Uro- Penile Disorders

What is Phimosis?

condition characterized by the inability to retract the foreskin over the glans penis

What typically causes pathologic phimosis?

balanitis xerotica obliterans

What is epispadias?

rare malformation of the urethral meatus characterized by failure of the urethra by failure of the urethra to tubularize on the dorsal aspect

What is epispadias commonly associated with?

bladder extrophy

What are features of epispadias?

short phallus, urethral meatus located on dorsal side, ± incontinence

What is the tx for epispadias?

surgical repair → repair bladder neck, epispadias repair

What is hypospadias?

congential defect characterized by abn development of the urethral fold and ventral foreskin causing abn position of the meatus

(urethra located w/in corpus spongiosum)

What causes hypospadias?

abn androgen metabolism or levels of androgen precursors, maternal exposure to environmental pollutants or endocrine disruptors

What are features of hypospadias?

urethral meatus located on ventral aspect, associated w/ abd curvature of penis, dorsal hooding of foreskin w/ incomplete ventral foreskin

What is the tx for hypospadias?

surgery recommended when pt is 6-18 months old

-late repairs are associated w/ more complications

What is Peyronie’s disease?

painful curvature of the erect penis d/t fibrous plaque of tunic albuginea

What causes Peyronie’s?

repeated penile injury, DM, smoking, EtOH, men > 60, hx of connective tissue disorder (Dupuytren’s)

What is the tx for Peyronie’s?

Meds: collagenase clostridium hisolyticum (Xiaflex), pentoxifylline (PTX), Verapamil

Alt: vit E, steroid injection, penile stretching

surgery: penile plication, grafting, penile prosthesis

may spontaneously resolve

Which medication is the only one that is FDA approved specifically for Peyronie’s?

collagenase clostridium histolyticum (Xiaflex)

What is priapism?

prolonged painful erection > 4 hrs; not associated w/ sexual arousal/desire

How does ischemic priapism present?

most common; true EMERGENCY

painful, penile shaft is hard, does not affect the glans

occurs in hemoglobinopathies, hypercoag states, or w/ PDE5Is

How does non-ischemic priapism present?

non-painful, NON-emergent

most of the penis is hard, typically after trauma that causes a fistula btwn the artery and corpus cavernosa

What causes ischemic priapism?

physiologic obstruction of venous drainage → buildup of highly viscous poorly oxygenated blood w/in corpora cavernosa; injures tissue

What cause non-ischemic priapism?

unregulated cavernous arterial flow; blood is neither hypoxic or acidotic

What is the tx for ischemic priapism?

SS pts → hydration, pain meds, oxygen

therapeutic aspiration; if persists → inject Phenylephrine (DOC) → still persists → surgery (shunt)

What is the tx for non-ischemic priapism?

observation, some have spontaneous resolution

corporal aspiration (only for dx)

arterial embolization or direct ligation if pt desires

What is urethritis?

inflammation of urethra typically secondary to STI

*gonococcal vs nongonococcal

What are features of urethritis?

pain at the tip of the penis, urethral discharge, dysuria

What is the tx for STI urethritis?

Ceftriaxone + Doxy

alt: Ceftriaxone + Azithro

*screen for syphilis/HIV; must tx all sexual partners

What findings of physiological phimosis?

prepuce adehesions (usually desquamate to allow retraction); by 3 yo, 90% should have full retraction

What is a characteristic finding of phimosis?

smegma -exfoliated epithelial cells and skin oils produced to keep the glans moist

What are findings of pathological phimosis?

stenosis, scarring, pallor of preputial opening; continued voiding → BXO; inc risk of STI & penile cancer

What is the medical tx for phimosis?

variety of creams available -must be used 4-8 wks to work

-clobetosol proprionate, betamethasone, hydrocortisone, diclofenac Na

What is the surgical tx for phimosis?

circumcision

-Mogen clamp, Gomco clamp, Plastibell

What are circumcision complications?

removing too much/too little foreskin, meatal stenosis, penile adhesions, penile skin bridge, trapped penis

What are the circumcision guidelines for pediatrics?

recommend < 12 months old

dec risk of UTI, penile cancer, STDs

What are the circumcision guidelines for adults?

recommended if true phimosis & failed medical tx

pts w/ recurrent balanitis/balanoposthitis

recurrent UTI (r/o GU anomalies first)

What is paraphimosis?

urologic emergency characterized by prepuce (foreskin) that becomes trapped behind the glans penis; usually iatrogenic cause

What are features of paraphimosis?

erythema, pain, swelling of prepuce & glans; ischemia and necrosis can occur if foreskin is not reduced → dark, dusky, pale, blue, or black discoloration of skin

What is the tx for paraphimosis?

manual reduction of foreskin; unsuccessful → consult uro

*elective circumcision or dorsal slit procedure is recommended in all pts w/ significant paraphimosis

What is balanitis?

inflammation of the glans penis

(+prepuce = balanoposthitis)

What are RF for balanitis?

uncircumcised, poor hygiene, CM, change in baseline pH, hx STI or candidiasis

What are features of balanitis?

glans appears shiny, eryethma, pain, pruritis, malodor, edema; skin excoriation, difficulty retracting foreskin, dysuria, meatal stenosis

What is the tx for fungal balanitis?

1st line: Clotrimazole 1%

alt: miconazole 2%

allergic to imidazoles → nystatin cream

What is the tx for bacterial balanitis?

mupirocin ointment

alt: bacitracin/neomycin ointment

severe: cephalexin

What is the tx for STI balanitis?

tx STI; if recurrent consider circumcision

What are disorders of sexual differentiation?

“intersex” or “hermaphroditism”

results from abnormal chromosomal, gonadal, or phenotypic sex determination

How might DSD manifest?

b/l undescended testes, severe hypospadias, clitoromegaly, fusion of labial folds, female external genitalia w/ palpable gonad, discordant genitalia, chromosomal amniocentesis differs from phenotype, maternal exposure to androgens, inguinal masses, urogenital sinus formation