Disorders of the Penis - MedPath

What does this refer to

• Penile foreskin (prepuce) is “too tight.”

• Foreskin cannot be retracted back over the glans

• Causes

  • Poor hygiene or chronic infections

• Symptoms: Edema, erythema, and tenderness of the prepuce and purulent discharge

• Treatment: circumcision

Phimosis

What does this refer to

• Foreskin is retracted and cannot be moved forward (reduced) to cover the glans.

• Causes edema of the glans

• Treatment: Surgery

• Severe paraphimosis: medical emergency

Paraphimosis

What does this refer to

• Fibrous plaques (thickening) slowly develop in the tunica albuginea causing penile curvature during erection.

• Occurs in middle-aged men and causes painful erections and intercourse

• No definitive treatment is available.

• Treatment:

  • Pharmacologic agents

    • Collagenase (Xiaflex) injection

    • Surgery (plication, grafting, penile device implantation (if coexisting ED)

Peyronie disease

What does this refer to

• Condition of prolonged penile erection

• Painful and not associated with sexual arousal

• Urologic emergency

• Idiopathic in 60% of cases

• Associated with spinal cord trauma, sickle cell disease, leukemia, pelvic tumors or infections, or penile trauma

• Also associated with cocaine use

• Treatments

  • Iced saline enemas

  • Ketamine administration

  • Spinal anesthesia

  • Needle aspiration of blood from the corpus through the dorsal glans, followed by catheterization and pressure dressings to maintain decompression

  • Aggressive surgical treatments: creation of vascular shunts to maintain blood flow

Priapism

What does this refer to

look at these

What does this refer to

• Inflammation of the glans penis

• Usually associated with foreskin inflammation (posthitis)

  • Accumulation under the foreskin (smegma), causing irritation of the glans

  • Phimosis, inadequate cleansing under the foreskin, skin disorders, and infections

• Most commonly in men with poorly controlled diabetes mellitus and candidiasis

• Treatment: antimicrobial agents to treat infection; circumcision to prevent recurrences and to be considered after the inflammation has subsided

Balanitis

What does this refer to

• Rare

• Mostly squamous cell carcinomas

• Risk factors: human papillomavirus (HPV), smoking, psoriasis treated with a combination involving the drug psoralen and ultraviolet (UV) light

• Often diagnosed in men older than 55 years of age

• Thick white plaque (leukoplakia), typically involving the meatus

• Penile carcinoma: higher incidence in uncircumcised men

• Treatment: surgery, radiation, chemotherapy

Penile cancer

What does this refer to

• Inflammation and dilation of the veins in the spermatic cord

• “Bag of worms”

• Cause: inadequate or absent valves in the spermatic veins

• Treatment: ligation of the spermatic vein or occlusion of the vein by percutaneous methods, such as balloon catheter and sclerosing fluids

• Scrotal support: if disorder is mild and fertility is not an issue

Varicocele

What does this refer to

• Scrotal swelling caused by the collection of fluid in the tunica vaginalis

• Imbalance between fluid secretion and reabsorption

• Treatment

  • Usually not required unless disorder causes considerable physical discomfort or undesirable cosmetic appearance

  • For uncomplicated hydrocele: aspiration of the fluid and injection of a sclerosing agent into the scrotal sac

  • Goals: to remove the hydrocele and to prevent recurrence by sclerosing or excising the tunica vaginalis

Hydrocele

What does this refer to

• Epididymal cysts

• Benign cystic collections of fluid of the epididymis located between the head of the epididymis and the testis

• Milky fluid that contains sperm and does not cover the entire anterior scrotal surface

• Exhibits discrete, firm, freely mobile masses distinct from the testis that may be transilluminated

• Treatment: none or excised or scrotal support

Spermatocele

What does this refer to

• Failure of one or more of the testes to descend from the abdominal cavity into the scrotum

• Complication: testicular cancer; if untreated, infertility

• Treatment: hormones or surgery

Cryptorchidism

What does this refer to

• Testis that has strayed from the normal pathway of descent

Ectopic testis

What does this refer to

• Rotation of a testis

• Rotation, causing twisting of the blood vessels in the spermatic cord

• Painful and swollen testis

• May be spontaneous or follow physical exertion or trauma

• Medical emergency

• Treatment: if torsion cannot be reduced manually, then surgery must be performed within 6 hours after the onset of symptoms to preserve normal testicular function

Torsion of a testis

What does this refer to

• Is an inflammation of the epididymis

• Is common in sexually active young men

• Pathogenic microorganism reaches the epididymis by ascending the vas deferens from an already infected bladder or urethra

