Male Genital Problems

1
Male Genital Problems

• Tintinallis Ch 95

2
Anatomy

• Penis
• Two corpora cavernosa
• Erectile bodies
• Encased in tunica albuginea
• Corpus spongiosum
• Surrounds urethra
• Blood supply internal pudendal art.,
• Lymphatics inguinal nodes

3
Penis
4
Anatomy

• Scrotum
• Dartos Fascia similar to Campers fascia
• Scarpas Fascia similar to Colles Fascia
• Blood supply femoral internal pudendal art.
• Lymphatics inguinal femoral nodes

5
Scrotum and testis
6
Anatomy

• Testes
• Avg 4-5 cm length, 3 cm width depth
• Suspended by spermatic cord
• Encased in tunica albuginea
• Enveloped in Tunica Vaginalis attaching testes to
  posterior scrotal wall
• Anchor gubernaculum

7
Anatomy

• Testes
• Maldevelopment of tunica vaginalis Risk of
  torsion
• Potential space btwn viscera and tunica vaginalis
  space for hydrocele development
• Blood Supply thru spermatic cord
• Internal spermatic external spermatic Art.
• Lymphatics drain to external, common iliac,
  periaortic nodes

8
Anatomy

• Epididymis
• Single, fine, tubular structure
• 4-5 m long compressed into 5 cm
• Promotes sperm maturation motility
• Appendix epididymis testis
• NO function

9
Anatomy

• Vas Deferens
• Distinct muscular tube
• Extends into spermatic cord from tail of
  epididymis, crosses behind the bladder
• Joins the seminal vesicles forming ejaculatory
  ducts

10
Anatomy

• Prostate
• Originates in the 3rd month of development
  continuing to grow throughout life
• Young males, may not be palpable on rectal
• In elderly men, can enlarge to obstruct urine
  flow

11
Physical Examination

• Visual inspection
• Fully retract foreskin to inspect glans, coronal
  sulcus, preputial areas for ulceration or
  malignancy
• Note position of urethral meatus
• Discharge?
• Shaft inspection
• Palpate for plaques, cysts, early abscesses

12
Physical Examination

• Supine or standing positions can be used
• Testes should be checked
• Nodularity or firmness carcinoma until proven
  otherwise
• Alignment, when standing
• Horizontal increased risk of torsion
• Epididymis
• Posterolateral of testis
• Tender with palpation, even when normal

13
Physical Examination

• Prostate
• Normal prostate exam causes discomfort
• Heart- shaped contour
• Consistency similar to tip of nose
• Carcinogenic Prostate similar to bony chin

14
Physical Examination

• Inguinal Canals
• Examine while standing
• Check for hernias, spermatic cord varicoceles
• UA
• In uncircumcised male, retract fore skin and wash
  glans before collecting midstream specimen

15
Common GU DisordersScrotum

• Scrotal Edema
• Insect/human bites
• Contact Dermatitis
• Idiopathic Scrotal Edema, boys 3-9 y/o
• Unilateral pain, scrotal/penile/perineal/inguinal
  swelling erythema
• U/S thickened skin, increased peritesticular
  blood flow, reactive hydrocele
• Recurrent 10-20
• Episode resolves 1-4 days
• Scrotal contiguous w/ penile Edema
• Fluid Overload, CHF, Anasarca

16
Common GU DisordersScrotum

• Scrotal Abscess, determine
• Localized to scrotal wall
• i.e. Hair follicle abscess
• ID, sitz baths
• Originates from intrascrotal structures
• Needs U/S evaluation
• Retrograde Urethrogram
• Referral to Urologist

17
Common GU DisordersScrotum

• Fournier Gangrene
• Polymicrobial, synergistic, necrotizing infection
  of perineal SQ fascia and male genitalia
• Origin rectum, skin, urethra
• Benign infection becomes virulent, leading to
  end-artery thrombosis necrosis
• Diabetic Male, immunocompromised hosts highest
  risk

18
Common GU DisordersScrotum

• Fournier Gangrene
• Mortality 20
• Prompt recognition
• Aggressive fluid resuscitation
• Abx coverage g-, g, anaerobic
• Surgical debridement
• Urologic consultation periurethral involvement,
  Urinary tract involvement
• Hyperbaric Oxygen Tx

