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Male Genital Problems

Male Genital Problems. Tintinalli’s Ch 95. Anatomy. Penis Two corpora cavernosa Erectile bodies Encased in tunica albuginea Corpus spongiosum Surrounds urethra Blood supply: internal pudendal art., Lymphatics: inguinal nodes. Penis. Anatomy. Scrotum

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Male Genital Problems

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  1. Male Genital Problems Tintinalli’s 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 Camper’s fascia • Scarpa’s 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 Disorders:Scrotum • 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 Disorders:Scrotum • Scrotal Abscess, determine: • Localized to scrotal wall • i.e. Hair follicle abscess • I&D, sitz baths • Originates from intrascrotal structures • Needs U/S evaluation • Retrograde Urethrogram • Referral to Urologist

  17. Common GU Disorders:Scrotum • 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 Disorders:Scrotum • 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 Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis

  22. Common GU Disorders:Penis • Paraphimosis: • Urologic Emergency • Inability to reduce the proximal edematous foreskin distally over the glans • Increasing edema can lead to arterial compromise and gangrene

  23. Common GU Disorders:Penis

  24. Common GU Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis • 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 Dupuytren’s contracture of hand

  28. Common GU Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis • 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 Disorders:Penis • 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 @ 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 • <35 y/o adults – STDs, urethral strictures • Homosexual males – fungal infections, STDs • >40 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 <35-40 think GC/Chl • Ceftriaxone 250mg IM, plus doxycycline 100mg po bid x 10 days • Ofloxacin 300mg po bid x 10 days • Age >35-40 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 Cx&S results

  44. Testes and Epididymis • Orchitis: • Rare • Inflammation of testis • Testicular tenderness, swelling • Dx with H&P • 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,varicella, 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

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