Male Genital Problems
Tintinalli’s Ch 95
Anatomy

Penis

Two corpora cavernosa
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Corpus spongiosum

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Erectile bodies
Encased in tunica albuginea
Surrounds urethra
Blood supply: internal pudendal art.,
Lymphatics: inguinal nodes
Penis
Anatomy

Scrotum

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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:
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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:
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
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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:


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Single, fine, tubular structure
4-5 m long compressed into 5 cm
Promotes sperm maturation & motility
Appendix epididymis &testis

NO function
Anatomy

Vas Deferens:


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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

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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:

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Nodularity or firmness = carcinoma until
proven otherwise
Alignment, when standing


Horizontal = increased risk of torsion
Epididymis:

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Posterolateral of testis
Tender with palpation, even when normal
Physical Examination

Prostate:



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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


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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

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i.e. Hair follicle abscess
I&D, sitz baths
Originates from intrascrotal structures

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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:


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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
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Balanoposthitis (both)
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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 –
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Causes:

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
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:

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Compression of glans may reduce edema


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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

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String, metal rings, wire, and hair
Penile Hair-tourniquet syndrome


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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:


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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

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May lead to erectile dysfunction & unsuccessful
vaginal penetration during intercourse
Thickened plaque on shaft of penis

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usu. dorsally; involves tunica albuginea of corpora bodies
Tx:
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Curvature with erections; Painful
Reassurance: pain usually improves with time
Urologic referral
Assoc. with Dupuytren’s contracture of hand
Common GU Disorders:
Penis
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Priapism

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Urologic Emergency, Consult required
Persistent, Painful, Pathologic erection

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Both corpus spongiosum engorged with
stagnant blood
Urinary retention may develop
Impotence may develop, 35% pts
Common GU Disorders:
Penis
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Priapism Causes:

Rx:
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Intracavernosal injections - Papaverine,
prostaglandin E1
Oral HTN Rx - Hydralazine, prazosin, Ca+
Ch.Blk.
Psych - Chlorpromazine, trazodone, thioridazine
Hematologic disorders: (see in Children)
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Sickle Cell
Common GU Disorders:
Penis
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Priapism
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High-flow, rare
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Non ischemic, nonpainful
Traumatic fistula b/w cavernosal art. & corpus
cavernosum
Dx by Doppler
Tx w/ embolization
Low-flow
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Ischemic, Painful
Dx by dark acidic intracavernosal blood aspirate
Common GU Disorders:
Penis
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Priapism Tx:
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Analgesia
Terbutaline 0.25 to 0.5 mg SQ in deltoid

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Pseudoephedrine 60 – 120 mg po
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Repeat q20 - 30 min. prn
Use within 4 hrs onset
Sickle Cell Pts
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Simple or exchange transfusions
Common GU Disorders:
Penis
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Carcinoma
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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
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Testicular Torsion:
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Potential infarction & infertility
Peak incidence @ puberty
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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
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Testicular torsion on exam:
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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
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Testicular Torsion:
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Radiology images
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If cannot be excluded by Hx/PE/Radiology:
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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
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Torsion of appendages:
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Four nonfunctional appendages:
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Testis Appendix 90%
Epididymis Appendix 8%
Paradidymis and vas aberrans
Twist more often than testis
Testes and Epididymis
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Torsion of appendages: Early
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Pain intense near head of epididymis or
testis
Tender palpable nodule
Blue dot sign, pathognomonic
If U/S shows normal testicular blood flow:
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pt avoids surgery
appendage calcifies/degenerates 10-14 days
Testes and Epididymis
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Torsion of appendages: Late
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Testicular swelling increased
Doppler equivocal
Urologic Consultation needed
Surgical Exploration to exclude testis
torsion
Testes and Epididymis
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Epididymitis:
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Pain usually gradual onset
Inflammation can spread to testis causing
epididymoorchitis (Must r/o torsion/abscess)
Initial exam isolated firmness & nodularity of
globus minor
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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
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Epididymitis: occurance
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Young boys – coliform bacteria
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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
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Older men with epididymitis secondary to UTI
needs evaluation for underlying pathology
Testes and Epididymis
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Epididymitis:
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Bacterial infection = most common cause
UA: pyuria 50% of pts
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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
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Epididymitis:
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Age <35-40 think GC/Chl
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Age >35-40 think g- bacilli
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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
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Orchitis:
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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
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Orchitis Causes:
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Systemic infections
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Mumps – unilateral 70% pts, spreads to contralateral day
#1-9days
Viral illnesses (coxsackie, Epstein-Barr,varicella, echovirus)
Bacterial assoc. w/ epididymitis
Immunocompromised pts.
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Mycobacteriosis
Cryptococcosis
Toxoplasmosis
Candidiasis
Testes and Epididymis
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Testicular Malignancy
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Any Asymptomatic testicular mass,
firmness or induration

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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

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Unexplained supraclavicular LAD
Abdominal mass
Chronic nonproductive cough from lung mets
Do testicular exam, may find primary
tumor
Acute Prostatitis
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Bacterial inflammation prostate
Sx/Sx

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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:
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Lower Urinary tract obstruction
Acute epididymitis or urethritis
Unprotected rectal intercourse
Phimosis
Intraprostatic ductal reflux
Catheter use
Acute Prostatitis

Common bacteria:

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E. coli, most common
Pseudomonas
Klebsiella
Enterobacter
Serratia
Staphylococcus
Acute Prostatitis

Clinical findings:
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Perineal tenderness, rectal sphincter
spasm, prostatic bogginess or tenderness
Dx:

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Clinical
UA, Cx & S, may be negative
Urethra Cx for GC/Chlamydia
Acute Prostatitis

Tx:
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Cipro 500mg po bid for 30 days

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TMP/SMX DS 1 po bid for 30 days

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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.

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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:



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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