S10C96 - Male genital problems Flashcards
1
Q
Penis: anatomy
A
- 3 cylindrical bodies: corpus spongiosum surround urethra and 2 corpora cavernosa (main erectile tissue)
- capped by glans penis
- 3 bodies are encased individually in thick tunica albuginea
- all three are surrounded by buck fascia
- internal pudendal artery supplies blood and branches into deep and superficial penile arteries
2
Q
Scrotal anatomy
A
- from outer to inner layers: skin, dartos fascia (eg. camper fascia), colles fascia (ie. scarpa fascia)
- blood supply is from femoral and internal pudendal arteries
- lymphatics drain to inguinal and femoral nodes
3
Q
Testicular anatomy
A
- size: 5cm long, 3cm wide
- each is encased in fibrous tunica albuginea (except posteriorly )
- tunica vaginalis covers anterior and lateral testes
- superiorly testis is attached to spermatic cord, inferiorly to the gubernaculum (scrotal ligament)
- poor dvpt of tunica vag is what leads to torsion
- hydrocele occurs when tunica vag is prevented from absorbing viscerally secreted fluid
- blood supply : internal/external spermatic arteries (spermatic cord)
- venous return via internal spermatic, epigastric, internal circumflex and scrotal veins
- lymphatic drainage via external/common iliac and periaortic nodes
4
Q
Epididymis: anatomy
A
- fine, tubular structure that promotes sperm maturation and motility
- appendix epididymis and appendix testis = vestigial structures
- appendix epididymis is attached to the head of epididymis (globus major)
- appendix testis is a pear shaped structure of mullerian duct origin situated uppermost portion of testis
- lies on posterolateral aspect of testis, has similar feeling as ear lobe
- has a head, body and tail, normally is sensitive
5
Q
Vas deferens
A
- muscular tube palpable w/in scrotal sac
- extends to spermatic cord from tail of epididymis
- joins seminal vesicles to form the paired ejaculatory ducts in the prostatic urethra
6
Q
Prostate: anatomy
A
- weighs 10-15g
- anterior, median, posterior and lateral lobes
7
Q
Scrotal edema: causes
A
- bites, dermatitis
- young boys: idiopathic edema, unilateral swelling, erythema and pain b/w 3-9yo, resolves in 1-4d with 15% recurrence
- fluid overload, hypoalbuminemia, anasarca
8
Q
Scrotal Abscess
A
- determine whether it is restricted to the skin or more complicated underlying structures
- if simple hair follicle scrotal wall abscess then I+D
- if testis involved then use u/s, refer to urology
9
Q
Fournier Gangrene
A
- polymicrobial
- necrotizing fasciitis of perineal, genital and perianal anatomy
- usually begins as benign infection that becomes virulent
- results in microthrombosis of small subcutaneous vessels leading to dvpt of gangrene of the overlying skin
- RF: immunocompromised, DM, EtOH use
- marked pain and swelling, crepitus, ecchymosis
- aggressive fluid resusc
- requires Abx coverage for gm-, gm+, and anaerobes
eg. imipenem ig IV q8h plus vanco if mRSA - plus wide surgical debridement
- mortality = 40%
- ** genital pain our of proportion or extending beyond the confined area of infxn
10
Q
Balanoposthitis
A
- balanitis: inflm of glans penis
- posthitis: inflm of foreskin
- balanoposthitis: inflm of glans and foreskin
- etiology: poor hygiene or external irritation (candida colonization), candida, gardernella and anaerobes
- o/e: if foreskin is retracted the glans and apposing prepuce appear purulent, excoriated, malodorous and tender
- tx: cleanse with mild soap, ensure dryness, apply antifungal cream (nystatin, clotrimazole), tx with oral azole (fluconazole) and consider circumcision
- bacterial infxn suggested by warmth, erythema, edema of glans/foreskin/shaft, if present use a 1st or 2nd generaiton cephalosporin in addition to aforementioned treatments
-if recurrent: think DM
11
Q
Phimosis
A
- inability to retract foreskin proximally and posterior to glans penis
