Bates Ch 20 Male Genitalia

If the peritoneal lining remains an open channel to the scrotum it can give rise to an?

Inguinal hernia

The parietal and visceral layers form a potential space for the abnormal fluid accumulation of?

A hydrocele

When assessing the femoral canal, femoral hernias protrude at this location and are more likely to present as?

Emergencies w/ bowel incarceration or strangulation

If loops of bowel force their way through the inguinal canal, they produce?

Inguinal hernias

Indirect inguinal hernias develop at?

at the internal inguinal ring, where the spermatic cord exits the abdomen

Direct inguinal hernias arise?

more medially due to weakness in the floor of the inguinal canal and are associated with straining and heavy lifting

When you find an inflammatory or suspect a possible malignant lesion on penis, scrotum, testes, assess?

the inguinal nodes carefully for enlargement or tenderness

Male sexual function depends on?

Normal levels of testosterone, arterial blood flow from the internal iliac artery to the internal pudental artery and its oenile artery et branches, et intact neural innervation from alpha adrenergic et cholinergic pathways

look for yellow penile discharge in?

gonorrhea

Look for white penile discharge in?

Nongonococcal urethritis from Chlamydia

What may occur in Disseminated Gonorrhea?

Rash, Tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms

Suspect this with pt complaining of intense pruritus with evidence of penile or pubic excoriations?

Scabies or peduculosis oubis

Scrotal swelling may be present with?

Mumps, orchitis, scrotal edema et testicular cancer

Scrotal swelling et pain with?

Testicular torsion, epididymitis, and orchitis

Men who engage in high risk sex behaviors, no condom, use illicit drugs or have prior STI HX are at increased risk for?

HIV and other STIs

Infections from oral-penile transmission include?

gonorrhea, chlamydia, syphilis, and herpes.

Symptomatic or asymptomatic proctitis may follow anal intercourse.

Fever et dysuria in a man suggests?

Acute prostatitis, Acute pyelonephritis, disseminated gonococcal infection, syphillis, or postobstructive UTI

Characteristic skin rashes can be seen in?

Reactive arthritis, gonococcemia, secondary syphilis.

Joint pains can be seen in?

Systemic disseminated gonococcal infection. Conjuctivitis suggests reactive arthritis

Phimosis is?

tight foreskin/prepuce that cant be retracted over glans

Paraphimosis is?

Tight prepuce that once retracted cannot be returned. Edema ensues

Balanitis is?

inflammation of the glans and prepuce of the penis

Hypospadias?

congenital ventral displacement of the urethral meatus the inferior surface of the penis. The meatus may be subcoronal, midshaft, or at the junction of the penis and scrotum (penoscrotal)

a congenital DORSAL displacement of the meatus?

epispadias

A definitive Dx for gonococcal urethritis or nongonococcal urethritis requires?

Gram stain and culture

What would you find with Peyronie disease?

Dorsal side of penis, plaques can sometimes be palpated under the skin on the right or left aspect of the shaft in the corpora cavernosa

What suggests a urethral stricture or possibly a carcinoma?

Most commonly occur in the proximal urethra, but induration or firmness along the ventral surface of the penis

A poorly developed scrotum on one or both sides, suggests?

Cryptorchidism (undescended testicle)

Common scrotal swellings include?

indirect inguinal hernias, hydroceles, scrotal edema, and rarely testicular carcinoma

Erythema and mild excoriation point to _____, not uncommon in this moist area.

Fungal Infection

dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium suggests?

Epidermoid cysts

Any painless nodule on the testis raises the possibility of?

Testicular cancer-Peak age 15-34;

Recall that lymph drainage from the testes parallels?

retroperitoneal venous flow from the renal vein et inferior vena cava, primary site of lymph node involvement in testicular cancer

If the vas deferens are chronically infected, it may feel?

thickened or beaded

A cystic structure in the spermatic cord suggests?

hydrocele of the cord

Femoral hernias most commonly present?

inferior to the inguinal ligament and medial to the femoral artery

What may be particularly useful in clinically doubtful cases of hernia types?

Ultrasonography

Hernias warrant surgical evaluation, especially when?

symptomatic or incarcerated

A hernia is incarcerated when?

its contents cannot be returned to the abdominal cavity

A hernia is strangulated when?

the blood supply to the entrapped contents is compromised

Suspect strangulation in the presence of?

tenderness, nausea and vomiting (and consider surgical intervention)

If you can place your fingers above the mass of the testis, what is suspected?

suspect hydrocele

During valsalva maneuver, a temporary increase in the diameter of the spermatic cord indicates?

filling of abnormally dilated spermatic veins draining the testis, suggesting Varicocele

Transillumination occurs with hydrocele, if no transillumination?

intestine containing hernia, those containing blood or tissue such as normal testis, a tumor, or most hernias

With high risk pts, review risk factors for testicular cancer:

Cryptorchidism-which confers a high risk carcinoma in undescended testicle

Hx of carcinoma in contralateral testicle

Mumps orchitis

Inguinal hernia

Hydrocele in childhood

Postive Family Hx

Genital Warts?

