Penile disorders Flashcards
Testicular, Urethral, and Penile Disorders- Anatomy
The penis consists of several major structures:
Glans: head of the penis
Urethra: tube located inside the penis that runs from the bladder to the head of the penis, crosses through the prostate gland
Meatus: opening at the tip of the glans where urine or semen exit the body
Prepuce: foreskin; loose fold of skin that covers the head of the penis
Removal of the foreskin is circumcision
Corpus Cavernosa 2 columns of spongy tissue that run along the interior shaft of the penis
When filled with blood, tissue stiffen, and this causes the erection
Corpus spongiosum: the third column of tissue that prevents the urethra from closing during an erection
Testicular, Urethral, and Penile Disorders- Anatomy and Function
Rete testis sperm cells travel toward the epididymis through this structure
Efferent ducts series of tubes that join the rete testis to the epididymis that absorb most of the fluid that helps to move sperm cells
Epididymis structure that stores sperm until they are mature
Testes are surrounded by several layers of tissue:
Tunica vasculosa> first thin layer of blood vessels
Tunica albuginea> thick protective layer to protect the testes
Tunica vaginalis> made up of three layers to further protect the testes
Varicocele
Nonacute scrotal condition
Dilatation of the pampiniform plexus of spermatic veins
Scrotal fullness with variability in size
“Bag of worms” consistency
Usually asymptomatic, may be associated with dull ache or decreased fertility
Generally, occur on the left side
Often enlarges with Valsalva/being upright and diminishes when lying down/testicular elevation
Most common surgically corrected cause of male infertility
Seen in 30% of infertile men because of the increased temperature from the increased venous blood flow inhibits spermatogenesis
Asymptomatic varicoceles seen in 10% of the population
May cause testicular atrophy
Soft scrotal mass with a “bag of worms” feel superior to the testicle
Testicular ultrasound is initial test of choice
Dilation of the pampiniform plexus > 2 mm
Variocele
Tx
Observation in most -> most do not require surgical intervention
Surgery in some patients:
Pain
Inferility
Delayed testicular growth
Variocele
Malignancy Associactions
Right-sided varicocele may be due to retroperitoneal or abdominal malignancy
Sudden onset of left-sided varicocele in an older man could be possibly due to renal cell carcinoma
Hydrocele
General
Nonacute scrotal condition
May be found in adults or children
Collection of serous fluid between the parietal and visceral layers of the tunica vaginalis, which directly surrounds the testis and spermatic cord
Unilateral or bilateral scrotal fullness, uniform in consistency
Transilluminates on exam
Typically, asymptomatic unless very large and may complain about dull ache or heavy sensation with increasing size
Hydrocele
Dx
Transillumination
Hydrocele
Subtypes
Most common cause of painless scrotal swelling
Etiologies include:
Idiopathic -> most common
Inflammatory -> acute reactive hydrocele can occur with inflammatory conditions
2 types:
1. Communicating –> peritoneal/abdominal fluid enters the scrotum via a patent processus vaginalis that failed to close
- Noncommunicating -> derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to the peritoneum)
Hydrocele
Clin man
Painless scrotal swelling (may increase throughout the day)
May complain of dull ache or heavy sensation with increasing size
Hydrocele
PE and diagnostics
Translucency (scrotal sac transilluminates well)
Fluid located anterior and lateral to the testis
Swelling worse with Valsalva if Commuicating
Testicular Ultrasound initial test of choice
Rule out:
Associated testicular tumor
Other masses
Inflammatory scrotal conditions like epididymitis or orchitis
Hydrocele
Tx
Usually no treatment needed (watchful waiting)
Surgical excision of the hydrocele sac may be needed if persists beyond 1 year of age in infants, older patients with communicating hydroceles (elective) to reduce the risk of hernia, complications, or persistent pain/pressure sensation
Spermatocele
general
Spermatocele is also known as an epididymal cyst.
Epididymal cyst that is larger than 2 cm is called a spermatocele
Localized fullness or firmness in the head of the epididymis
Typically, asymptomatic painless cystic testicular mass
Spermatocele
PE
round, soft mass in the head of head of the epididymis superior, posterior, and separate from the testicle
Freely movable mass above the testicle that transilluminates
Spermatocele
Dx
Scrotal Ultrasound is performed for diagnosis
Spermatocele
Tx
No treatment is usually necessary unless the mass is bothersome
Surgical excision for chronic pain (rarely needed)
Priapism
general and types
Prolonged, painful erections without sexual stimulation
2 types:
1. Ischemic (low-flow)- decreased venous outflow may lead to compartment syndrome, increasing acidosis and hypoxia in the cavernous tissues
Painful and rigid erection
MOST COMMON TYPE
-
Nonischemic (high-flow)- increased arterial inflow due to a fistula between the cavernosal artery and corpus cavernosum
Commonly related to perineal or penile trauma
Less painful and not fully rigid compared to ischemic
Priapism
etiologies
Etiologies:
Idiopathic most common (50%)
Sickle cell disease (10%)
Injection of erectile agent for ED, drugs (cocaine, marijuana), alcohol
Trauma (high flow) may cause rupture of the cavernosal artery
Medications:
PDE-5 inhibitors
Trazadone
Antipsychotics
Anticonvulsants
Alpha blockers
Neurologic:
Head trauma
Meningitis
Subarachnoid hemorrhage
Postoperative
Priapism
Dx
Based on history and PE
Blood gas may be performed in erections > 4 hours
Cavernosal blood gas-> high-flow results similar to ABG and normal glucose