- cause: infxn, poor hygience, previous preputial injury with scarring
- definitive tx: circumcision
- other tx: topical steroid betamethasone 0.05-0.1% OD from tip of foreskin to glandis corona for 4-6w is 70-90% effective
12
Q
Paraphimosis
A
- urologic emergency
- inability to reduce proximal edematous foreskin distally over the glans penis
- glans edema and venous engorgement can progress to arterial compromise and gangrene
- reduction: compression of glans for several minutes to reduce edema then roll foreskin over glans
- do a local anesthetic block
13
Q
Removing constricting bands from penis:
A
- compression, cooling, cutting
- wrap penis distal to proximal with ubilical tape or thick suture, try to pass tape under the ring/object
14
Q
Hair tourniquet
A
- if it has been present for some time, urethra and dorsal nerve supply may be damaged
- may require a retrograde urethrogram to ensure urethral integrity and a doopler for distal penile arterial blood supply
15
Q
Zipper entrapment:
A
- provide local anesthesia
- try coating zipper with mineral oil or lubricant
- if that doesn’t work then cut zipper free of clothing to make it easier then try cutting the sliding bar of the zipper and the zipper teeth
- can also cut the bottom bar of the zipper apparatus
16
Q
Factured Penis
A
- occurs when tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to the erect penis
- can be associated with a partial/complete urethral rupture or deep dorsal vein injury
- causes: sexual intercourse, animal bite, stabbing, bullet wounds, self-mutilation
- o/e: swollen penis that is flaccid, discolored and tender
- may require a retrograde urethrogram
- surgical tx: hematoma evacuation, suture apposition of tunica albuginea
17
Q
Peyronie Disease
A
- progressive penile deformity, curvature erections
- painful, may result in ED or impede vaginal intercourse
- o/e: thickened plaque, usually on dorsum involving the tunica albuginea of both corpora bodies
- uro referral
- assoc with dupuytrens
18
Q
Priapism
A
- persistent, painful, pathologic erection
- both corpora cavernosa are engorged with stagnant blood
- impotence can occur in 35% of cases
- etiology: intracavernosal injection (papaverine, prostaglandin E1) or meds (ED meds, chlorpromazine, trazodone, CCB, prazosin or SCD
- high flow and low-flow priapism
-high-flow: rare, painless, caused by fistulae b/w cavernosal artery and corpus cavernosum, dx with doppler and treated with embolization
-low-flow priapism: common, painful, dx by aspn of dark acidic intracavernosal blood from corpus cavernosum
Tx:
-analgesia
-terbutaline 0.25-0.5mg SC deltoid repeat q20-30min x3 PRN
-corporal aspn followed by irrigation with plain saline or phenylephrine (alpha adrenergic agonists)
-if priapism secondary to SCD, may require exchange TFN
19
Q
Carcinoma of penis
A
- often in 5th or 6th decade of life in an uncircumcised male
- may appear as nontender ulcer or warty growth beneath foreskin, often hidden by inflamed phimotic foreskin
20
Q
Acute scrotal pain: ddx
A
- testicular torsion
- torsion of testicular appendages
- epididymitis
- incarcerated hernia
- trauma
- vasculitis
21
Q
Testicular Torsion
A
- incidence 1:4000
- bimodal age distribution, perniatal and puberty
- only 4-8% occur due to trauma, the rest are spontaneous
- hx: severe pain (lower quadrant, groin or testis), n/v
- o/e: firm, tender testis that is higher than contralateral side and has a transverse lie
- absence of cremasteric reflec = 99% sensitive
- prehn sign (Relief with elevation of affected testicle) does not reliably distinguish b/w epididymitis and torsion
- important to treat w/in 6h, best outcomes
- manual detorsion: consider not giving analgesia so you can determine success…
- open the book
- right testis is rotated in a counterclockwise fashion and left testis in a clockwise fashion
