Male Reproductive + STI (male/female)

What are the three erectile tissues of the penis?

The penis is composed of three erectile bodies:

• two corpora cavernosa located dorsally and one corpus spongiosum located ventrally.

• The corpus spongiosum surrounds the urethra and expands distally to form the glans penis. The corpora cavernosa fill with blood during erection to produce rigidity.

What is the function of the corpora cavernosa?

The paired corpora cavernosa are the primary erectile tissues responsible for penile rigidity. During sexual arousal they become engorged with blood while being enclosed by the tough tunica albuginea, producing an erection sufficient for intercourse.

What is the function of the corpus spongiosum?

surrounds the penile urethra, preventing compression of the urethra during erection so semen and urine can pass. It also forms the glans penis.

What is the role of the urethra in the penis?

passes through the corpus spongiosum and functions as the passageway for urine and semen to exit the body.

What is the tunica albuginea?

dense fibrous connective tissue layer surrounding the corpora cavernosa. It helps trap blood within the erectile tissue during erection, allowing maintenance of rigidity.

What is Colles' fascia?

superficial perineal fascia that provides structural support to the external genitalia and perineum.

What is phimosis?

condition in which the prepuce (foreskin) is too tight to be retracted over the glans penis.

What causes phimosis?

• Poor hygiene + chronic infections

• young baby = tight

  • ages 2-3yrs pull back for cleaning

• lead to inflammation and scarring of the foreskin.

What are the clinical concerns associated with phimosis?

• Tight foreskin may make hygiene difficult

• increase the risk of recurrent infections

• cause pain during urination or sexual activity

• predispose the individual to balanitis or urinary obstruction.

How is phimosis treated?

• gentle manual retraction exercises

• topical corticosteroids to soften and loosen the foreskin

  • if a pathological reason

• circumcision if conservative therapy fails or symptoms are severe

What is paraphimosis?

when the foreskin has been retracted behind the glans penis and cannot be returned to its normal position

• results in swelling that traps the foreskin behind the glans.

Why is paraphimosis considered an emergency?

The trapped foreskin can compress blood vessels, reducing venous return and eventually arterial blood flow.

• Untreated = ischemia and tissue necrosis

What causes paraphimosis?

• failure to return the foreskin after retraction during hygiene, catheterization, or examination

• often iatrogenic (adverse effect caused unintentionally by medical treatment, diagnostic procedures, or a doctor's actions) + OBVIOUS

  • pull foreskin back for urinary cath, etc and forgot to pull it back

What are common iatrogenic causes of paraphimosis?

Healthcare providers may accidentally leave the foreskin retracted after urinary catheter insertion, physical examination, or cystoscopy, leading to paraphimosis.

How is paraphimosis treated?

• antibiotics if infection is present

  • topical

• warm soaks to reduce swelling

• definitive management with circumcision or dorsal slitting of the prepuce when necessary.

What is Peyronie's disease?

disorder characterized by fibrous plaque formation within one of the corpora cavernosa, resulting in abnormal penile curvature during erection.

• bent nails syndrome

What causes Peyronie's disease?

• occur spontaneously

• be associated with family history or connective tissue disorders

• result from trauma causing scar tissue formation within the corpora cavernosa.

• plaque formation on erectile tissues

• fibrous tissue formation in erectile tissues = prevents insufficient blood flow = curvature

How does Peyronie's disease cause penile curvature?

Fibrous plaques prevent normal expansion of one side of the corpora cavernosa during erection.

• unaffected side expands normally while the scarred side cannot, causing the penis to bend toward the plaque.

What are the clinical manifestations of Peyronie's disease?

• penile deformity with curvature during erection

• painful erections

• erectile dysfunction

How is Peyronie's disease diagnosed?

• history + physical examination

• Doppler ultrasound = evaluate plaque formation and penile blood flow.

How is Peyronie's disease treated?

Treatment depends on severity + underlying cause

• NSAIDs for pain

• penile modeling

• collagenase Clostridium histolyticum (Xiaflex) injections to break down plaques (reduce collagen)

• extracorporeal shock wave therapy

• reconstructive surgery for severe disease.

What medication is specifically used to break down plaques in Peyronie's disease?

Collagenase Clostridium histolyticum (Xiaflex) is injected into the fibrous plaque to weaken collagen and reduce penile curvature.

What is priapism? - EMERGENCY!

• prolonged, painful penile erection lasting longer than 4hrs

• NOT associated with sexual arousal or stimulation.