Low-flow shows hypoglycemia, hypercarbia, and acidemia
Doppler US-> may be performed as an alternative to ABG to differentiate between ischemic and nonischemic types
Normal or high- blood flow in nonischemic
Minimal or absent blood flow in ischemic
Priapism
Tx of ischemic (low flow)
Management of Ischemic (Low-Flow):
Requires rapid detumescence to avoid long-term sequalae and urgent urologic consultation should be obtained
FIRST LINE medication is Phenylephrine intracavernosal injection if < 4 hours duration
CI-> cardiac or cerebrovascular history
Needle Aspiration of corpus cavernous, and irrigation to remove blood especially if > 4 hours duration without or without Phenylephrine (combo therapy)
Ice packs
Terbutaline orally or SQ and may be used < 4 hours
Not as effective
If no response to the above, then shunt surgery may be performed
Priapism
Tx of of Nonischemic (high-flow)
Observation as most resolve within hours to days
MUST RULE OUT ISCEHMIC PRIAPISM FIRST
if Refractory, then nonpermanent arterial embolization or surgical ligation may be used if refractory or inpatients who prefer an intervention rather than observation
Testicular Cancer
general and RF
Most common solid tumor in young men aged 15-35 years (average age is 32 years old)
Risk Factors:
Cryptorchidism (most significant) 4-10x the risk in both the undescended and normal testicle
Caucasians
Klinefelter’s syndrome
Hypospadias
testicular cancer
Types
Major Types:
A. Germinal cell tumors account for 95% (most common)
Nonseminomas:
1. Embryonal cell carcinoma, teratoma, yolk sac is most common in boys 10 and younger
2. Choriocarcinoma has worse prognosis
3. Mixed tumors are Seminomatous + Nonseminomas (these are treated as Nonseminomas)
They are associated with increased serum alpha-fetoprotein and beta-HCG and resistance to radiation
Seminomas:
1. Simple (lacks the tumor marker alpha-fetoprotein)
2. Sensitive (sensitive to radiation)
3. Slower growing
4. Associated with stepwise spread
B. **NonGerminal cell tumors (3%) **
Leydig cell tumors:
May be benign
May secrete hormones (androgens or estrogens) which may lead to precious puberty in 6–10-year-old boys or gynecomastia, ED, or loss of libido in adults (26–35-year-old males)
Sertoli cell tumors
Often benign
May secrete hormones (estrogen and androgens)
testicular cancer
Clin man
Clinical Manifestations:
Testicular mass most common and usually painless -> painless testicular swelling or firmness
May have dull pain or testicular heaviness
Acute pain in only 10% of patients
Gynecomastia rare
May have SOB, cough, and hemoptysis are result of lung metastases
Testicular Cancer
PE and Dx
On PE:
Firm, hard, fixed mass that does not transilluminate
Secondary hydrocele present in 10%
Diagnosis:
Scrotal US in initial test of choice
Seminoma will be a hypoechoic mass
Nonseminoma will be cystic or nonhomogeneous mass
Serum tumor markers:
Alpha-fetoprotein is elevated in Nonseminomas (80-85%) and not elevated in Seminomas
Beta-hCG is elevated in Nonseminomas (especially in choriocarcinoma) and < 25% Seminomas
Lactate Dehydrogenase (LDH) may be elevated in both types, marker for disease burden, and helpful in assessing metastatic disease
Staging is done using High-resolution CT of abdomen, pelvis, and chest
testicular cancer
Tx
Low grade (Stage 1) Nonseminoma (limited to testes) tx w radical orchiectomy
Can be followed by active surveillance, chemotherapy, or nerve-sparing retroperitoneal lymph node dissection depending on risk factors
Stage II Nonseminoma tx w radical orchiectomy
Can be followed by nerve-sparing retroperitoneal lymph node dissection (IIA) or chemotherapy (IIB or IIC)
Low grade Seminoma tx w radical orchiectomy is curative
May be followed by active surveillance, or need radiation or single-agent Carboplatin chemotherapy
Stage II Seminoma tx w radical orchiectomy
Usually followed by radiation therapy or cisplatin-based combo chemotherapy
Persistent tumor markers after orchiectomy BEP (Bleomycin, Etoposide, Cisplatin) x 3 cycles or EP x 4 cycles
Testicular Cancer
Prognosis
Very curable, high survival rate if treated appropriately
5-year survival rate of 95%
Large majority of patients relapse withing the first 2 years of treatment completion
Testicular examination by a clinician is recommended for men with a history of contralateral testicular cancer
Men who live for 2 years after diagnosis without relapsing have a high probability of being cured and very low risk of dying of the cancer
Phimosis
general
Inability to retract the foreskin over the glans
NOT AN UROGLOGIC EMERGENCY (unlike paraphimosis)
Pathophysiology:
Distal scarring of the foreskin (after trauma, inflammation, or infection)
Phimosis
Tx
Management:
Proper hygiene and stretching exercises of the foreskin (many spontaneously resolve)
4-8 weeks of topical corticosteroids can increase foreskin retractility (may be an adjunct to stretching)
Circumcision definitive management
Paraphimosis
general
Retracted foreskin in an uncircumcised male that cannot be returned to the normal position
The foreskin cannot be pulled forward
UROLOGIC EMERGENCY
Pathophysiology:
Retracted foreskin becomes trapped behind the corona of the glans and forms a tight band, constricting penile tissues, which can lead to gangrene
etiologies:
Forceful retraction of phimotic foreskin (phimosis)
Infants and young boys usually physiologic or iatrogenic (retraction by the caretaker)
Adolescents and adults can occur after balanoposthitis or penile inflammation (DM) or after sexual activity
Paraphimosis
S/Sx
Severe penile pain
Swelling of the penis
Enlarged, painful glans and distal foreskin with a constricting band of foreskin behind the glans at the coronal sulcus
paraphimosis
Tx
Manual reduction
Pharmacologic therapy
Definitive management
