Male Genital Problems Tintinalli’s Ch 95
Male Genital Problems Tintinalli’s Ch 95 Anatomy Penis Two corpora cavernosa Corpus spongiosum Erectile bodies Encased in tunica albuginea Surrounds urethra Blood supply: internal pudendal art., Lymphatics: inguinal nodes Penis 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 Scrotum and testis 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 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 Anatomy Epididymis: Single, fine, tubular structure 4-5 m long compressed into 5 cm Promotes sperm maturation & motility Appendix epididymis &testis NO function 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 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 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 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 Physical Examination Prostate: Normal prostate exam causes discomfort Heart- shaped contour Consistency similar to tip of nose Carcinogenic Prostate similar to bony chin 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 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 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 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 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 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 Common GU Disorders: Penis Phimosis – Causes: inability to retract foreskin prox. & post. to glans Infection, poor hygiene, injury with scarring Tx: circumcision traditional Topical steroids for 4-6 weeks 70-90% effective Avert circumcision Common GU Disorders: Penis 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 Common GU Disorders: Penis Common GU Disorders: Penis Paraphimosis Tx: Compression of glans may reduce edema Tightly wrap glans in 2 in elastic bandage 5 minutes Expressing edema out of glans (Local anesthetic block may be used) Punture glans several times w/22g to 25g needle Superficial Dorsal Incision of band 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 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 Common GU Disorders: Penis Peyronie Disease Progressive penile deformity 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: Curvature with erections; Painful Reassurance: pain usually improves with time Urologic referral Assoc. with Dupuytren’s contracture of hand 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 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 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 Common GU Disorders: Penis Priapism Tx: Analgesia Terbutaline 0.25 to 0.5 mg SQ in deltoid Pseudoephedrine 60 – 120 mg po Repeat q20 - 30 min. prn Use within 4 hrs onset Sickle Cell Pts Simple or exchange transfusions 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 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 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) Testes and Epididymis Testicular Torsion: Radiology images If cannot be excluded by Hx/PE/Radiology: Color-flow doppler U/S Radionuclide scintigraphy Either is useful if promptly available Emergent Urologic Consultation Surgical Exploration Tx: OPEN THE BOOK! Testicular torsion detorsion Testes and Epididymis Torsion of appendages: Four nonfunctional appendages: Testis Appendix 90% Epididymis Appendix 8% Paradidymis and vas aberrans Twist more often than testis 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 Testes and Epididymis Torsion of appendages: Late Testicular swelling increased Doppler equivocal Urologic Consultation needed Surgical Exploration to exclude testis torsion 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 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 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 Testes and Epididymis Epididymitis: Age <35-40 think GC/Chl Age >35-40 think g- bacilli Ceftriaxone 250mg IM, plus doxycycline 100mg po bid x 10 days Ofloxacin 300mg po bid x 10 days 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 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 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 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 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 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 Acute Prostatitis Risks: Lower Urinary tract obstruction Acute epididymitis or urethritis Unprotected rectal intercourse Phimosis Intraprostatic ductal reflux Catheter use Acute Prostatitis Common bacteria: E. coli, most common Pseudomonas Klebsiella Enterobacter Serratia Staphylococcus 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 Acute Prostatitis Tx: Cipro 500mg po bid for 30 days TMP/SMX DS 1 po bid for 30 days Best, initial Tx Lower cure rates Discharges home with urologic F/U Admit when pt Evidence of sepsis Diabetic, immunosuppressed 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 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 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 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 Urethra Urethra Stricture: Emergency Bladder Decompression Suprapubic cystostomy Seldinger technique cystostomy Cystostomy kit for suprapubic indwelling catheter insertion Urologic followup in 2-3 days 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 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 Urinary Retention Exam: Inspect meatus for stenosis Palpate entire length urethra Lower abdomen R/O masses, fistulas, abscess 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 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 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 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
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