L3- penile and testicular disorders

erectile dysfunction: epi

• consistent or recurrent inability to attain or maintain a suff rigid penile erection for sexual satisfaction

• occurs in >50% of men 40-70yo

erectile dysfunction- patho

• penile erection is a reflex mediated by CNS

• triggered by tactile stimulation or mental/emotional arousal

• occurs via increased blood flow into peis (corpora cavernosa) vis vasodialtion

erectile dysfunction- eti and rf

• often multifactorial

  • neurogenic (PNS or CNS)

    • pelvic surgery DM, spinal cord injury, parkinsons, MS, SLE, aging

  • vascular (arterial/venous)

    • any condition that results in imbalance btwn contractile and relaxant factors in corpora cavernosa, penile arteries/veins

    • HTN, hypertriglyceridemia, DM, obesity, smoking, lack of exericesm metabolic syndrome

    • ED is an independent marker of systemic vascular disease and should prompt CV risk assessment (esp younger pts)

      • can be warning sign for CVD with lad tiem of 2-3 years btwn moderate ED adn presentation with clinically sig systemic vascular disease

erectile dysfunction- additional etiologies adn rf

hormonal

• hypogonadism (≥2 separate early morning total T <300)

• hyperprolactinemia/hypothyroidism (suppression of LH)

• hyperthyroidism

med induced

• antiHTN

• SSRIs/benzos

• antipsychotics

• finasteride

physchogenic

• meantla health problems

• emotional stress

• interpersonal relationship difficulties

• porn induced ED

erectile dysfunction- hx

• describe inability to either attain, maintain, or both

• important to ask:

  • onset

  • duration

  • rigidity during partnered relations vs masterbation

  • presence.rigidity of nocturnal erections

    • ED iwth ability to attain nocturnal erection can be greater indicator for psychogenc

  • use of prior meds/tx for ED

  • issues with libido, desire, ejaculatory dysfunction, orgasm, peyronies

erectile dysfunction- physical exam

• waist circum and BMI

• basic CV< neuro, and vascular exam

• presence of gynecomastia

• male secondary characteristics (to assess for signs of testosterone deficiency) such as beard growthm pubic hair

• penile examination

  • skin lesions, hypospadias, palpation for plaques

• scrotal exam

  • testoicular size, consistency, location

erectile dysfunction- labs

• fasting lipid profile, two early morning (before 10AM) testosterone levels, glucose

• considera dding prolactin, FSH, H especially in young

• penile duplex doppler US

  • gold standard

  • eval erectile hemodynamics, but not rountiney required initial eval

erectile dysfunction- mgmt

modify reversible causes

• meds

• tobacco cessatio

• endocrineopathy (low T)

• poor diet, sedentary lifestyle, weight loss

erectile dysfunction- first lien therapies

• PDE5inhibitors

  • viagra (silenafil)

    • best absorbed on empty stomach

  • cialis (tadalafil)

    • also helps with BPH

  • sexual stimulation required

  • try o n5-8 separate occasions before determine tx failure

erectile dysfunction- PDE5i contraindications

• concurrent use of nitrate containing meds (SL NTG, isosorbide mononitrate or dinitrate)→ hypotension

• relative:

  • concomitant use of alpha blocker (tamsulosin) due to orthostatic hypotension risk; should take 4hours apart from one another

erectile dysfunction- PDE5i ADE

• HA, flushing, rhinitis/congestion, myalgias, visual disturbances

• rare bur dangerous- priapism

erectile dysfunction- tx: intracavernosal injections (ICI)

• trimix- alprostadil/papaverine/phentolamine

• preffered second line therapy after PDE5i failure

erectile dysfunction- non pharm mgmt

vacuum erection device (VED)

• creates vacuum aroufn flaccid penis→ dilation of cavernous spaces by negative pressure→ draws venous blood in penis

• usually couple with constriction device at base of penis to prevent venous outflow

  • max band application is 30min

penile implant

testosterone replacement therapy

• only indicated fro low T adn if pt is sx

• not guaranteed to resolve ED

priapism

• erection >4hrs or painful erection

• can be side effect of ED meds

• can be caused by alcohol and cocaine use

• sickle cell anemia= RF

why should person with priapism go to emergency department

• urologic emergency

  • most causes are ischemic priapism, which requires immediate tx to prevent permanantED

  • tx involves icing, injectable phenylphrine (vasoconstrictor), or if refractory, shunt

    • phenylphorine= monitor BP and HR bc systemic absorption can occur

peyronie’s disease: epi

• fibrotic disorder of tunica albuginea of penis

• results in varying degrees of penile pain, curavture, deformity

• occurs in up to 10% of men

• incidence increases with age

• avg age of ppresentation =55

peyronie’s disease: eti

• unknown exact cause, but repettive microtrauma durign sexual activity in genetically sus individuals is hte leading proposed mech

• familial disease patterns suggest genetic component in some cases

• can be ass with urethritism iatrogenic trauma during cystoscopy, cath, transurethral resection of prostate (TURP), radical prostatectomy

peyronie’s disease- clinical presentation

• progressie condition that can result in penile shortening, narrowing, adn or curvature and in pain with intercourse

