Penile Disorders B&B

Question 1

what causes Peyronie disease?

Answer 1

localized fibrosis of penile tunica albuginea causes abnormal kink/curvature when erect

rx: pentoxifylline: phosphodiesterase inhibitor, prevents collagen deposition

Question 2

what penile disorder can be treated with pentoxifylline?

Answer 2

Peyronie disease: localized fibrosis of penile tunica albuginea causes abnormal kink/curvature when erect

pentoxifylline: phosphodiesterase inhibitor, prevents collagen deposition

Question 3

how do patients with penile fracture present?

Answer 3

blunt trauma causes rupture of the tunica albuginea

patients say they heard an audible “snap” and present with pain, swelling, and ecchymosis (penile bruising)

Question 4

priapism

Answer 4

persistent erection lasting more than 2-4 hours

due to failure of penile corpora smooth muscle to constrict to cut off blood flow

ischemic (most common, due to lack of outflow) vs non-ischemic (due to fistula, following trauma)

Question 5

what are the 2 types of priapism and how can they be diagnosed?

Answer 5

priapism = erection lasting more than 2-4 hours

ischemic (most common): lack of outflow is causing ischemic injury —> blood gas of penis will show LOW O2, HIGH CO2, LOW pH

non-ischemic/ “high flow”: due to fistula between arteries and corpus cavernosum following trauma, blood gas will be normal

Question 6

what are the 2 classic causes of ischemic priapism (prolonged erection)?

Answer 6

1. sickle cell anemia - causes veno-occlusion
2. drugs which block smooth muscle contraction (needed to cut blood supply off) - SSRIs, alpha blockers (“-zosins”), erectile dysfunction drugs

Question 7

what are 2 non-surgical methods of treating ischemic priapism?

Answer 7

aka ischemic prolonged erection, urological emergency due to hypoxia/acidosis of tissue

1. corporal aspiration - removing blood with a needle
2. intracavernosal phenylephrine: alpha-agonist, induces contraction needed to cut off blood supply to penis

Question 8

Pt is a 31yo M presenting to their doctor with soft, tan, cauliflower-like lesions on their penis that appear verrucous. Upon questioning, they admit to have multiple sexual partners. What is the likely diagnosis and cause of their condition?

Answer 8

condylomata acuminata, aka anogenital warts - caused by HPV (papillomavirus) 6 & 11

[“verrucous” = warts]

Question 9

You suspect your patient has condylomata acuminata and decide to order a biopsy. What are you expecting to find on histological examination?

Answer 9

aka anogenital warts, caused by HPV 6 & 11

key finding is koilocytosis: peri-nuclear clear vacuolization (nuclei appear like raisins in a clear cytoplasm)

Question 10

what 3 major risk factors are associated with penile squamous cell carcinoma?

Answer 10

1. uncircumcised penis - debris collects underneath
2. HPV types 16 and 18
3. smoking

Question 11

Bowen disease vs erythroplasia of Queyrat vs Bowenoid papulosis

Answer 11

all versions of in situ carcinoma (no basement membrane invasion) of penile squamous cell carcinoma (pre-malignant)

Bowen disease: grey-white plaques (leukoplakia) on shaft

Erythroplasia of Queyrat: Bowen disease on the glands, appears as dark red lesions

Bowenoid papulosis: multiple brown-red papules

Question 12

A male patient presents to their physician with concern of grey-white plaques on the shaft of their penis. What does this indicate?

Answer 12

Bowen disease: in situ carcinoma (no basement membrane invasion) of penile squamous cell carcinoma (pre-malignant)

associated with high-risk HPV (usually 16)

grey-white plaques = leukoplakia

Question 13

A male patient presents to their physician with concern of dark red lesions on the glans of their penis. What does this indicate?

Answer 13

Erythroplasia of Queyrat: in situ carcinoma (no basement membrane invasion) of penile squamous cell carcinoma (pre-malignant)

really just Bowen disease on the glands that appears dark red

Question 14

what type of drug can be used for erectile dysfunction?

Answer 14

phosphodiesterase 5 inhibitors (Sildenafil, Vardenafil, Tadalafil)

recall PDE5 breaks down cGMP in smooth muscle cells - if you inhibit PDE5, there is more cGMP and therefore more relaxation

also recall that erection requires relaxation of arterial smooth muscle to allow blood to flow into penis

Question 15

what kind of drugs are Sildenafil, Vardenafil, and Tadalafil?

Answer 15

phosphodiesterase 5 inhibitors - used to treat erectile dysfunction and pulmonary HTN (lower PVR!)

recall PDE5 breaks down cGMP in smooth muscle cells - if you inhibit PDE5, there is more cGMP and therefore more relaxation

Question 16

how do PDE5 inhibitors treat erectile dysfunction?

Answer 16

ex - Sildenafil, Vardenafil, Tadalafil

recall PDE5 breaks down cGMP in smooth muscle cells - if you inhibit PDE5, there is more cGMP and therefore more relaxation

also recall that erection requires relaxation of arterial smooth muscle to allow blood to flow into penis

Question 17

why can’t a patient simultaneously take Sildenafil and nitroglycerine?

Answer 17

Sildenafil = PDE5 inhibitor used to treat erectile dysfunction of pulmonary HTN (inhibits breakdown of cGMP)

nitroglycerine = nitrates (increase nitric oxide activity)

together, these can cause life-threatening hypotension!

Question 18

Viagra, aka ______, is noted to have this strange side effect…

Answer 18

Viagra = sildenafil, PDE5 inhibitor (prevents cGMP breakdown to treat erectile dysfunction)

may cause temporary cyanopia (blue vision) due to cross-reaction with PDE6 in the retina (resolves within hours)

Question 19

phimosis

Answer 19

when the orifice of the penile foreskin (prepuce) is too small to permit normal retraction

most often due to repeated bouts of infection that cause scarring of the preputial ring

secretion may accumulate under foreskin and favor development of secondary infections or penile carcinoma