Male Genitalia and Hernias Flashcards
Shaft of the penis is formed by what three columns of vascular erectile tissue?
Corpus spongiosum (contains urethra, ends in glans)
2 corpora cavernosa
Smegma
- Cheesy whitish material - a combination of exfoliated (shed) epithelial cells, transudated skin oils, and moisture. It occurs in both female and male mammalian genitalia.
- collects under prepuce/foreskin
- Normal
epididymis
on posterolateral surface of each testis
soft, comma shaped
consists of tightly coiled spermatic ducts that provide a reservoir for storage, maturation, and transport of sperm from testis to vas deferens
What happens during ejaculation?
- the vas deferens transports sperm from tail of epididymis along a somewhat circular route to the urethra
path of the vas deferens
vas ascends scrotal sac into pelvic cavity through external inguinal ring, then loops over the ureter to the prostate behind the bladder. There it merges with the seminal vesicle to form the ejaculatory duct, which traverses the prostate and empties into the urethra
what structures contribute secretions to spermatic fluid?
vasa deferentia, seminal vesicles, prostate
(plus sperm stored in epididymis)
How does erection occur
- venous engorgement of the corpora cavernosa.
- Results from 2 types of stimuli
- visual, auitory, or erotic cues trigger sympathetic outflow from higher brain centers to the T11 through L2 levels of spinal cord
- Tactile stimulation initiates sensory impulses from the genitalia to S2to S4 reflex arcs and parasympathetic pathways through the pudendal nerve
- both seem to increase levels of nitric oxide and cyclic GMP –> local vasodilation
Anatomy: inguinal ligament, inguinal canal, external inguinal ring, pubic tubercle
Is the external inguinal ring palpable?
Yes. Triangular, slitlike structure palpable just above and lateral to the pubic tubercle
Are the internal inguinal ring and inguinal canal palpable?
No.
How do inguinal hernias form?
When loops of bowel force their way through weak areas of the inguinal canal
Indirect Inguinal Hernia
- develops at interna inguinal ring, where spermatic cord exits abdomen
- most common.
- Occur across all ages, even kids.
- Palpate: Above inguinal ligament near internal inginal ring, often in scrotum. Hernia comes down between inginal canal to touch finger.
direct inguinal hernia
- more medial than indirect
- from weakness in the floor of the inguinal canal
- associated with straining and heavy lifting
- less common
- men >40yo, rare in women.
- Palpate: Above inguinal ligament near external inguinal ring. Rare in scrotum. Hernia bulges anteriorly and pushes side of finger forward during exam
Femoral hernia
- in femoral canal below inguinal ligament
- lateral, never in scrotum
- Least common
- More in women than men
- more likely to present as emergencies with bowel incarceration or strangulation
How to find femoral canal
- can’t see it, so estimate by placing right index finger, from below, on right femoral artery.
- Your middle finger will then overlie the femoral vein
- your ring finger,the femoral canal - where hernias protrude
DDx for lack of libido
- psychogenic causes, e.g., depression
- endocrine dysfunction
- side effects of meds (e.g., SSRIs)
DDx Erectile Dysfunction
- psychogenic - esp if early morning erection is preserved
- decreased testosterone
- decreased blood flow in hypogastric arterial system
- impaired neural innervation
- diabetes
Premature ejaculation
common, esp in young men
reduced or absent ejaculation in middle-aged or older men
- less common
- ddx: meds, surgery, neurologic deficits, lack of androgen
lack of orgasm with ejaculation
usually psychogenic
yellow penile discharge suggests…
gonorrhea
White penile discharge suggests…
gonococcal urethritis from Chlamydia
Symptoms of disseminated gonorrhea
rash, tenosynovitis, monoarticular arthritis, meningitis
with or w/o urogenital symptoms
Chancre
ulcer seen in syphilis
warts seen in…
HPV
swelling of scrotum seen in…
mumps orchitis, scrotal edema, testicular cancer, indirect inguinal hernias, hydroceles
Scrotal pain seen in…
testicular cancer, epididymitis, orchitis
infexn, torsion, strangulated inguinal hernia
phimosis
tight prepuce that cannot be retracted over the glans
paraphimosis
tight prepuce that, once retracted, cannot be returned - edema ensues
balanitis
inflammation of the glans
balanoposthitis
inflammation of glans and prepuce
pubic or genital excoriations suggest…
lice (crabs), or, sometimes, scabies
Temperature and sperm production
- Temp regulated by distance of testes from body, and by muscular contraction
- Proper sperm production requires cool body temp, under 37 deg celcius
what is severed in a vasectomy?
vas deferens
function of spermatic cord
suspend testis & scrotum
What to ask about discharge
•color, consistency, odor
Why ask about history of cardiac dz?
