Penis Flashcards
Identify picture 2
Pearly penile papules
What are pearly penile papules
Benign papules on corona of glans. Due to uncircumcision
Often confused with condyloma acuminata
Identify picture 3
Prince Albert ring
Complication of Prince Albert ring
Urethral fistula
Why do people get Prince Albert ring
Increases sexual pleasure
Define priapism
Painful, prolonged (>6h) erection unaccompanied by sexual desire
Define Peyronie’s disease
Fibrous plaque involving tunica albuginea of penis causing penile pain on erection, chordee usually dorsal, erectile dysfunction.
Etiology of Peyronie’s disease
Repetitive microvascular trauma due to coitus (wound healing disorder causing prolonged inflammation and remodelling)
Clinical features Peyronie’s disease? (5)
- Penile pain when erect
- Penile curvature (chordee) usually dorsal (inelastic plaque restricts expansion )
- loss of erections in late stage. (Interfere with veno-occlusive mechanism)
- palpable plaque usually on dorsum, mid-shaft or distal penis.
- later: penile shortening, narrowing, hourglass deformity.
Risk factors Peyronie’s disease? (5)
• Middle aged 40-60 • connective tissue disorder (20% have associated Dupuytren's contracture)! • diabetes • post radical prostatectomy . Hypertension • hypogonadism • smoking • familial predisposition, vascular disease
Treatment Peyronie’s disease? (4)
• 50% resolve spontaneously within a year.
• penile pain: vitamin E and colchicine ( gout medication), NSAIDs orally or intralesional injection with verapamil (ccb), collagenase or interferon. None of these very successful.
• penile curvature: surgery if unable to have intercourse and disease stabilised.
- Nesbit procedure (plication) ( disadvantage penile shortening) (most common)
- excision of plaque (complex)
- shock therapy
• loss erections: medications like pde5 inhibitors unsatisfactory, need penile implant if loss function .
What is BXO?
Balanitis xerotica obliterates, or lichen sclerosis et atrophicus
pre-malignant white patch on glans and penis from chronic infection, phimosis
Treatment penile leukoplakia?
Local excision
Treatment condyloma acuminatum?
• Podophyllin
. Fulgaration (diathermy)
• cryotherapy
What is bowenoid papulosis
- Rare, sexually transmitted disorder caused by HPV 16.
- resemble cis
- many papules or flat granular lesions, reddish brown or violet, solid, velvety
What is condyloma acuminatum
• Genital wants caused by HpV 16 and 18.
• pre-malignant, associated with SCC of penis
- soft, multiple lesions on glans, prepuce and shaft.
Treatment of penile cancer (primary lesion and lymph nodes)? (6)
• Primary lesion: surgical under antibiotic cover
Confined to foreskin: circumcision
- glans or distal shaft: partial penectomy
- proximal shaft; total penectomy and perineal urethrostomy
- small lesions: radiotherapy (external beam or brachytherapy ) (low chance lymph involve)
•lymph nodes:
- radical inguinal node dissection only if malignant nodes confirmed on aspiration cytology (high complication rate)
- Rest of cases bilateral modified inguinal node dissections
- Inoperable inguinal nodes (fixed or ulcerated) must be treated to avoid ulceration and haemorrhage: initial chemo → salvage surgery (best) or radiotherapy
What is the factor associated with the worst prognosis in penile cancer?
Iliac lymph node involvement. No chance of 5 year survival.
Define erectile dysfunction
Consistent, > 3 months, or recurrent inability to obtain or maintain an adequate erection sufficient for penetration and successful intercourse
Describe the normal physiology and steps of an erection (6)
1 psychogenic erections mediated by central erection centres ;
reflexogenic by genital stimulation mediated peripherally by spinal cord erection centres: s2-s4 parasympathetic ( Point );
Nocturnal erections during REM sleep mediated by central
(somatic : dorsal penile, cavernous and pudendal nerves must be intact too)
- Nitric oxide released in corpora cavernosa from NANC neurons and endothelium
- NO activate guanylate cyclase → increased cyclic guanosine monophosphate (CGMP ) from GTP → sinuosidal smooth muscle relaxation
4 increased blood flow to penis: iliac arteries → internal pudendal → cavernous → helicine arteries of penis
- Increased intracavernosal pressure causing venous obstruction to maintain erection
- normal hormone environment (testosterone, prolactin and thyroid) is necessary.
Describe the normal physiology and steps of an ejaculation (4)
- Sensory afferents from glans
- secretions from prostate , seminal vesicles and ejaculatory ducts enter prostatic urethra (sympathetic T10/11- L2 )
- bladder neck closure (sympathetic)
- spasmodic contraction of bulbocavernosus and pelvic floor muscles (somatic)
Describe the normal physiology and steps of an detumescence (4)
- Mediated by sympathetic t10 /11 - L2 via alpha receptors (norepinephrine/noradrenaline), endothelin 1
- breakdown cGMP to GMP in corpora cavernosa mediated by phosphodiesterase type 5 (pde5)
- arteriolar and sinusoidal constriction
- venous outflow
What type of erectile dysfunction will not have morning erections?