19
Common GU DisordersPenis

• Balanoposthitis (both)
• Balanitis inflammation glans penis
• Posthitis inflammation foreskin
• Recurrent episodes can be only sign DM
• Candida, Gardnerella, anaerobes
• Tx mild soap, adequate drying, antifungal
  creams/po Rx, circumcision
• Tx if suspect bacterial infection Broad spectrum
  axbx, 1st or 2nd gen Cephalosporin

20
Common GU DisordersPenis

• Phimosis
• inability to retract foreskin prox. post. to
  glans
• Causes
• Infection, poor hygiene, injury with scarring
• Tx circumcision traditional
• Topical steroids for 4-6 weeks
• 70-90 effective
• Avert circumcision

21
Common GU DisordersPenis
22
Common GU DisordersPenis

• Paraphimosis
• Urologic Emergency
• Inability to reduce the proximal edematous
  foreskin distally over the glans
• Increasing edema can lead to arterial compromise
  and gangrene

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Common GU DisordersPenis
24
Common GU DisordersPenis

• Paraphimosis Tx
• (Local anesthetic block may be used)
• Compression of glans may reduce edema
• Tightly wrap glans in 2 in elastic bandage
• 5 minutes
• Expressing edema out of glans
• Punture glans several times w/22g to 25g needle
• Superficial Dorsal Incision of band

25
Common GU DisordersPenis

• Entrapment Injuries
• String, metal rings, wire, and hair
• Penile Hair-tourniquet syndrome
• Usu. 2-5 y/o circumcised boys
• Hair may be invisible in swollen coronal sulcus
• May involve urethral or dorsal Nerve compression
• Check retrograde urethrogram penile Artery
  doppler before discharge
• Remove object with ingenuity care

26
Common GU DisordersPenis

• Fracture of Penis
• Acute tear/rupture corpus cavernosa tunica
  albuginea
• Acute swelling, Flaccid, Discolored, Tender
• Hx trauma with intercourse/sexual activity
• Sudden snapping sound
• Usu. 30-40 y/o
• Tx Retrograde urethrogram
• Surgical hematoma evacuation, suture disrupted
• tunica albuginea

27
Common GU DisordersPenis

• Peyronie Disease
• Progressive penile deformity
• Curvature with erections Painful
• May lead to erectile dysfunction unsuccessful
  vaginal penetration during intercourse
• Thickened plaque on shaft of penis
• usu. dorsally involves tunica albuginea of
  corpora bodies
• Tx
• Reassurance pain usually improves with time
• Urologic referral
• Assoc. with Dupuytrens contracture of hand

28
Common GU DisordersPenis

• Priapism
• Urologic Emergency, Consult required
• Persistent, Painful, Pathologic erection
• Both corpus spongiosum engorged with stagnant
  blood
• Urinary retention may develop
• Impotence may develop, 35 pts

29
Common GU DisordersPenis

• Priapism Causes
• Rx
• Intracavernosal injections - Papaverine,
  prostaglandin E1
• Oral HTN Rx - Hydralazine, prazosin, Ca Ch.Blk.
• Psych - Chlorpromazine, trazodone, thioridazine
• Hematologic disorders (see in Children)
• Sickle Cell

30
Common GU DisordersPenis

• Priapism
• High-flow, rare
• Non ischemic, nonpainful
• Traumatic fistula b/w cavernosal art. corpus
  cavernosum
• Dx by Doppler
• Tx w/ embolization
• Low-flow
• Ischemic, Painful
• Dx by dark acidic intracavernosal blood aspirate

31
Common GU DisordersPenis

• Priapism Tx
• Analgesia
• Terbutaline 0.25 to 0.5 mg SQ in deltoid
• Repeat q20 - 30 min. prn
• Pseudoephedrine 60 120 mg po
• Use within 4 hrs onset
• Sickle Cell Pts
• Simple or exchange transfusions

32
Common GU DisordersPenis

• Carcinoma
• Rare,1 in 100,000 reported malignancies
• 5th to 6th decades of life
• Uncircumcised males
• Nontender ulcer or warty growth beneath foreskin,
  on glans or coronal sulcus
• Often hidden by phimotic foreskin

33
Testes and Epididymis

• Testicular Torsion
• Potential infarction infertility
• Peak incidence _at_ puberty
• Occurs at any age
• Results from maldevelopment of fixation btwn
  tunica vaginalis and posterior scrotal wall
• Horizontally aligned testis at greater risk

34
Testes and Epididymis

• Testicular torsion on exam
• Firm, tender, high riding in scrotm testis
• Epididymis may be displaced
• Cremasteric reflex absent
• Torsion vs epididymitis
• NOT distinguished by Prehn Sign (Elevation of
  testis causing relief OR exacerbation of pain)

35
Testes and Epididymis

• Testicular Torsion
• Radiology images
• Color-flow doppler U/S
• Radionuclide scintigraphy
• Either is useful if promptly available
• If cannot be excluded by Hx/PE/Radiology
• Emergent Urologic Consultation
• Surgical Exploration
• Tx OPEN THE BOOK!

