Penile disorders

Question 1

Question 1

Testicular, Urethral, and Penile Disorders- Anatomy

Answer 1

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

Question 2

Testicular, Urethral, and Penile Disorders- Anatomy and Function

Answer 2

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

Question 3

Varicocele

Answer 3

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

Question 4

Variocele

Tx

Answer 4

Observation in most -> most do not require surgical intervention

Surgery in some patients:
Pain
Inferility
Delayed testicular growth

Question 5

Variocele

Malignancy Associactions

Answer 5

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

Question 6

Hydrocele

General

Answer 6

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

Question 7

Hydrocele

Dx

Answer 7

Transillumination

Question 8

Hydrocele

Subtypes

Answer 8

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

2. Noncommunicating -> derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to the peritoneum)

Question 9

Hydrocele

Clin man

Answer 9

Painless scrotal swelling (may increase throughout the day)

May complain of dull ache or heavy sensation with increasing size

Question 10

Hydrocele

PE and diagnostics

Answer 10

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

Question 11

Hydrocele

Tx

Answer 11

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

Question 12

Spermatocele

general

Answer 12

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

Question 13

Spermatocele

PE

Answer 13

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

Question 14

Spermatocele

Dx

Answer 14

Scrotal Ultrasound is performed for diagnosis

Question 15

Spermatocele

Tx

Answer 15

No treatment is usually necessary unless the mass is bothersome

Surgical excision for chronic pain (rarely needed)

Question 16

Question 17

Priapism

general and types

Answer 17

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

2. 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

Question 18

Priapism

etiologies

Answer 18

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

Question 19

Priapism

Dx

Answer 19

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

Question 20

Priapism

Tx of ischemic (low flow)

Answer 20

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

Question 21

Priapism

Tx of of Nonischemic (high-flow)

Answer 21

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

Question 22

Testicular Cancer

general and RF

Answer 22

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

Question 23

testicular cancer

Types

Answer 23

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)

Question 24

testicular cancer

Clin man

Answer 24

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

Question 25

Testicular Cancer

PE and Dx

Answer 25

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

Question 26

testicular cancer

Tx

Answer 26

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

Question 27

Testicular Cancer

Prognosis

Answer 27

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

Question 28

Phimosis

general

Answer 28

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)

Question 29

Phimosis

Tx

Answer 29

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

Question 30

Paraphimosis

general

Answer 30

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

Question 31

Paraphimosis

S/Sx

Answer 31

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

Question 32

paraphimosis

Tx

Answer 32

Manual reduction
Pharmacologic therapy
Definitive management