Single or. multiple papules or plaques of variable shapes; May be round, acuminate (pointed), or thin et slender. may be raised, flat, cauliflower like (verrucous).

-Caused byHPV 6, 11-Infection may have none

HSV?

Small scattered vesicular 1-3mm. Appear as erosions if vesicular membrane breaks

Caused by HSV 2 (Double stranded DNA)

Incubation 2-7 days after exposure

Assoc Sym=Fever, malaise, headache, arthralgias local pain et edema, lympadenopathy. Must distinguish from Herpes Zoster (usually in older pts et follow dermatomal pathway)

Primary syphilis?

Small red papule that becomes a chancre (painless erosion) up to 2 cm in diameter. Base of chancre is clean, red, smooth with raised borders; heals within 3-8 weeks

Causative organism-Treponema pallidum

May develop inguinal lymphadenopathy w/i 7 days. lymph nodes are rubbery, nontender, mobile

Chancroid?

Red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base.

Caused by Haemophilus ducreyi, an anaerobic bacillus.

Incubation 3-7 days after exposure

Painful inguinal adenopathy

Need to distinguish primary syphilis, genital herpes simplex, lymphogranuloma venereum, granuloma inguinale from?

Klebsiella Granulomatis-gram negative rod shaped bacterium of the genus Klebsiella known to cause the STI granuloma inguinale (both rare in US)

Peyronie disease?

Palpable, nontender, hard plaques are found just beneath the skin, usually along the dorsum of the penis. The patient complains of crooked, painful erections.

Scrotal edema?

Pitting edema may make the scrotal skin taut; seen in heart failure or nephrotic syndrome

Hydrocele presentation?

non-tender fluid filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can palpate the mass above the scrotum

Carcinoma of the penis?

An indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious.

Scrotal hernia?

Usually an indirect inguinal hernia, that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum.

cryptorchidism?

the testis is atrophied and lies outside the scrotum in the inguinal canal, abdomen, or near the pubic tubercle; it may also be congenitally absent. there is no palpable testis or epididymis in the unfilled scrotum. Even with surgical correction of this, it markedly raise the risk of testicular cancer

Early Tumor of the testes presents as?

Usually appears as a painless nodule. Any nodule warrants investigation for malignancy

Late Tumor of the testes presents as?

As neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal

Small testis?

In adults, testicular length is usually ≤3.5 cm. Small, firm testes in Klinefelter's syndrome, usually ≤2 cm. Small, soft testes suggesting atrophy are seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow orchitis.

Acute Orchitis?

The testis is acutely inflamed, painful, tender, and swollen. It may be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections; usually unilateral.

Spermatocele et Cyst of the Epididymis presents as?

A painless, movable cystic mass just above the testis suggests this. Either will transilluminate. The former contains sperm, and the latter does not, but they are clinically indistinguishable

acute epididymitis

An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. Causes include infection from Neisseria gonorrhoeae, Chlamydia trachomatis (younger adults), Escherichia coli, and Pseudomonas (older adults); trauma; auto immune disease. Barring urinary symptoms, urinalysis is often negative

-It occurs chiefly in adults, most commonly with Chlamydia infection. Coexisting urinary tract infection or prostatitis supports the diagnosis

The chronic inflammation of TB produces this? (Tuberculosis Epididymis)

firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens

Varicocele of the Spermatic Cord?

Varicocele refers to gravity-mediated varicose veins of the spermatic cord, usually found on the left. It feels like a soft "bag of worms" in the spermatic cord above the testis, and if prominent, appears to distort the contours of the scrotal skin. A varicocele collapses in the supine position, so examination should be both supine and standing. If the varicocele does not collapse when the patient is supine, suspect a left spermatic vein obstruction within the abdomen.

Testicular Torsion?

Produces an acutely painful, tender, and swollen organ that is often retracted upward in the scrotum. The cremasteric reflex is nearly always absent on the affected side in boys or men, though this can difficult to assess during acute pain episodes. If the presentation is delayed, the scrotum becomes red and edematous.

No associated urinary infection

Most common in neonates et adolescents(can occur in any age)

Surgical emergency b/c obstructed circulation and requires urgent surgical consultation

Indirect Inguinal hernia

Most common, all ages et sexes. often in children; may occur in adults.

Above inguinal ligament, near its midpoint (the internal inguinal)

Course (Examining finger in inguinal canal during coughing pr straining)-Often into the scrotum. The hernia comes down the inguinal canal and touches the fingertip

Direct Inguinal Hernia?

- Less common

- Usually in men over age 40; rare in women

- Above the inguinal ligament, close to pubic tubercle (near external inguinal ring)

- Rarely into the scrotum

- Bulges anteriorly and pushes the side of the finger forward

Femoral Hernia

Least common. More common in women

Below inguinal ligament, appears more lateral than inguinal. Can be hard to differentiate from lymph nodes

Never into the scrotum. The inguinal canal is empty