36
Testicular torsion detorsion
37
Testes and Epididymis

• Torsion of appendages
• Four nonfunctional appendages
• Testis Appendix 90
• Epididymis Appendix 8
• Paradidymis and vas aberrans
• Twist more often than testis

38
Testes and Epididymis

• Torsion of appendages Early
• Pain intense near head of epididymis or testis
• Tender palpable nodule
• Blue dot sign, pathognomonic
• If U/S shows normal testicular blood flow
• pt avoids surgery
• appendage calcifies/degenerates 10-14 days

39
Testes and Epididymis

• Torsion of appendages Late
• Testicular swelling increased
• Doppler equivocal
• Urologic Consultation needed
• Surgical Exploration to exclude testis torsion

40
Testes and Epididymis

• Epididymitis
• Pain usually gradual onset
• Inflammation can spread to testis causing
  epididymoorchitis (Must r/o torsion/abscess)
• Initial exam isolated firmness nodularity of
  globus minor
• Positive Prehn sign Pt with transient relief of
  pain in recumbent position with scrotal elevation
  
• Later developing into large, tender scrotal mass

41
Testes and Epididymis

• Epididymitis occurance
• Young boys coliform bacteria
• Often congenital anomalies lower urinary tract
• lt35 y/o adults STDs, urethral strictures
• Homosexual males fungal infections, STDs
• gt40 y/o men E. coli Klebsiella
• Older men with epididymitis secondary to UTI
  needs evaluation for underlying pathology

42
Testes and Epididymis

• Epididymitis
• Bacterial infection most common cause
• UA pyuria 50 of pts
• Negative, does NOT r/o epididymitis
• Urine Cx S send in children or older men
• Cx for GC/Chl if urethral D/C present
• Doppler U/S r/o torsion, hydrocele

43
Testes and Epididymis

• Epididymitis
• Age lt35-40 think GC/Chl
• Ceftriaxone 250mg IM, plus doxycycline 100mg po
  bid x 10 days
• Ofloxacin 300mg po bid x 10 days
• Age gt35-40 think g- bacilli
• Cipro 500mg po bid x 10-14 days
• Levofloxacin 250mg po qd x 10-14 days
• TMP/SMX 160/800mg (DS) po bid x 10-14 days
• Adjust for CxS results

44
Testes and Epididymis

• Orchitis
• Rare
• Inflammation of testis
• Testicular tenderness, swelling
• Dx with HP
• U/S r/o testicular torsion or abscess
• Tx symptomatic and disease specific

45
Testes and Epididymis

• Orchitis Causes
• Systemic infections
• Mumps unilateral 70 pts, spreads to
  contralateral day 1-9days
• Viral illnesses (coxsackie, Epstein-Barr,varicell
  a, echovirus)
• Bacterial assoc. w/ epididymitis
• Immunocompromised pts.
• Mycobacteriosis
• Cryptococcosis
• Toxoplasmosis
• Candidiasis

46
Testes and Epididymis

• Testicular Malignancy
• Any Asymptomatic testicular mass, firmness or
  induration
• 10 present with pain Secondary to hemorrhage
  within tumor
• ANY unexplained testicular mass must be
  approached as possible tumor
• Urgent Urological Referral needed

47
Testes and Epididymis

• Think testicular CA metastasis if
• Unexplained supraclavicular LAD
• Abdominal mass
• Chronic nonproductive cough from lung mets
• Do testicular exam, may find primary tumor

48
Acute Prostatitis

• Bacterial inflammation prostate
• Sx/Sx
• Low back pain
• Perineal, suprapubic or genital discomfort
• Obstructive urinary sx/sx, freq, urg, dysuria
• Perineal pain with ejaculation
• Fever or chills

49
Acute Prostatitis

• Risks
• Lower Urinary tract obstruction
• Acute epididymitis or urethritis
• Unprotected rectal intercourse
• Phimosis
• Intraprostatic ductal reflux
• Catheter use

