PD II - Quiz 7 Male GU

what is the path of sperm?

SEVEN UP

• seminiferous tubules of testes (formation)

• epididymis (maturation/storage)

• vas deferens —> external ring

• ejaculatory duct

• nothing

• urethra

• penus

what is included in sexual history?

• # of partners

• male, female, or both

• vaginal, oral, anal

• protection and type

• STD Hx and Tx

• last STD check

what lymph node drains the penis?

inguinal LN

what lymph node drains the testes?

abdominal LN

what is the Prehn sign?

elevation of scrotum —> pain improved

what is the Cremasteric reflex?

stroke superior medial thigh —> elevation of ipsilateral testicle

what are the columns of the penis?

• corpus spongiosum (1)

• corpus carvernosa (2)

in which column is the urethra?

corpus spongiosum

what column is enveloped by tunics?

corpus carvernosa

what column is engorged with blood during erection?

corpus carvernosa

what is the first thing that must be done during exam of the penis?

retract foreskin

how does a normal urethral meatus present?

glistening, pink

how does an abnormal urethral meatus present?

pain, discharge, obstruction

what is a penile fracture?

partial or complete rupture of 1+ tunica albuginea

what can cause a penile fracture?

rapid, blunt force to erect penis during intercourse or aggressive masturbation

what are the s/sxs of a penile fracture?

• popping or crack sound

• pain

• flaccidity

• hematoma

how does a penile fracture present on exam?

• ecchymosis

• edema

• angulation

what are signs of a urethral injury associated with a penile fracture?

• blood at urethral meatus

• hematuria

• inability to void

what is Peyronie’s disease?

palpable, painless, plaque of tunica albuginea

what are the s/sxs of Peyronie’s disease?

crooked/angulated, painful erections

how is Peyronie’s disease treated?

• nothing

• traction splint

• surgery

• injection of verapamil

• injection of Xiaflex (Collagenase)

what is necessary for erectile function?

• testosterone (T)

• arterial flow (A)

• nerves intact (N)

what system controls erection?

parasymp NS

what system controls ejaculation?

symp NS

what is libido?

interest in sexual activity

what is arousal?

ability to achieve an erection

what is ejaculation?

ejection of semen

how is erectile dysfunction treated?

• RX (-afil)

  • Sidenafil (Viagra), Taldalafil (Cialis), Vardenafil (Levitra, Staxyn)

• vacuum constriction

• intraurethral suppository

• penile prosthesis

• low intensity shock wave therapy

what is priapism?

persistant, often painful erection lasting > 4 hours and continuing beyond or unrelated to sexual stimulation

what is engorged during priapism?

BOTH corpus cavernosa

what are the causes of priapism?

• high cell burden (sickle cell, leukemia)

• spinal injury (trauma)

• meds (ED, opioids, psychiatric, illicit)

• iatrogenic

• AVMs

what is low flow priapism?

• MC type

• ischemic

• decreased venous outflow —> compartment syndrome

• painful, VERY time sensitive (911)

what is high flow priapism?

• less common

• non-ischemic

• increased arterial flow

• fistula (communication) between cavernosa and artery

• less painful, less time sensitive

what history is necessary to obtain for priapism?

• duration

• degree of pain

• previous history of same and Tx

• use of precipitating drugs

• Hx of trauma (abdominal, genital, perineal)

• medical Hx

what is the workup for priapism?

• CLINICAL DX

• color duplex US

• penile arteriography

• ABG (visual inspection)

• workup 2º causes PRN

how is priapism treated?

• ice packs

• sympathomimetic (alpha agonists)

• terbutaline (beta 2 agonist)

• aspiration

• shunt

what is hypospadias?

ventral and anterior displacement of urethral meatus

what is epispadias?

dorsal and posterior displacement of urethral meatus

what are the s/sxs of penile carcinoma?

• non tender, indurated nodule or ulcer

• ANY PERSISTENT PENILE SORE

what risk factors are associated with penile carcinoma?

• older men > 60

• viral Hx (HSV, HPV)

• uncircumcised

how is penile carcinoma treated?

• excision

• chemo

• radiation

what is the foreskin (prepuce)?

sheath of skin covering glans penis (homologous to clitoral hood in females)

what is underlying smegma?

• thick secretion from oil glands mixed with skin cells

• between foreskin and glans penis

• natural lubricant

what is the function of the foreskin?

protect urinary meatus

what is circumcision?

surgical demoval of foreskin

what are the benefits of circumcision?

• decreased risk of penile cancer

• decreased risk of HSV, HPV, HIV transmission (STDs)

what is posthitis?

foreskin inflammation

what is balanitis?

glans inflammation

what is balanoposthitis?

foreskin and glans inflammation

what can cause balanoposthitis?

poor hygiene —> irritation/infection, diabetes

how is balanoposthitis treated?

hygiene and creams (Abx, steroid, antifungal)

what is paraphimosis?