- initial attempt should be one and 1/2 rotations (540 deg)
- if pain is made worse with this procedure then try going in the opposite direction
**consider testicular torsion in male with abdo pain
22
Q
Appendageal torsion
A
- 4 appendages: appendix testis, appendix epidiymis, paradidymis and vas aberrans
- appendix testis accounts for 90% of appendage torsion
- o/e: pain localized to upper pole of testis or epididymis, blue spot sign (pathognomonic)
- tx: self-limiting, analgesia, bed rest, supportive underwear, reassurance
- symptom resolution in 3-5d
23
Q
Epididymitis / epididymo-orchitis
A
- hx: usually a gradual onset of pain
- bacterial infxn is most common cause
- young boys: sterile reflux, coliform bacteria
- 40yo: e. coli, klebsiella
- elderly men: could be associated with BPH and urethral strictures
- chemical epididymitis: reflux of sterile urine
tx: usually can be managed as out-pt with Abx for 14d
- admit if f/c, toxic
- admission mgmt: bedrest 1-2d, scrotal elevation, ice application 10-15min q4-6h, NSAIDs, IV Abx, analgesia
- can wear a scrotal supporter, no heavy lifting, no straining with BM
- re-evaluate by urology in 5-7d
24
Q
Orchitis
A
- isolated orchitis is rare
- ddx: viral illness - coxsackia, EBV, varicella, echovirus, mumps (starts as one testicle then spreads to other)
- bacterial orchitis almost always is assoc with epididymitis
- immunocompromised: mycobacteriosis, cryptococcosis, toxoplasmosis, candidiasis
- sx: testicular tenderness and swelling for a few days
- often a clinical diagnosis
- tx: symptomatic and disease specific
25
Q
Testicular Malignancy
A
- asymptomatic testicular mass, firm, indurated
- 10% will present with pain secondary to acute hemorrhage w/in tumor
26
Q
Acute prostatitis
A
- bacterial inflm of prostate gland
- Sx: low back pain, perineal/suprapubic/genital discomfort, LUTS, frequency, dysuria, perineal pain with ejaculation, f/c
- RF: LUT obstruction, epididymitis, urethritis, rectal intercourse, phimosis, intraprostatic ductal reflux
- organisma: e coli, pseudomonas, klebsiella, enterobacter, serratia, staphylococcus
- o/e: perineal tenderness, rectal sphincter spasm, boggy tender prostate
- clinical diagnosis - u/a and urine Cx may be negative
- tx: fluoroquinolone for 30d
- can also use septra DS one tabe PO BID x30d but not as good
-admit if immunocompromised, septic, or urinary retention
27
Q
Urethritis
A
- purulent uretheral d/c
- dx: clinical, confirmed by pyuria or bacteriuria in u/a
- pathogen: neisseria gonorrhea, chlamydia trachomatis, HSV, ureaplasma urealyticum, trichomonas vaginalis
-tx: CTX 125mg IM + azithromycin 1g PO
or CTX plus doxycycline 100mg PO BID x10d
-may consider flagyl
28
Q
Urethral strictures
A
- secondary to STI
- if pt having difficulty voiding and a 14F or 16F foley or coude is difficult to pass then Ddx is: urethral stricture, voluntary external sphincter spasm, bladde rneck contracture, BPH
- susptected voluntary ext sph spasm can be overcome by holding penis upright and eencouragin pt to relax their perineum and breathe slowly while inserting the catheter
- if stricture suspected, consult urology after 3 gentle attempts have been made
- decompress bladder with suprapubic catheter if emergent
29
Q
Urethral FB
A
- bobby pins, paint brushes, ball point pens
- bloody urine with infxn and slow painful urination is suspicious of fB
- xr bladder and urethra
- tx: cystoscopic removal or oepn cystotomy, can try gentle milking action followed by retrograde urethrography to confirm intact urethra
30
Q
Hematospermia
A
- ddx: trauma, tumor with erosion, inflm, infection of any part of the mail ejaculatory tract
- can occur after vigorous sexual activity
- consider STI
- all pts with hematospermia should be referred to urology
- > 40yo have higher risk for cancer