50
Acute Prostatitis

• Common bacteria
• E. coli, most common
• Pseudomonas
• Klebsiella
• Enterobacter
• Serratia
• Staphylococcus

51
Acute Prostatitis

• Clinical findings
• Perineal tenderness, rectal sphincter spasm,
  prostatic bogginess or tenderness
• Dx
• Clinical
• UA, Cx S, may be negative
• Urethra Cx for GC/Chlamydia

52
Acute Prostatitis

• Tx
• Cipro 500mg po bid for 30 days
• Best, initial Tx
• TMP/SMX DS 1 po bid for 30 days
• Lower cure rates
• Discharges home with urologic F/U
• Admit when pt
• Evidence of sepsis
• Diabetic, immunosuppressed

53
Urethra

• Urethritis
• Purulent or mucopurulent urethral D/C
• Dx usu. clinical
• Confirm w/Pyuria, bacteriuria in first void
  specimen
• Causative bacteria
• N. gonorrhea or C. trachomatis usu.
• HSV, U. urealyticum, Trich. Less frequent

54
Urethra

• Urethritis
• R/O epididymitis, disseminated GC, or Reiter
  syndrome
• Tx with Abx
• Ceftriaxone 125 mg IM and Azithromycin 1g po
• Or Doxycycline 100 mg po bid x 7 days
• Recurrent think
• Trich, Tx w/ metronidazole
• doxycycline resistant U. urealyticum, use
  azithromycin

55
Urethra

• Urethral Stricture
• Teenagers/young adults
• think STD, GC/Chl
• Bulbous urethral strictures
• Traumatic, will be at site of injury
• Older pop.
• Postendoscopy meatal stenosis
• Localized strictures

56
Urethra

• Urethral Stricture
• D/Dx of nonpassible catheter
• stricture, sphincter spasm, bladder neck
  contracture, BPH
• Dx
• Retrograde urethrography can give location and
  extent of stricture
• Endoscopy confirms bladder contracture and BPH
  role

57
Urethra

• Urethra Stricture
• Emergency Bladder Decompression
• Suprapubic cystostomy
• Seldinger technique cystostomy
• Cystostomy kit for suprapubic indwelling catheter
  insertion
• Urologic followup in 2-3 days

58
Urethra

• Urethral Foreign Bodies
• Bobby pins, long thin paint brushes, ball point
  pens
• Bloody urine combined with infection and slow,
  painful urination
• Xray may disclose radiopaque foreign bodies
• Removal often via endoscopy
• Once removed, retrograde urethrogram or endoscopy
  needed to evaluated urethra

59
Urinary Retention

• Bladder Outlet Obstruction
• Urinary retention
• Chronic systemic medical illness or carcinoma
• Motor or sensory deficits
• Medications sympathomimetic agonists causing
  muscle constriction
• Long trips, voluntary infrequent voiding coupled
  with borderline obstructive Sx
• Mechanical causes

60
Urinary Retention

• Exam
• Inspect meatus for stenosis
• Palpate entire length urethra
• R/O masses, fistulas, abscess
• Lower abdomen
• R/O Suprapubic mass
• Rectal Exam
• Anal sphincter tone, Size consistency of
  prostate
• Lrg intravesical prostate feels normal but
  obstructs
• Lrg nodular prostate may shrink, postvoid
• U/S for distention/postvoid residual

61
Urinary Retention

• Catheter
• Alleviates pain, distress, urinary retention
• Use Lidocaine lubricant
• If fail to pass 16fr, try 16 Coude
• Pass catheter to fullest extent obtaining free
  flow urine
• Then Inflate balloon
• Avoid inflating balloon in prostatic urethra

62
Urinary Retention

• Catheter
• Rapid decompression
• Transient gross hematuria may occur
• Post micuritional/decompression syncope is rare
• Postobstructive diuresis may occur
• Hypovolemia and Hypotension develops
• Monitor hourly I/O, vitals, urine and serum
  electrolytes
• Dissipates in 24-48 hrs after tubules recover

63
Urinary Retention

• D/C home
• Leave indwelling catheter with leg bag
• Educate pt/family on care and for emergency
  balloon deflation catheter removal
• Antibiotics if evidence of UTI
• Urologist consult for F/U and GU eval
• Observe in ED 4-6 hrs or admit
• Chronic or insidious urinary retention pts
• Postobstructive diuresis occurs