Organic ED (psychogenic will still have)
Name 10 organic causes of erectile dysfunction
• Vasculogenic:
- decreased arterial inflow: large vessel disease eg iliac arteries, small vessel disease eg diabetic vasculopathy
- Venous leak: congenital abnormal venous channels or “leaky” tunica albuginea of corpus cavernosa
• neurogenic
- CNS: CVA, Alzheimer’s, multiple sclerosis
- Spinal cord: traumatic paraplegia
- peripheral nerves: diabetic autonomic neuropathy
- diabetes mellitus
- endocrine: decreased serum testosterone, especially loss libido
- trauma: pelvic #
- surgery: radical prostatectomy!, radical cystectomy, penectomy, bilateral orchidectomy, resection rectal carcinoma
A radiotherapy: external beam or brachytherapy for prostate cancer
• drugs (As)
- antihypertensives except alpha blockers and CCBS (neutral)
- antiandrogens: spironolactone, oestrogens
- antidepressants: tricyclic (increase serum prolactin mainly delayed ejaculation )
- antipsychotics: typical tranquilisers (increase serum prolactin)
- Alcohol, smoking, recreational drugs
- alpha stimulants
- antihistamines- h2 receptor antagonists (increase serum prolactin)
- chronic systemic disease: heart, obstructive airway disease, renal failure, liver disease
- penile problems: peyronie , chordee, neglected priapism, microphallus
Classification of erectile dysfunction and major differences? (7) prevalence, onset, frequency, variation, age, risk factors, nocturnal erections
Psychogenic VS organic
• 10% vs 90%
• sudden vs gradual
• sporadic vs always
• vary with partner and circumstance vs no variation
• younger vs older
• no organic risk factors vs risk factors
• nocturnal and morning erection present vs absent
Investigations for erectile dysfunction? (5)
• History sexual function assessment: ED, libido, ejaculation, orgasm, sexually related genital pain
• exams: secondary sex characteristics, penile deformities, bp, PvD, neurological examination s 2 -s4,
. urine dipstick for glycosuria and fasting blood glucose
• lipid profile
• serum testosterone if clinically indicated (low libido, tropic testes )
Etc
Non-invasive Treatment erectile dysfunction? (4)
- Lifestyle changes: alcohol, smoking
- psychological: sexual counselling and education
- change precipitating medications
- treat underlying causes:DM, CvD, ht, endocrinopathies
Minimally invasive Treatment erectile dysfunction? (3)
- Oral medication: first line = pde5 inhibitors: sildenafil (viagra!) 50 mg, tadalafil (cialis!) 20 mg, vardenafil (levitra!)(increase intracavernosal cgmp)
- vacuum devices: draw blood into penis via negative pressure, then put constriction ring at base of penis. Can be used for all types of ED but is cumbersome.
- MUSE: male urethral suppository for erection- vasoactive substance (pge1- alprostadil ) capsule inserted into urethra
Identify pathology picture 6
Peyronie’s disease
Label picture 8 cross section of penis
See picture 9
What is the most common form of male sexual disfunction?
Premature ejaculation. Almost always psychogenic
Treatment premature ejaculation? (4)
- Topical lidocaine-prilocaine spray, remicaine lotion
- ssri eg sertraline, fluoxetine = worst sexual side effects of ssri eg loss libido, ED
- TCA eg clomipramine works best, but worst sexual side effects of TCAs; imipramine much better for side effects
- NDRI bupropion least side effects!
Name 2 secondary causes of premature ejaculation
- Hyperthyroidism
* prostatitis
Name 3 causes phimosis
- congenital: 90% natural separation by age 3
- banalitis (foreskin and glans).
- poor hygiene
- traumatic
What is pathological phimosis?
Unable to retract foreskin at puberty
Name 4 treatment options phimosis
Physiological will settle by itself
• Proper hygiene
• topical corticosteroids for mild and moderate
• dorsal slit
• circumcision if pathological and severe
Name 5 symptoms short frenulum
• Concord penis when erect
• Discomfort or pain in penis during erection
• premature ejaculation
• tearing and bleeding underneath head of penis
. Trouble pulling back foreskin
Name 5 causes frenulum breve
- Congenital mostly
- Balanitis
- balanoposthitis
- STDs causing banalities
- skin conditions
Treatment short frenulum?
