Penile Pathology Flashcards
what is the autonomic nerve supply involved in erection?
Parasympathetic (S2-S4) discharge causes erection
sympathetic (T11-L2) discharge causes ejaculation and detumescence.
what are the organic causes of erectile dysfunction?
SMOKING, ALCOHOL,
DIABETES
Also hypogonadism, hyperthyroidism, ↑prolactin, cord lesions, MS, autonomic, trauma and pelvic surgery, Radiotherapy, Atheroma, Prostatic hyperplasia, post-priapism or Pyronines
what drugs can cause erectile dysfunction?
digoxin, B-blockers, diuretics, anti-psychotics, antidepressants, oestrogens, finasteride, narcotics
what are the psychological causes of erectile dysfunction?
o Depression
o Relationship problems
o Sexual orientation uncertainties
o Primary psychogenic erectile dysfunction
what is the clinical feature of erectile dysfunction?
Inability to achieve or maintain an erection
what investigations are required to diagnose erectile dysfunction?
- Full sexual and psychological history
- U&E, LFTs, glucose, TFT, LH, FSH, lipids, testosterone, prolactin
- +/- Doppler
what is the management of erectile dysfunction?
- Treat causes
- Counselling
- Lifestyle
- Medications
- Surgery – penile implant
what medications are involved in the management of erectile dysfunction?
o Phosphodiesterase-5 inhibitors eg. Sildenafil citrate (Viagra), tadalafil, vardenafil
o Intracavernosal injections of alprostadil +/- vacuum erection device
o Intracavernosal combination – alprostadil, papaverine, phentolamine
what is the pathophysiology of balantis?
inflammation of the foreskin and glans
what is the cause of balantits?
associated with strep and staph infections, more common in diabetics. Young children with tight foreskins
what is the management of balantis?
antibiotics, circumcision, hygiene advice
what is the pathophysiology of phimosis?
foreskin cannot be retracted behind the glans, occludes the meatus
what are the clinical features of phimosis?
o Young boys: Recurrent balanitis and ballooning
o Adults: painful intercourse, infection, ulceration, balanitis xerotica obliterans
o Overgrowth of bacteria behind foreskin – smegma bacillus
what is the pathophysiology of paraphimosis?
o Foreskin becomes trapped behind the glans penis and cannot be reduced
o Prevents venous return leading to oedema and even ischaemia of the glans
what is the cause of paraphimosis?
incorrect handling of foreskin – retraction for catherization or cystoscopy and not replaced properly, sex for first time, old age you has not/cannot
what are the clinical features of paraphimosis?
painful swelling of the foreskin distal to a phimotic rim, palpable tight band
what is the management of paraphimosis?
Ask patient to squeeze glans. Try applying a 50% glucose soaked swap. Ice packs and lidocaine gel may also help. May require aspiration/dorsal slit/circumcision.
o Retraction – ring block then squeeze for 20 mins “white knuckle pressure”
what are the causes of priapism?
- Idiopathic - 80%
- Intracorporeal injection for ED e.g. papaverine (low flow)
- Trauma (high flow)
- Haematological dyscrasias e.g. sickle cell
- Neurological conditions – spinal cord lesions
what is priapism?
prolonged priapism
what is the pathophysiology of low flow priapism?
o Excessive release of neurotransmitters, blockage of drainage venules, paralysis of the intrinsic mechanism, prolonged relaxation of the intracavernous smooth muscles
o Vascular stasis + decreased venous outflow = compartment syndrome
o Lots of deoxygenated blood in penis can cause necrosis and tissue damage
what is the pathophysiology of high flow priapism?
o Fistula between the cavernosal artery and the corpus cavernous = unregulated blood entry + filling of corporea
what are the clinical features of priapism?
- Prolonged erection
- Low flow – corpora cavernosa are rigid and tender, penis often painful
- High flow – not painful
how is priapism diagnosed?
Aspirate blood from corpus cavernosum – dark blood, low O2, high CO2 in low flow, normal arterial blood in high flow
Colour duplex – USS
o minimal or absent flow in cavernousal arteries in low flow
o normal to high flow in non-ischaemic priapism
what is the management of ischaemic priaprism?
aspiration +/- irrigation with saline, injection of alpha agonist e.g. phenylephrine 100-200micrograms every 5-10 mins up to max
surgical shunt, >7 hrs unlikely to respond, penile prosthetic
what is the management of non-ischaemic priaprism?
observe, respond spontaneously, selective arterial embolization
what is Fournier’s gangrene?
necrotising fasciitis of penis
what are the risk factors to Fournier’s gangrene?
diabetes, local trauma, periurethral extravasation, perianal infection
where does Fournier’s gangrene arise from?
skin, urethra and rectal region
what is the pathophysiology of Fournier’s gangrene?
Necrosis of superficial and deep fascial planes, fibrinoid coagulation of nutrient arterioles, polymorphonuclear cell infiltration
what are the clinical features of Fournier’s Gangrene?
o Starts as cellulitis – swollen, red, tender, marked pain, fever, systemic toxicity
o Swelling + crepitus of scrotum, dark purple areas
how is Fournier’s gangrene diagnosed?
plain Xray or USS
how is Fournier’s gangrene managed?
antibiotics and surgical debridement
what is balantis xerotica obliterans?
Pre-malignant Cutaneous Lesions
what is the cause of balantis xerotica obliterans?
genetic, autoimmunity, infection, hormones, local skin changes
what are the clinical features of balantis xerotica obliterans?
white patches, fissuring, scarring, bleeding, thin patches, itchy, fibrosis of tissue that prevents retraction
where does balantis xerotica obliterans occur?
appears on foreskin and the glans penis
what does a biopsy of balantis xerotica obliterans show?
thin epidermis, basal layer damage, pink
what is the management of balantis xerotica obliterans?
simple = circumcision, complex = glans resurfacing
what is the causes of a penile carcinoma in situ?
solar damage, arsenic, immunosuppression (AIDs), viral infection (PV), chronic skin injury
what are the microscopic features of penile carcinoma in situ?
Atypical squamous cells proliferate through whole thickness of epidermis – entire tumour is confined to epidermis + doesn’t invade into dermis
what are the types of penile carcinoma in situ?
o Erythroplasia of Querant = glans prepuce or shaft of penis
o Bowmen’s disease = remainder of genitalia
how is penile carcinoma diagnosed?
biopsy
what is the management of penile carcinoma in situ?
Excision/circumcision/glans resurfacing
Topic 5 fluorouracil/imiquod/laser
what are the causes of penile squamous carcinoma?
Infection = HPV (also HIV and genital warts)
Hygiene + Injury circumcision
Others – age, tobacco, UV light
how does penile squamous carcinoma grow?
o Grow laterally along surface and can cover entire glans, prepuce before invading the corpora and shaft of the penis
o Metastasis to femoral + inguinal nodes
o Originate at C15
what are the clinical features of penile squamous carcinoma?
o Often delayed
o Red, raised area of penis
o Fungating mass = foul smelling
o Phimosis
how are the different types of penile squamous carcinoma diagnosed?
o Primary – physical, histology/cytology, USS, MRI
o Regional – physical, histology/cytology, sentinel node biopsy
o Distant Metastases – pelvic CT, bone CT, chest Xray, bone scan
o Staging
what is the management of penile squamous carcinoma?
Surgery – total/partial penectomy and reconstruction
Inguinal nodes – imaging, radionucleotide, sentienal node biopsy, inguinal lymphadectomy
Combined
Radiotherapy – primary lesion, lymphnodes
chemo – 5FY, cisplatin