• entrapment of foreskin behind coronal sulcus

• inability to return to original anatomic position

what is the MCC of paraphimosis?

iatrogenic

is paraphimosis a urologic emergency?

• YES

• foreskin acts as a tourniquet, restricting venous outflow

• edema, ischemia, necrosis

how is paraphimosis treated?

• manual manipulation

  • lubricant, cold compress, anesthesia

• surgical (dorsal slit, circumcision)

what is phimosis?

inability to retract foreskin proximally

what can cause phimosis?

infection, poor hygiene, trauma

what complications are associated with phimosis?

urinary obstruction 2º to blockage of meatus (leads to retention and obstructive uropathy)

how is phimosis treated?

• topical steroids

• gentle traction

• hemostat dilation

• circumcision

what is the scrotum?

a pouch with 2 compartments, each containing 1 testis

what is done during a scrotal exam?

palpation + transillumination

what is scrotal edema?

seen with any condition that causes generalized edema

what can cause scrotal edema?

• heart failure

• cirrhosis

• nephrotic syndrome

what are the s/sxs of scrotal edema?

• taut scrotal skin, pitting

• no masses

how is scrotal edema treated?

treat primary cause

what is Fournier’s gangrene?

polymicrobial necrotizing fasciitis leading to gangrene of the scrotum and perineum

what risk factors are associated with Fournier’s gangrene?

DM, immune suppression

what are the s/sxs of Fournier’s gangrene?

• pain, swelling, systemic infection

• PAIN OUT OF PROPORTION TO EXAM

• subcutaneous emphysema (crackling)

how is Fournier’s gangrene treated?

911

• Abx

• debridement

• hyperbaric O2 therapy

what is a spermatocele or epididymal cyst?

painless movable cyst superior to testis

which contains sperm, a spermatocele or an epididymal cyst?

spermatocele

what is an epidermoid cyst?

firm, yellow non-tender, CUTANEOUS cyst

where are the testes located?

rest in the scrotum

what surrounds the testes?

tunica

which testes is usually lower?

LEFT

what is the function of the testes?

produce sperm (spermatogenesis) and testosterone

what is a necessary part of the testicular exam?

palpate the epididymis along the posterolateral surface

in what population is testicular cancer most commonly seen?

young men, 15-25 y/o

what risk factors are associated with testicular cancer?

• crypto

• hernia

• mumps

• Caucasian

what is the MC tissue type associated with testicular cancer?

seminomas

what are the s/sxs of testicular cancer?

• painless lump (MC)

• edema, fullness/heaviness, +/- ache

• lower abdominal pain

• mastalgia +/- organ dependent sxs (metastatic sxs)

how is testicular cancer diagnosed?

• imaging

• tumor markers (HCG, AFP)

• NO BIOPSY

why isn’t a biopsy done to diagnose testicular cancer?

spilling tumor cells

how is testicular cancer treated?

• orchiectomy

• chemo/radiation

what is orchitis?

acute inflammation of 1 or both testicles

what are the s/sxs of orchitis?

• testicular pain

• edema

• blood in semen

• hemat-/dysuria

• LAD

what can cause orchitis?

• mumps (child)

• spread from epididymal infection (adult)

how is orchitis treated?

• rest

• ice

• elevation

• analgesics

• Abx if epididymal infection

what is epididymo-orchitis?

epididymitis + orchitis

what is testicular torsion?

twisting of spermatic cord —> blood flow impairment

what can cause testicular torsion?

• trauma, exercise, sex, idiopathic (PHYSICAL)

• Bell clapper deformity

what are the s/sxs of testicular torsion?

SUDDEN ONSET

• severe UL testicular pain

• edema

• elevation

• nausea/vomiting

how does testicular torsion present on exam?

• ipsilateral absence of cremasteric reflex

• negative Prehn’s sign

• testicle is tender, form

• high riding or horizontal lie

what variables make up the TWIST score?

• presence of testicular swelling = 2

• presence of hard testicle = 2

• absence of cremasteric reflex = 1

• presence of high riding testicle = 1

• presence of nausea/vomiting = 1

what TWIST score is considered high risk?

6+

how is testicular torsion diagnosed?

CLINICAL +/- color doppler US (duplex)

what is the maximum time for treatment to prevent ischemia as a result of testicular torsion?

6 HOURS

how is testicular torsion treated?

• manual detorsion —> BL orchiopexy

• surgical detorsion + BL orchiopexy

• orchiectomy (if not salvageable)

what is a testicular appendage torsion?

benign torsion of the small piece of vestigial tissue along the testicle

how does a testicular appendage torsion present on exam?

• local tenderness to palpation of anterosuperior aspect of testicle

• generally non tender testicle

• (+) BLUE DOT (focal ecchymosis)