• urological emergency

• sickle cell disease, leukemia, damage to spinal cord, DM

  • increased viscosity of blood or nerve/blood vessel damage

Why is priapism considered a urological emergency?

Prolonged trapping of blood within the corpora cavernosa leads to ischemia.

• Without rapid treatment, permanent erectile dysfunction and penile tissue necrosis may occur.

What causes priapism?

• thrombosis of the corpus cavernosal veins

• leukemia

• sickle cell disease

• diabetes mellitus

• degenerative spinal lesions

• neoplasms - brain/spinal cord

Why does sickle cell disease increase the risk for priapism?

Sickled red blood cells obstruct venous drainage from the corpora cavernosa, causing blood to become trapped and resulting in prolonged painful erection.

How is priapism diagnosed?

• severe PAIN
  history + physical examination

• corporal blood gas analysis - aspirate blood

• penile duplex Doppler ultrasound to determine whether the priapism is ischemic or non-ischemic.

  • can affect the urethra (urine stuck and back-up to bladder + kidney = hydronephrosis)

What does corporal blood gas analysis evaluate in priapism?

Corporal blood gas distinguishes ischemic from non-ischemic priapism by assessing oxygenation, carbon dioxide levels, and pH of blood trapped within the corpora cavernosa.

What complications can result from untreated priapism?

• penile tissue necrosis

• hydronephrosis

• permanent erectile dysfunction

• fibrosis of erectile tissue

• irreversible loss of erectile function.

How is priapism treated?

• hydration

• analgesia

• intracavernosal phenylephrine injection (high-risk med) - priority treatment

  • causes vasoconstriction (alpha 1 = increase HR/BP)

• corporal aspiration

  • if clot

• aspiration with irrigation

  • if clot

• surgical interventions = shunt procedures if conservative treatment fails.

What medication is first-line for ischemic priapism?

Intracavernosal phenylephrine is the preferred first-line medication because it causes vasoconstriction, reducing blood flow into the penis and promoting venous drainage.

What is corporal aspiration?

Procedure in which blood is removed directly from the corpora cavernosa using a needle to relieve pressure and restore circulation.

What is the purpose of irrigation after corporal aspiration?

flushes stagnant blood from the corpora cavernosa, improving oxygenation and reducing tissue ischemia.

When is surgery indicated for priapism?

Surgical intervention, including shunt procedures, is considered when aspiration, irrigation, and phenylephrine injections fail to resolve the prolonged erection.

NCLEX Tip: Which penile disorders require immediate medical attention?

Paraphimosis and priapism are urological emergencies because delayed treatment can lead to ischemia, tissue necrosis, and permanent erectile dysfunction.

What is balanitis?

Inflammation of the glans penis that commonly results from the accumulation of smegma beneath the foreskin, leading to irritation, pain, swelling, and infection.

• phimosis increase risk of infection

What is smegma?

normal accumulation of shed epithelial cells, skin oils, and moisture beneath the foreskin.

• Poor hygiene can cause excessive buildup, increasing the risk of balanitis.

What are the common causes and risk factors for balanitis?

• Poor genital hygiene and phimosis (foreskin pulled over glans/head)

  • trapped moisture and bacteria beneath the foreskin.

• common in children

What are the clinical manifestations of balanitis?

• Inflammation of the glans penis

• redness

• pain

• tenderness

• swelling

• irritation

• discomfort

• possible infection due to smegma accumulation.

How is balanitis treated?

• careful cleaning of the glans and foreskin

• antifungal medications if a fungal infection is present

  • white-cheesy discharge = prescribe antifungal cream

• antibiotics if bacterial infection is suspected.

  • purulent drainage

prostate cancer

• most common cancer (besides skin cancer)

• median age at dx = 66yrs at stage I

• 5yr survival rate = 99%

• risk factors

  • increasing age

  • African-American race

  • family hx

testicular cancer

• median age at dx = 33yrs at stage I

  • younger men

• 5yr survival rate = 95%

• risk factors

  • cryptorchidism - one or both testicles fail to move down into the scrotum before birth

  • family hx

  • HIV infection

  • caucasian

penile cancer

• more rare

• median age at dx = 68yrs at stage I

• 5yr survival rate = 85%

• risk factors

  • HIV/HPV infection

  • inflammation of the glans associated with poor hygiene

  • phimosis - (foreskin pulled over glans/head)

  • smoking

What type of cancer accounts for approximately 95% of penile cancers?

penile cancers are well-differentiated squamous cell carcinomas.