• Main symptoms: pain and the Prehn sign (positive if pain is relieved by elevation of the scrotum)

• Treatment: antibiotics, analgesics, ice, and scrotal elevation

Epididymitis

What does this refer to

• Acute infection of the testis

• Complication of a systemic disease (mumps) or related to epididymitis

• Treatment

  • Bed rest, scrotal support, elevation of the scrotum, hot or cold compresses, analgesic agents for relief of pain

  • Antimicrobial drugs for bacterial orchitis

  • Corticosteroids for nonspecific granulomatous orchitis (autoimmune inflammatory disease in middle-aged men)

Orchitis

What does this refer to

• Is among the most curable of cancers

• Is common in men between 15 and 35 years of age

• Risk factors

  • High androgen levels, genetic predisposition

  • History of cryptorchidism, trauma, or infection

• Causes painless testicular enlargement

• Treatment: is based on the type of tumor, stage of the disease, general health, and age

  • Surgery

  • Radiation and chemotherapy, singly or in combination

Cancer of the testis

What does this refer to

• Is an enlargement of the prostate gland

• Is also called benign prostatic hypertrophy

• Symptoms associated with urethral compression

  • Urge to urinate often

  • Some delay in starting urination

  • Decreased force of the urinary stream

• Has a relationship to aging

• Evaluation

  • Digital rectal examinations

  • Prostate-specific antigen (PSA) monitoring

• Treatment: drugs, minimally invasive therapies, and surgery

Benign prostatic hyperplasia

What does this refer to

• Inflammation of the prostate

• Acute bacterial infection: ascending infection of the urinary tract

  • Symptoms: signs of infection

  • Treatment: antibiotics, analgesics, antipyretics, bed rest, adequate hydration; Foley catheter contraindicated

• Chronic bacterial infection: recurrent urinary tract symptoms and persistence of pathogenic bacteria

  • Treatment: surgery

• Nonbacterial infection

• Chronic prostatitis or chronic pelvic pain syndrome: no pathogenic bacteria is localized to the prostate

• Nonbacterial infection: complaint of pain or a dull ache that is continuous or spasmodic in the suprapubic, infrapubic, scrotal, penile, or inguinal area

  • Treatment: hot sitz baths, bed rest, alpha-blockers, anticholinergics, and antiinflammatory drugs

Prostatitis

What does this refer to

• Most commonly diagnosed nonskin cancer in men in the United States

• Considered to be the second most frequently diagnosed cancer and the sixth leading cause of death worldwide

• Asymptomatic until its advanced stages

Cancer of the prostate

What does this refer to

• Dietary factors

  • Change in diet from animal products to vegetables and fruits may decrease the incidence of prostate cancer.

• Hormones

  • Prostate is the equivalent to the uterus.

  • Estrogens participate in the pathogenesis and development of benign prostatic hyperplasia and prostate cancer by activating estrogen-receptor α.

  • Exposure to arsenic or estrogens can disrupt normal deoxyribonucleic acid (DNA) methylation patterns and histone modifications.

Cancer of the prostate

What does this refer to

• Androgen-receptor signaling

  • Stromal androgen receptors are the priority.

• Prostatic epithelial neoplasia

• Vasectomy

  • Circulating free testosterone is elevated.

• Chronic inflammation

  • Risk for prostate cancer is increased.

• Genetic and epigenetic factors

  • Has a strong familial tendency; BRCA2 mutations

• Stromal environment

• Multifactorial hypothesis of prostate carcinogenesis

  • Androgens act as strong tumor promoters to enhance DNA toxic carcinogens (reactive estrogen metabolites and estrogen, and prostate-generated reactive oxygen species).

  • Alterations in autocrine/paracrine growth-stimulating and growth-inhibiting factors between the prostate tumor cells and the microenvironment influence cancer athogenesis.

  • Possibly unknown environmental-lifestyle carcinogens may contribute to prostate cancer.