- Stretching and steroid creams
- frenuloplasty
- frenulectomy
- circumcision
Name 5 complications phimosis
- balanitis,
- posthitis,
- paraphimosis,
- voiding dysfunction,
- penile carcinoma
- prepuce calculi
- obstruction to urine flow - hydronephrosis or ureter
Name 3 possible etiologies hypospadias
•Genetic, family history
• maternal: SGA, monochorionic twins, GHT, oligohydramnios, preterm delivery, IVF and icsi
Hormonal: disruption prenatal androgen exposure, fetal exposure to maternal oestrogen
Name the grading of hypospadias
Grade 1: glanular opening
Grade 2: distal
Grade 3: proximal
Grade 4: opening in scrotum to perineum
Define paraphimosis
Retracted foreskin behind glans penis that cannot be reduced
Name 3 causes paraphimosis
- Iatrogenic: post cleaning or instrument
- Trauma
- infections: balanitis, balanoposthitis
Clinical features paraphimosis? (3)
- Painful, swollen glans penis due to obstruction venous and lymphatic drainage
- constricting band proximal to Corona - donut shape
- dysuria, decreased urinary stream in children
Treatment paraphimosis?
- penile ring block using lignocaine without adrenaline
- emergency: reduce. Constant pressure on glans forces interstitial fluid out of glans and foreskin, allowing reduction
- if this is unsuccessful, incise band dorsally.
- definitive treatment = circumcision
Classification and pathogenesis of priapism?
• Low flow / veno-occlusive/ ischaemiac - common
- persistent arterial inflow
- corpus cavernosa only
- dark blood on aspiration
• high flow/ arterial / non- ischaemic - uncommon
- Most commonly due to perineal trauma causing AVF
- bright red blood on aspiration because no ischaemia
- Corpus cavernosum and spongiosum
- Painless, good prognosis
• (recurrent/stuttering - variant of ischaemic brought on with REM sleep)
Differential diagnosis of genital ulcers? (13)
STD . Syphilis/lues • chancroid (haemophilus ducreyi) • lymphogranuloma venereum (chlamydia) • granuloma inguinale (calymmatobacterium granulomatis) • herpes simplex virus
Pre-malignant lesions
• carcinoma in situ
• leukoplakia
• Malignant: squamous carcinoma of penis
. Traumatic ulcer eg during intercourse
. Tb
- non specific
- allergic
- behcet’s syndrome
Describe syphilitic genital ulceration:organism, incubation, pyrexia, primary lesion, multiplicity, pain, depth, edges, base, induration, inguinal lymph nodes
- Treponema palladium
- incubation 20-25 days
- no pyrexia
- Primary lesion papule at coronal sulcus
- single painless
- deep
- edges well defined!
- base smooth non-purulent!
- induration firm
- firm, non tender! Bilateral inguinal lymph nodes with no complications!
Describe chancroid genital ulceration:organism, incubation, pyrexia, primary lesion, multiplicity, pain, depth, edges, base, induration, inguinal lymph nodes and complications
- Haemophilus ducreyi
- incubation 1-14 days
- pyrexia
- primary lesion papule
- Multiple
- painful
- deep
- irregular edges
- purulent base
- soft induration!
- tender, unilateral inguinal lymph nodes with suppuration, sinus formation, genital lymphoedema
Describe lymphogranuloma venereum genital ulceration:organism, incubation, pyrexia, primary lesion, multiplicity, pain, inguinal lymph nodes and complications
- Chlamydia trachomatis
- incubation 3-40 days
- pyrexia
- primary lesion vesicle!
- single painless superficial!
- tenders unilateral inguinal lymph nodes with suppuration, sinus formation, genital lymphoedema
- other: rectal stenosis
Describe granuloma inguinale genital ulceration:organism, incubation, pyrexia, primary lesion, multiplicity, pain, depth, edges, base, induration, inguinal lymph nodes and complications
- Calymmatobacterium granulomatis
- incubation 2-3 months! (Longest)
- no pyrexia
- primary lesion papule
- single or multiple, painless
- elevated!
- edges elevated / irregular
- red, rough base!
- firm induration
- inguinal lymph nodes granulomatous swelling with skin ulceration!, inguinal sinuses,genital lymphoedema
- other: rectal stenosis
Describe herpes simplex genital ulceration:organism, incubation, pyrexia, primary lesion, multiplicity, pain, depth, edges, base, induration, inguinal lymph nodes
- HSV 2
- incubation 2-10 days! (Shortest)
- no pyrexia
- primary lesion vesicle
- multiple
- painful
- superficial!
- edges erythematous !
- base serous!
- no induration!
- tender, bilateral inguinal lymph nodes
Differential diagnosis penis oedema? (8)
Balanoposthitis progressing to cellulitis Urine extravasation Idiopathic lymphoedema of penis and scrotum, acutely painful Bee or insect sting Early Fourneirs Congestive heart failure Nephrotic syndrome with anasarca Elephantiasis