• rare cancer

What are the major risk factors for penile cancer?

• HPV infection

• phimosis (foreskin pulled over glans/head)

• lack of circumcision

• poor genital hygiene

• weakened immune system

• Previous ultraviolet light therapy for psoriasis (long-term, noncontagious autoimmune skin disease that causes the rapid buildup of skin cells, leading to scaly, itchy patches)

Why does HPV increase the risk of penile cancer?

dysplastic cellular changes that may progress to squamous cell carcinoma.

What are the clinical manifestations of penile cancer?

• Lumps, discoloration, superficial sores, lesions

• abnormal penile discharge

• pain or tenderness

  • spread = pain around groin area

• difficulty retracting the foreskin

  • depending on size of the lump

• enlarged inguinal lymph nodes

Which lymph nodes are commonly enlarged in penile cancer?

The inguinal (groin) lymph nodes commonly become enlarged because penile cancer frequently spreads through lymphatic drainage.

How is penile cancer treated?

Treatment depends on stage and may include

• chemotherapy (Fluorouracil/5-FU) - topical cancer drug (don gloves, etc) - pt education on not having unprotected intercourse

  • early-stage management

• radiation therapy

• laser surgery

• cryosurgery - extreme cold

• Mohs surgery

  • remove layers of skin until you reach the cancer

  • clear margins before they stop

• lymphadenectomy

• partial/total penectomy

What is Fluorouracil (5-FU)?

chemotherapeutic medication commonly used to treat squamous cell carcinoma of the penis.

What is lymphadenectomy?

surgical removal of lymph nodes that may contain metastatic cancer cells.

What is a penectomy?

surgical removal of part or all of the penis for advanced penile cancer.

Types of scrotal masses

• epididymitis = inflammation

• hydrocele = fluid

• spermatocele = cyst

• testicular cancer = mass

• torsion = twisted spermatic cord

• varicocele = dilated veins

What is a hydrocele?

collection of serous fluid within the processus vaginalis surrounding the testicle.

• very common

• usually unilateral, sometimes bilateral

What causes a hydrocele?

result from a defect in the inguinal ring that allows fluid to accumulate around the testicle.

What is the most common cause of scrotal swelling?

hydrocele

What is transillumination?

physical examination technique in which a light is shone through the scrotum.

• hydrocele transilluminates because it contains clear fluid.

• mass = won’t be transilinate

Why does a hydrocele transilluminate?

The accumulated serous fluid allows light to pass through, differentiating it from solid masses such as tumors.

How are congenital hydroceles managed?

resolve spontaneously during the first year of life without intervention.

• congenital, one sided, resolves on own

• does not resolve on own = communicating hydrocele

When is surgery indicated for a hydrocele?

if the hydrocele persists, becomes symptomatic, enlarges significantly, or fails to resolve spontaneously.

non-communicating vs communicating hydrocele

• communicating = trapped inguinal passageway = swelling, pain, stuck = incarcerated hernia

  • surgeon pushes stuck content into abdominal cavity for temporary measure, but over time, passageway remains open; need surgery to fix

  • increase risk of inguinal hernia - crying can increase this

What is a varicocele?

abnormal dilation of the veins within the spermatic cord caused by incompetent venous valves (venous insufficiency).

• like varicose veins, but in the scrotum area

How does a varicocele feel on physical examination?

It classically feels like a "bag of worms" upon palpation.

• pooling of blood

What causes a varicocele?

Failure of the venous valves allows blood to pool within the pampiniform plexus of the spermatic cord.

How does a varicocele affect fertility?

Pooling of blood raises scrotal temperature, decreases testicular blood flow, interferes with spermatogenesis, and may result in infertility.

Why does increased scrotal temperature impair fertility?

Sperm production requires temperatures slightly below body temperature. Elevated scrotal temperature reduces sperm production and quality.

How is a varicocele treated?

• Treatment may not be necessary if asymptomatic

• snug underwear for support (like compression stockings for varicose veins (analogy))

• Surgical options include embolization or varicocelectomy.

  • if severe, and infertile, young persons

What is embolization for varicocele?

minimally invasive procedure that blocks abnormal veins to redirect blood flow into healthy veins.

What is a varicocelectomy?

surgical ligation of the dilated spermatic veins to improve blood flow and fertility.

What is a spermatocele?

benign retention cyst containing milky fluid and sperm that develops between the head of the epididymis and the testicle.