Cancer of the prostate

What does this refer to

• Treatment

  • No treatment

  • Watchful waiting

  • Surgical treatments

    • Total prostatectomy

    • Transurethral resection of the prostate (TURP)

    • Cryotherapy

  • Nonsurgical treatments

    • Radiation therapy

    • Hormone therapy

    • Chemotherapy

    • Immunotherapy

Cancer of the prostate

What does this refer to

• Causes

  • Physical or psychologic factors that impairs erection, emission, or ejaculation

  • Vascular, endocrine, and neurologic disorders

  • Chronic diseases

    • Renal failure and diabetes mellitus

  • Penile diseases and penile trauma

  • Iatrogenic factors

    • Surgery and pharmaceuticals

Erectile Dysfunction

What does this refer to

• Vascular disorders

  • Prevent erection

• Endocrine disorders

  • Reduce testosterone production, which affects sexual function and libido

• Neurologic disorders

  • Interfere with the important sympathetic, parasympathetic, and central nervous (CNS) mechanisms required for erection, emission, and ejaculation.

• Chronic diseases

  • Can lead to erectile dysfunction, impotence, low energy levels, and low libido

• Penile trauma

  • Damages the erectile tissue, disrupts the posterior urethra, and disrupts the pudendal arteries or nerves.

Erectile Dysfunction

What does this refer to

• Iatrogenic factors

• Certain surgeries can cause erectile dysfunction.

  • Caused by severing of the small nerve branches that are essential for erection.

• Drug-induced sexual dysfunction

  • Decreased desire

  • Decreased erectile ability

  • Decreased ejaculatory ability

  • Decreased quality and quantity of sperm

Erectile Dysfunction

What does this refer to

• Treatment

  • Nonsurgical interventions

    • Correct underlying disorders, particularly drug-induced dysfunction and endocrinopathy-related dysfunction (e.g., reduced testosterone associated with chronic renal failure).

    • Vasodilators and cessation of smoking can benefit individuals with vasculogenic erectile dysfunction.

  • Surgical interventions

    • Penile implants, penile revascularization, and the correction of other anatomic defects that contribute to sexual dysfunction

Erectile Dysfunction

What does this refer to

• Spermatogenesis requires

  • Adequate secretion of FSH and LH by the pituitary glands

  • Sufficient secretion of testosterone by the Leydig cells

  • Sufficient function of the Sertoli cells, including secretion of androgen-binding protein, growth factors, inhibin B, and a number of other important (but poorly understood) peptides

  • Adequate spermatogonia

Sexual Dysfunction: Infertility

Sexual Dysfunction: Infertility

• Disruptions of the hypothalamic-pituitary-gonadal axis that reduce testosterone secretion

• Testicular trauma or atrophy from any cause

Impaired spermatogenesis (sperm production by the testes)

Sexual Dysfunction: Infertility

• Neoplastic disease, cryptorchidism, or any factor that causes testicular temperature to rise

Impaired sperm production

Sexual Dysfunction: Infertility

• Chromosomal abnormalities resulting from genetic factors, irradiation, or toxins

Impaired sperm quality

Sexual Dysfunction: Infertility

• Unfavorable constituents or characteristics of semen

Impaired sperm motility

What does this refer to

• Hormone and growth factors for sperm production

  • FSH, LH, and testosterone

  • Androgen-binding protein, inhibin B, other peptides

• Sperm count >20 million/mL for fertility

• Sperm motility for fertility

• Anti–sperm antibodies adversely affect fertility

  • Decreases sperm motility and number of sperm

• Drugs and toxins in the semen adversely affect fertility

Sexual Dysfunction: Infertility

What does this refer to

• Overdevelopment of the breast tissue in a man

• Results from hormone alterations

  • Idiopathic and system disorders, drugs, or neoplasms

• Estrogen/testosterone ratio altered

  • Estrogen levels may be excessively high, although testosterone levels are normal.

  • Testosterone levels may be extremely low although estrogen levels are normal.

• Incidence greatest among adolescents and men older than 50 years of age

Gynecomastia

What does this refer to

• Breast enlargement consists of hyperplastic stroma and ductal tissue

• Treatment

  • Identification and treatment of the cause are likely to be followed by resolution of the gynecomastia.

  • Man should be taught to perform breast self-examination.

  • Examined at 6- and 12-month intervals if the gynecomastia persists

  • All unilateral breast enlargement in men

    • Evaluation for malignancy

    • Workup includes fine-needle aspiration, cytology, mammography, ultrasound, and biopsy.

Gynecomastia

What does this refer to

• Most commonly seen after age 60

• Different than female breast cancers with Luminal A and Luminal B most common

• Symptoms: crusting and nipple discharge

• Tends to be advanced by the time of diagnosis

• Treatment

  • Endocrine therapy used more often for males since male tumors are hormone dependent

  • Modified mastectomy with axillary node dissection

  • Tamoxifen is standard adjuvant therapy

  • Chemotherapy

Male breast cancer