• curvature can occur in any direction, although dorsal curvature is most common

• deformity can be noticeable when penis is flaccid

• natural hx

  • active phase (8-18 months): progressive changes,/deformationm usually painful

  • chronic phase: cessation of plaque progression, pain decreases, deformity progression stabilizes

peyronie’s disease- hx

• onset

• degree of curvature (helpful if pt can bring in autophotograph)

• presence of pain

• previous surgical hx

• erectile abilitydysfunction

• presence of nocturnal erections

• does it bother pt or their partner

peyronie’s disease- physical exam

• palpation of shaft to ID palques (apply side to side and dorso ventral pressure)

peyronie’s disease- mgmt

• collagenase clostridium histolyticum= only FDA approved med specifically indicated for PD

  • must be in chronic phase, do not offer when in acute phase

• penile traction therapy may improve curvature and preserve penile length and approriately selected pt

• NSAIDs for pain mgmt

• surgical management

  • penile plication

  • plaque incision/excision and graft

  • penile presthesis

phimosis

• inability to retract foreskin proximally an dposterior to glans penis

phimosis- eti

• infection

• poor hygiene

• previous preputial injuries with scarring

phimosis- tx

• circumcision

• topical steroid (betemethasone) tx applied from trip of foreskin to glans corona + daily preputial retractions

• never forcibbly retract a physiologic foreskin in young children

paraphimosis

• urologic emergency

• inability to reduce porximal edematous foreskin distally over glans penis into natural position

paraphimosis- eti

• in peds, accidental retraction during cleaning

• in adults, intercourse/masturbation, trauma (piercing), forgetting to replace foreskin

paraphimosis- tx

• ice/compression of glans for several min to reduce edema to reduce glans through foreskin

• manual reduction using firm cicumferential compression of the edematous glans/foreskin after adequate analgesia

• dorsal slit: superficial dorsal incision of band after local lido (WITHOUT EPI)

balanitis

• inflammation of glans penis

balanoposthitis

• inflammation of the glans penis + foreskin

balanitis- eti and RF

• most cases occur in uncircimscribed males

• commonly associated with candida infection, poor hygiene, diabetes, or hcronic irritaiton

• RF:

  • DM

  • trauma

  • obesity

  • fluid overload conditions

    • cirrhosis, CHF, nephrotic syndrome

balanitis- clinical presentation

• pain, tenderness, erythema, pruritis, edema of glans ± foreskin

• possible excoriations/ulcerations

• possibel exudate (curd like) under foreskin

balanitis- tx

• optimize diabetes control

• encourage good hygiene

  • daily gentle retractions of foreskin to clean

  • washign glans and foreskin with mild soap or saline solution

• treat underlying cause:

  • candida: topica antifungal (clotrimazole)

  • inflammatory dermatoses: topical or oral abx as indicated

balanitis- tx failure

• refer to urology or derm for possible biopsy

  • eval premalignant disease or other chronic skin conditions

• PEARL: consider checking an A1c or screening or diabetes in pts with recurrent balanitis

anterior male urethral stricture disease

• anterior urethra include urethral meatus, fossa navicularis, penile urethra, and bulbar urethra

• occurs when normal urethral mucosa and its ass corpus spongiosum is replaces with scar tissue

• result sin narrowing of urethral lumen via scar contracture or fibrosis

posterior urethral narrowing

• narrowing known as urethral stenosis or bladder neck contracture as corpus spongiosum is absent in posterior urethra

male urethral stricture disease: epi

• peak incidence at 55yo

male urethral stricture disease- eti

• occur after damage to urothelium and/or corpus spongiosum→ progressive fibrosis

• iatrogenic (cath, endoscopic procedures, radiation)

• inflammatory (STI, lichen sclerosus)

• trauma (straddle injuries, trauma to perineum)

• idiopathic

male urethral stricture disease- clinical presentation

• obstructive urinary sx

  • incomplete emptying

  • reduction in flow/weak stream

  • split/spraying stream

• UTis

• urinary retention

male urethral stricture disease- hx

• eval of urinary and sexual function

  • urgency, freq, incontinence, nocturia, feeling of incomplete emptying, split/spraying stream

• urologic surgery, UTI/STI hx, and perineal/urethral trauma hx

male urethral stricture disease- physical exam

• complete genitalia exam of penis, scrotum, perineum, and mouth (oral miusoca is often used for urethral reconstruction)

male urethral stricture disease- testing

• PVR, uroflowmetry

• retrograde urethrography (RUG) and voiding cystourethography (VCUG)

male urethral stricture disease- mgmt

• acute urinary retention

  • endoscopic tx o rimmediate suorapubic tube placement (SPT)

    • SPT placement x1-3 mommths allow fro urethral rest (to allow stricture to mature prior to surgical intervention)

  • endoscopic: urethral dilation or direct vision internal urethrotom (DVIU)

