism? is it bilateral or unilateral?
Failure of testis/testes to descend. epididymis likely deformed
2/3 unilateral, 1/3 bilateral
44
what is the most common birth defect of male genitalia?
cryptochordism
45
4 things that cryptochordism can cause
atrophy
increased risk of torsion
testicular Ca
infertility
46
txt for cryptochordism, what age do you txt this issue?
Urology referral between 6 mos - 2 years for orchiopexy
47
what is an orchiopexy?
surgical distention of an undescended testes (cryptochordism)
48
what is varicocele?
Dilatation of the pampiniform plexus
usually left sided b/c the left gonadal vein comes straight from the renal vein. occurs due to nutcracker syndrome (dilation of SMA or abdominal aorta pinching off the left renal vein)
49
varicocele effects __ - ___% of post-pubertal males (weeds)
15-20
50
what is important about a right-sided varicocele?
they are RARE and should prompt evaluation for an abdominal or pelvic mass – especially if presentation >40 yo
51
how does varicocele present?
soft mass, like a "bag of worms" in the scrotal sac, more noticeable when standing
- dull, aching pain
- described as "dragging or heaviness"
52
what two complications can varicocele cause?
1. testicular atrophy (secondary to loss of germ cell mass and increased scrotal temp)
2. infertility (inc. scrotal temP
53
dx of varicocele
PE and US (with color)
54
txt for varicocele
```
varicocelectomy (removal)
varicocele embolization (catheter to place coils- blood drains back out)
```
55
what is a hydrocele
Collection of peritoneal fluid between parietal & visceral layers of tunica vaginalis
56
how does hydrocele present?
Often asymptomatic
| despite sometimes considerable scrotal enlargement
57
most hydroceles close spontaneously by age __
2
58
Dx of hydrocele
transillumination
59
txt for hydrocele
hydrocelectomy
60
what is a spermatocele?
AKA ‘epididymal cyst’
| Retention cyst of a tubule of the rete testis or the head of the epididymis distended with sperm
61
are spermatoceles worrisome?
no generally benigns and non-painful
62
what is the most common solid tumor in men 18-40?
testicular cancer (but still pretty rare)
63
median age of Dx of testicular cancer?
34
64
prognosis of testicular cancer
VERY sensitive to chemo: curable even when metastatic
| Risk of death: 1/5000= 0.02% chance
65
testicular CA risk factors (kinda weeds)
1. An undescended testicle
2. Family history of testicular cancer
3. HIV infection
4. Carcinoma in situ of the testicle
5. Previous testicular Ca (3-4%)
6. Caucasian (4-5x)
7. Height (tall)
66
testicular cancer PE
- Painless mass or disruption in parenchyma
Acute pain from rapidly-growing tumors 2° hemorrhage & infarction
-Firm, non-tender; does NOT transilluminate
67
-Any solid, firm mass within the testis IS________ _______until proven otherwise
testicular CA
68
Dx of testicular cancer
US
then Get AFP & β-HCG (tumor markers)
Immediate Urology referral
69
what is epididymitis? what are the types?
Inflammation of the epididymis
- acute, subacute, chronic
- infectious (e.g. GC/chlamydia) and non-infectious
70
epididymitis is most common in what age groups?
20-40yo
71
up to __% of cases of epididymitis involve the testicle
40
72
how does epididymitis come about?
- Gradual onset of scrotal pain and swelling: over several days
- Usually unilateral
- Irritative voiding symptoms(Dysuria, frequency, and/or urgency)
- maybe fever and chills (more so for kids)
73
how does epididymitis spread about the testicle?
Tenderness and induration first occurs in the epididymal tail
then appears to spread to the body, head, and even the spermatic cord (funiculitis) or the ipsilateral testis
74
is prehn's sign useful for dx of epididymitis?
NO (elevating scrotum and pt feels relief)
75
how can you rule out testicular torsion?
positive cremasteric reflex
76
organisms that cause epididymitis ? nonspecific vs STD (weeds)
nonspecific: E coli, Pseudomonas, Proteus & Klebsiella species
STD: CHLAMYDIA, N. gonorrhea, T. pallidum, Trichomonas & Gardnerella
77
3 things that may cause epididymitis
1. Scrotal trauma
2. Idiopathic
3. Post-vasectomy
78
dx of epididymitis
urethral culture swab (before void)
| [For GC & chlamydia if patient is in the at-risk age group or if the patient is older than 40 and not monogamous]
79
epididymitis txt
1st line: doxycycline or zithromax (if GC/chlamydia is suspected)
- if enteric organism: levofloxacin
- NSAIDs and Narcs for pain
80
non-pharm txt of epididymitis
-reduce activity, sitz bath, ice packs, scrotal support and elevation
81
what is testicular torsion?
Cremaster muscle spasms and twists
Compromising blood flow in testicular artery
Can torse up to 720° (2x around)
82
Extent & duration of torsion influences what?
the immediate salvage rate and late testicular atrophy
83
is testicular torsion worrisome?
YES! emergency! time is testicle!
84
who gets testicular torsion?
men in their 30s, usually with exertion or sleep
85
how does testicular torsion present? (5)
1. Acute onset SEVERE pain, Constant, may radiate into ipsilateral abdomen
2. Nausea & vomiting in 90%
3. Scrotal swelling shortly thereafter
4. elevated teste
5. abnormal cremasteric reflex
86
Acute scrotal swelling in ANYONE – but especially children – is a _____ until proven otherwise
torsion
87
torsion is a ____ Dx
clinical.
| but US is the modality of choice if you're unsure
88
testicular torsion prognosis
- <6 hours = testicular salvage
Can be up to 12 -24 hrs if torsion is <360°
- 24 + hrs = testicular necrosis
89
what predisposes someone for testicular torsion?
```
bellclapper deformity
(Failure of normal posterior anchoring of the gubernaculum, epididymis and testis. testis free to swing and rotate within the tunica vaginalis of the scrotum)
```
90
what can testicular torsion progress to?
In time, a reactive hydrocele, scrotal wall erythema, and ecchymosis can occur
91
testicular torsion, if urology isnt available, what can you do?
attempt de-torsion: rotate tested OUTWARD like the opening of a book
92
how do you know the de-torsion was successful?
1. Relief of pain!!!
2. lower position of testis in scrotum
3. normal arterial pulsations on Doppler ultrasound
93
although most testes torse medially, ___ torse laterally
1/3
94
what is appendiceal torsion?
small vestigal structures on testes that torse.
| Pedunculated (hanging on a "stalk) which predisposes to twisting/torsion
95
what is the Leading cause of acute scrotal pathology in childhood?
appendiceal torsion
| 80% of cases are between age 8-14
96
appendiceal torsion PE?
gradual onset of pain- mild to severe
- maybe reactive hydrocele
- localized
- "blue dot" sign
97
what is the blue dot sign?
in appendiceal torsion:
Infarction/necrosis seen through thin scrotal skin
‘Classic’ finding (present only in ~21%)
98
how to distinguish appendiceal torsion vs testicular torsion?
US for appendiceal will show normal bloodflow
99
appendiceal torsion txt (4)
Conservative tx
1. Rest, ice, NSAIDs/analgesics
2. Infarcted tissue is resorbed
3. Recovery is usually slow (weeks – months)
4. surgery not necessary BUT its safe and fast ( local anesthesia)