anti-hypertensives can affect sexual functioning
•Hypospadias
-congential displacement of urethral meatus, often inferior to penis (ventral displacement); groove from normal location to the tip of glans (primary); shaft of penis (secondary); base of penis (tertiary)
•Epispadias
-orifice of urethral meatus on dorsal aspect of penis
•Carcinoma of penis
indurated nodule often nontender; or persistent penile sore; almost exclusively in uncircumcised males; masked by the prepuce
Epidermoid cyst
•common; dome shaped white or yellow papules; origin is occluded follicles filled with keratin debris and desquamated follicular epithelium; multiple; benign
How to palpate the scrotum
- Palpate each testis and epididymis between your thumb and two fingers
- Locate the epididymis (nodular, cordlike)
- Note size, consistency, shape, tenderness, presence of nodules
- Palpate the spermatic cord; include the vas deferens between thumb and fingers from epididymis to superficial inguinal ring
•Scrotal edema - causes
-often due to dependent edema; seen in CHF or nephrotic syndrome
Scrotal edema: relief inpatient and outpatient
Outpatient: Scrotal swings
inpatient – soft towels to lift + diuresis
•Hydrocele
-nontender, fluid-filled, smooth mass within the tunica vaginalis
•Usually confined to scrotum
confirming hydrocele
- Fingers can move above mass in scrotum
- Transilluminates + (b/c fluid filled) + f/u w/US
•Cryptorchidism
- atrophied testis which may be in the inguinal canal or abdomen; scrotum is unfilled
- “undescended left testicle”; no palpable left testis
- > risk for testicular cancer
•Small testis
- ≤ 3.5 cm in length;
- small, firm with Klinefelter’s syndrome (≤2cm) or small soft, atrophied;
- seen with use of cirrhosis, estrogen, or hypopituitarism
•Tumor of testis
- early may be painless; late may feel heavy;
- irregular, fixed;
- transillumination negative
- confirm with U/S
•Acute orchitis-
inflamed, painful testis
•Unilateral, often associated with a viral condition
•May be difficult to differentiate from epididymitis
abnormality of epididymis:
•Spermatocele vs cyst
painless mobile cyst above the testis;
spermatocele contains sperm; cyst has no sperm; both transilluminate +
•Acute epididymitis
- acutely inflamed
- tender
- scrotal edema
- +erythema
- +urethral discharge
- +fever
- coexisting UTI, prostatitis, STI
- urine with WBC and bacteria
•Tuberculous epididymis
- chronic inflammation of TB
- firm enlargement of epididymis
- tender, thickened, beading of vas deferens
•Varicocele of spermatic cord
- “varicose vein” often found on left spermatic cord
- soft “bag of worms”
- separate from testis
- supine position when scrotum is elevated, the bag collapses
- +infertility
•Torsion of spermatic cord
torsion or twisting of the testicle on its spermatic cord
- Acute pain, edematous; scrotal discoloration; testis is retracted up into scrotum
- Absence of cremasteric reflex on side of acute swelling
- No UTI associated
- Surgical emergency-obstructs circulation; needs to be resolved within 6 hours
Prostate gland
- chestnut shaped. Similar size to testis.
- Ejaculatory fluid and enzyme that liquefies coagulated sperm.
- Seminal vesicles extend from prostate onto superior portion of bladder
Tanner Staging: Stage 1
prepubescent – no pubic hair
Tanner Stage 2
sparse hair or at base of penis. Slight enlargement of penis, testes slightly larger w/altered texture
Tanner Stage 3
darker coarser curlier hair. Penis larger and longer. Scrotum further enlarged.
Tanner Stage 4
coarse curly hair. Penis is enlarged in width and length. Scrotum is enlarged, skin very dark
Tanner Stage 5
hair spread to medial surfaces of thighs. Penis, testes, scrotum to full maturity
Diagnosis of gonorrhea or nongonococcal urethritis
gram stain and cuture
induration along ventral surface of penis suggests
urethral stricture or possibly carcinoma
induration along ventral surface of penis + tenderness suggest
periurethral inflammation secondary to a urethral stricture
Peak ages of testicular cancer
15-34yo - watch out for painless nodules on testis!
multiple tortuous veins in area of spermatic cord indicate
varicocele
why happens to a chronically infected vas deferens?
may feel thickened or beaded
What is suggested by a cystic structure in spermatic cord?
hydrocele of the cord
Scrotal Swelling & transillumination
+ indicates serous fluid such as hydrocele
- indicates blood or tissue, e.g., normal testis, tumor, most hernias
Distinguishing between hydrocele & hernia in scrotum
transillumination
auscultation - bowel sounds over hernia
hernias: incarcerated vs strangulated
incarcerated: annot be returned to abdominal cavity
strangulated: blood supply to entrapped contents is compromised
Signs of a strangulated hernia
tenderness, N/V
consider surgical intervention
Best time to perform testicular self exam
after warm bath or shower