    • best for short bulbar urethral strictures or meatal/fossa navicularis strictures

    • avoid in penile urethral strictures due to high recurrence rate

    • often just temporaizing measure

    • intermittent self cath to help maintain patency after endoscopic tx or when definitive reconstruction is not appropriate

• drug coated balloon dialtion for recurrent anterior urethral stricture

  • uses paclitaxel for prevention of cell tumor

male urethral stricture disease- surgical mgmt

urethroplasty

• can be one or two stage procedure

• usuallu uses buccal mucosal graft

• hgihest success rate

• recurrent strictures after multiple endoscopic preocedures shoudl prompt referral for definitive resconstruction rather than repeated dialtion/DVIU

perineal urethrostomy

• usually used in panurethral strictures

varicocele

• caused by dilation of the pampiniform plexus of spermatic veins

varicocele- epi adn eti

• present in 15-20% of postpubertal males

• usually left sided

• may first appear at puberty and becomes larger over time

varicocele- clinical presentation

• often asx

• dull, aching, usually left sided scrotal pain

  • usually noticeable when standing and relieved bby recumbency

• atrophy of affected testicle

• decreased fertility

varicocele- physical exam

• can range from minimal scrotal fullness on valsalva to large, soft scrotal mass (“bag of worms”)

• graded according to size (I,II,III)

• examine whiel pt is recumbent, standing, at rest, and while performing valsalva

varicocele- testing

• can obtain scrotal US if incertain

• consider abdominal/retroperitoneal imaging for an isolated right sided varicocele that is new, nonreducible, sudden onset, or associated with other concerning findings suggestive of retroperitoneal pathology

varicocele- mgmt

• most incidentally discovered asx varicoceles do not require surgical intervention

  • can treat sx with scrotal supports adn NSAIDs

• if painful, can pursue surgical ligation

• if in young men (<21), eval fro testicular atrophy (or testicular volume discrepancy) on PE and semen analysis

  • if evidence of hypotrophy or abnormal semen paramteres, pursue surgical ligation or percutaneous venous embolization

  • if semen paramters are normal, monitor with semen analaysis every 1-2yrs

hydrocele

• collection of peritoneal fluid btwn pariteal and visceral layers of tunica vaginalis, which diresctly surrounds testis and spermati ccord

hydrocele- epi and eti

• htrough to arise from imbalance of secretion and reabsorption form tunica vaginalis

• most are idiopathic, but an acute reactive hydrocele can occur due to infalmmatory scrotal conditions (epididymitis, torsion appendiceal torsion)

hydrocele- clinical presentation

• range in size from small, soft collection that still allow for palpation of testes to massive, tense collections of several liters, amking palpation of testes impossible

• pain/disability correlate with size

hydrocele- eval and dx

• hydrocele fluid in scrotum transilluminates well (differentiates from other scrotal swelling etiologies: hemotcele, hernia, solid mass)

• scrotal US

  • esp if dx is uncertain and prior ro any intervention

hydrocele- mgmt

• most do not require intervention

  • indicatd with sx with pain or pressure from swelling is affecting skin integrity

• simp[le aspiration

  • usually performe din office

  • has very high re accumulation rate, so it is generally reserved fro pts who are poor surgical candidates

• aspiration with instillation of sclerosing agent (teatracycline, alcohol) into sac

• hydrocelectomy

testicular torsion- epi and eti

• MC ages 12-18

• increased ridk with hx of cryptorchidism (undescended testicle)

testicular torsion- clinical presentation

• acute onset of testicular/scrotal pain

• often occurs after sports/activity but can also occur during sleep

• scrotal edema, high riding testis, horizontal lying testis, absent creamateric reflex

testicular torsion- physical exam

• generalized testicular tenderness

• creamasteric reflex

  • absence

• negative phrens sign

• ipsilateral scrotal elevation (as cord twistsm its length decreases)

• thickening of ipsilateral spermatic cord

• blue dot sign

  • unreliable findings ass with torsion of testicular appendage

• scrotal edema

• bell clapper deformity

  • due to partial or complete failure of fusion o ftunica vaginalis along epididymis

  • puts tetsis at hgih risk of intravaginal torsion

  • 12% of ma;es

testicular torsion- labs and imaging

• UA (pyuria o rbacteremia usually ass with epididymo-orchitis)

• pre op CBC and coag profile (poss leukocytosis)

• imaging:

  • torsion=clinical dx, if clinical sus os strongm do not delay scrotal exploration to obtain imaging

  • doppler US: will show minimal blood flow compared to contralateral testicle

testicular torsion- mgmt

• testicular torsion is. asurgical emergency

• can attempt a manula de-torsion, but this shoudl not delay surgical mgmt

• scrotal exploration, ipsilateral de-torsion, possible orchiectomy, contralateral vs bilateral orhciopexy

• risk of orchiectomy is 5% if surgery is within 6hrs

  • 20% at 7-12 hrs

  • 40% at 13-18hrs

  • 60% 19-24 hrs

  • >80% over 24hrs