W2 Penile Pathologies (Joey) Flashcards
Phimosis
What is physiologic and pathological phimosis?
Phimosis Definition: Inability to retract the prepuce (foreskin) over and below the glans of the penis, often 2/2 physical adherence of the epithelial linings of the prepuce (foreskin) to the glans penis
physiologic phimosis in 95% of newborn
most able to fully retract foreskin b/t ages 3-5, but there is no specific age cutoff, may take days to years, may even last to pre-pubescence)
Counseling parents and pts on regular progressive gentle
foreskin retraction, cleansing, drying, & subsequent foreskin
reduction may help in progressive loosening of adherent penile tissue
patholoic phimosis = worsening w/ age and pt approach sexual activity
—Distal penile pain w/ erection or sexual activity aka dyspareunia
—+/- abnormal urinary stream
—increase risk of UTIs
—may present as balantis
Adult pathological phimosis treatments
3
Mild — urology can manually retract the foreskin
@ home — short term application of topical steroids such as beclomethasone for 1-2 months
Operative
—if manual retractions + steroids is unsuccessful, circumcision
Paraphimosis
What is it?
Why does it happen?
Entrapment of the retracted prepuce (foreskin) behind the coronal sulcus of the glans, typically 2/2 prolonged rectration of the foreskin, that cannot be returned to normal reduced position
the “ring” of the retracted prepuce starts putting circumferential band-like constrictive pressure on the venous & lymphatic vessels proximal to the corona…
Leads to swelling and congestion
Pressure then builds up in penile arteries
ultimately may lead to subsequent ACUTE compromise of arterial supply to the glans & distal penis → acute ischemia of the glans !! → necrosis !!!
🆘 Paraphimosis is a urologic EMERGENCY!! 🆘
Paraphimosis
Presentation
Causes
Treatments
Presentations
—moderate/severe distal penile pain
—swelling of the prepuce proximal to the corona
—peds: inconsolable crying
Causes
—iatrogenic, failing to reduce the prepuce after exam/foley catheter placement
—failing to replace prepuce after sex
—peds: hair band constriction
Treatments
—try to reduce if actually Paraphimosis
apply pressure first, administer pain medication, use press and pull method, gliding glans under prepuce while pulling prepuce over glans, _regularly check that foreskin hasn’t gone back. Do not retract foreskin for a week
—call urology immediately if any concern for necrosis
Paraphimosis treatments
Procedural vs operative
If manual reduction is unsuccessful or if pt has e/o acute ischemia or necrosis, may need to advance to procedural / OR tx options (exs below)
If no manual compressive reduction unsuccessful, and there is no concern for acute ischemia / necrosis, may consider the following:
● Puncture & Drainage of Edematous Prepuce Procedure
If unsuccessful or concern for necrosis
⭐️“Dorsal Slit” Reduction:
=Incision of the dorsal aspect of the prepuce at the site of the constriction band
Ultimately, circumcision may need to occur (often considered in pt’s w/ recurrent paraphimosis, pts who develop phimosis 2/2 tx of paraphimo)
What are these superficial and cutaneous penile pathologies?
Balanitis —which pathogen?
Posthitis
Balanoposthitis
Thromboses superficial penile vein
Balanitis:
—Inflammation of the glans of the penis (infectious vs noninfectious)
—2/2 period of poor hygiene
—Candidal infection is most common
Posthitis:
—Inflammation of the foreskin / prepuce (infectious vs noninfectious)
—Causes and treatments similar to the above
Balanoposthitis:
—Inflammation of both the glans and foreskin / prepuce (infectious vs noninfectious)
—Causes and treatments similar to the above
Thrombosed Superficial Penile Vein:
—Often a/w penile trauma, but may be spontaneous / idiopathic.
—Typically starts as focal pain, then w/ times pain resolves.
—Often self resolves w/ time
What are these superficial and cutaneous penile pathologies?
HSV: presentation, dx and tx
Chancre: which infection? Tx?
Chancroid: which infection? Tx?
Condyloma: 2/2 which infection? Increased risk of what?
HSV 1 & 2 Lesion:
—Ulcerative or pustular herpetic appearing lesion 2/2 HSV 1 vs 2 infection
—Classically HSV 1 more oral transmission & HSV 2 more sexual mucosal transmission
—painful or painless herpetic lesion, +/- discharge, may be a/w pruritus, neuropathic pain / sensation
—Diagnose via lab studies (swab of open lesion, serum studies for HSV abs)
—Tx: valacyclovir
Chancre:
—⭐️Painless ulcerative sore of the genitalia / penis, associated with primary syphilis infection
—Treatment: Penicillin G
Chancroid:
—⭐️Painful ulcerative lesion of the penis, a/w ⭐️haemophilus ducreyi infection
—Treatment: Azithromycin 1g 1x PO or
—Ceftriaxone 250 mg 1x IM
Condyloma:
—Exophytic lesion of the skin, often 2/2 HPV infection of squamous cells:
—Patients w/ HPV-associated condyloma are at increased risk of developing ⭐️ Penile Cancer
HPV Infections & Malignancy
Which virus strain a/w 50% of cervical cancers? And penile cancers?
What is the other risk factor?
⭐️HPV Infection increases risk of developing penile, cervical, vaginal, anal cancer, and several head & neck / oropharyngeal cancers
(FYI with various HPV genotypes being a/w specific malignancies):
Cervical cancer (FYI): High risks HPV types for cervical cancer include 16 (~50% of cases), 18, 31, 33, 35, 39
⭐️Penile cancer: various, most commonly including HPV 16
Risk factors:
⭐️smoking + HPV infection
Penile Cancer
Classic presentation?
Diagnosis?
General treatment options?
Surveillance
Prevention
Classic penile cancer presentation is a painless mass or ulcer on penis
Diagnosis: Biopsy / need tissue !!!
Resection of Lesion vs Partial Penectomy vs Radical (total) Penectomy
—+/- resection of LNs
—Rarely presents w/ disseminated disease
—if v focal can consider topical chemo agents like 5-FU/laser ablation
Surveillance
—Q3-12 months
Prevention
—HPV vaccines!! garadasil
Hypospadias and urethral ectopia
Definition
Hypospadias is a congenital anomaly of the natal male urethra that results in abnl ventral termination of the male urethral meatus (the distal urethral opening), commonly associated with abnl prepuce development +/- penile curvature at birth
Hypospadias and urethral ectopia
Where is it usually found?
What are other classic findings
What genetic syndromes are you going to check for?
What imaging?
Definitive treatment?
What should these patients NOT have done?
—almost always an ectopic ventral urethral meatus
—+ abnormal foreskin development
—dorsal nodded prepuce appearance
—abnormal curvature of the penis chordee
Genetic
—XXY
—Kallmann
Imaging
—U/S to r/o other abnormalities
FYI: classified based on where the meatus is located
Definitive treatment
—surgical: urethroplasty
—specific indications include:
⭐️significant deflection of urinary stream
⭐️ incomplete bladder emptying
⭐️ frequent UTIs
⭐️ urolithiasis
⭐️ ED or ejaculatory dysfunction
⭐️ male dyspareunia
DO not circumcise these newborns
What is ureteral ectopia and duplication?
Congenital abnormal location or implantation of the ureter relative to the bladder
Some cases of ureteral ectopy however may result in ureteral implantation into other structures than the bladder, including bladder neck, urethra, reproductive structures
Treatments: Depending on the complications, some
patients may or may not need procedural intervention.
For patients with UTIs, obstructions, stones, may need to
consider resection of the non-dominant duplicate ureter