• vary in size

• little = incidental finding from ultrasound (does not cause problems)

• can affect fertility since where sperm located

Where is a spermatocele located?

It develops between the head of the epididymis and the superior aspect of the testicle.

What is found inside a spermatocele?

Milky fluid containing sperm.

Are spermatoceles usually symptomatic?

No. Most spermatoceles are asymptomatic and discovered incidentally.

How are spermatoceles treated?

• aspiration + inject med of seal off

• sclerotherapy

• spermatocelectomy if symptoms become significant.

What is aspiration of a spermatocele?

Aspiration removes cyst fluid using a needle but has a relatively high recurrence rate.

What is sclerotherapy?

injecting a sclerosing agent into the cyst after aspiration to reduce recurrence.

What is a spermatocelectomy?

surgical removal of a spermatocele.

disorders of the testis

• cryptorchidism

• testicular torsion

• orchitis

What is cryptorchidism?

failure of one or both testes to descend into the scrotum.

• why do thorough head to toe assessment on newborn

• premature = higher chance

• can be alarming for parents but can also be normal and will descend in mths-1yr

Where may undescended testes remain?

Remain within the abdomen or descend only to the penoscrotal junction instead of reaching the scrotum.

Is cryptorchidism usually congenital or acquired?

It is primarily a congenital condition.

When do most undescended testes descend spontaneously?

Most descend naturally within the first year of life.

What complications occur if cryptorchidism is left untreated?

• Impaired fertility and an increased lifetime risk of testicular cancer.

  • why follow-up care for the child very important

• Puberty and secondary sexual characteristics usually remain normal.

Does cryptorchidism prevent puberty?

No. Puberty and development of secondary sexual characteristics generally occur normally despite impaired fertility.

Why does cryptorchidism increase the risk of infertility?

The higher intra-abdominal temperature impairs spermatogenesis and damages germ cells.

Why does cryptorchidism increase the risk of testicular cancer?

Persistent undescended testes have abnormal germ cell development, significantly increasing the likelihood of malignant transformation.

How is cryptorchidism treated?

Observation is appropriate during infancy because many testes descend spontaneously.

• Persistent cryptorchidism is treated surgically with orchidopexy.

What is orchidopexy?

surgical procedure used to move an undescended testicle into the scrotum and permanently secure it.

What is testicular torsion?

Twisting of the spermatic cord that interrupts blood flow to the testicle, causing ischemia and potentially necrosis.

• Generally in younger populations (adolescents, feel embarrassed, delayed care, walk like duck, thorough physical exam + doppler, let dr know)

Why is testicular torsion considered a surgical emergency?

Permanent ischemic damage can occur within hours. Delayed treatment greatly increases the likelihood of losing the testicle.

• fix by min 6hrs

What are the clinical manifestations of testicular torsion?

• Sudden severe unilateral testicular pain + swelling

  • absence cremasteric reflex (negative reflex)

• marked swelling

• absent or abnormal cremasteric reflex

• nausea, vomiting

• testicular tenderness.

Is testicular torsion usually unilateral or bilateral?

It is usually unilateral.

What is the cremasteric reflex?

Normal elevation of the ipsilateral testicle after lightly stroking the inner thigh while lying on back (positive reflex) (not 100%).

• It checks the health of the L1 and L2 spinal nerves and helps protect the testicles

How is the cremasteric reflex affected in testicular torsion?

The cremasteric reflex is usually absent on the affected side, making it an important clinical finding.

How is testicular torsion diagnosed?

• history + physical examination

• Doppler ultrasound to assess testicular blood flow.

How is testicular torsion treated?

• Immediate surgical detorsion with fixation (orchiopexy) of both testes.

• If ischemia is prolonged and the testicle is nonviable, orchiectomy (remove testicle) may be necessary.

What is an orchiectomy?

surgical removal of a testicle when irreversible ischemic necrosis has occurred.

NCLEX Tip: Which scrotal disorders are emergencies?

Testicular torsion is always a surgical emergency due to loss of blood supply. Paraphimosis and priapism are also urologic emergencies requiring immediate treatment.

NCLEX Tip: Which scrotal mass transilluminates?

A hydrocele transilluminates because it contains clear fluid. Solid tumors generally do not transilluminate.

NCLEX Tip: Which disorder feels like a "bag of worms"?

Varicocele classically feels like a "bag of worms" on palpation due to dilated spermatic veins.