Male Genitalia

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

indirect inguinal hernia

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

hydrocele

Femoral hernias protrude at the _______________ and are more likely to present as emergencies with ________________________

femoral canal; bowel incarceration or strangulation

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

inguinal hernias

Indirect inguinal hernias

develop 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

Which inguinal hernia is associated with straining and heavy lifting?

direct inguinal hernia

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

assess the inguinal nodes carefully for enlargement or tenderness

What are the basic landmarks of the groin?

- ASIS

- pubic tubercle

- inguinal ligament

GRH is secreted from the ____________ and stimulates the secretion of ___________ and __________

hypothalamus; LH; FSH

LF acts on ___________ to promote synthesis of testosterone which is converted to _______________ to trigger pubertal growth of male genitalia, prostate, seminal vesicles, and secondary sex characteristics.

leydig cells; 5alpha-DHT

FSH regulates sperm production by the germ cells and _______________ of the seminiferous tubules

sertoli cells

Male sexual function depends on

- testosterone

- arterial blood flow from internal iliac artery to the internal pudendal artery and its penile artery and branches

- intact neural innervation from alpha-adrenergic and cholinergic pathways

Common or concerning symptoms

- penile discharge or lesions

- scrotal or testicular pain, swelling, or lesions

- STIs

yellow penile discharge

gonorrhea

white discharge in nongonococcal urethritis

chlamydia

Rash, tenosynovitis, monoarticular arthritis, meningitis, not always with urogenital symptoms, occur in

disseminated gonorrhea

ulcer

syphilitic chancre and herpes

multiple frond-like genital warts

hpv

What should you suspect in a patient complaining of intense pruritis with evidence of penile or pubic excoriations?

scabies or peduculosis pubis (lice)

scrotal swelling

mumps orchitis, scrotal edema, and testicular cancer

scrotal pain

testicular torsion, epididymitis, and orchitis

Men who engage in high-risk sexual behaviors (multiple sex partners, condomless sex), use illicit drugs, or have prior history of STIs are at increased risk of

HIV infection and other STIs

Infections from oral-penile transmission

gonorrhea

chlamydia

syphilis

herpes

_____________ or _____________ may follow anal intercourse

symptomatic or asymptomatic proctitis

Fever and dysuria in a man suggests

- acute prostatitis

- acute pyelonephritis

- disseminated gonococcal infection

- syphilis

- postobstructive urinary tract infection

Characteristic skin rashes can be seen in

- reactive arthritis

- gonococcemia

- secondary syphilis

Joint pains can be seen in

systemic disseminated gonococcal infection

Conjunctivitis

reactive arthritis

Pubic or genital excoriations

peducuclosis pubis (lice or crabs) or scabies in the pubic hair

If present, retract the prepuce or ask the patient to retract it. This step is essential for the detection of

chancres and carcinomas

Phimosis

tight prepuce that cannot be retracted over the glans

Paraphimosis

tight prepuce that, once retracted, cannot be returned; edema ensues

Balanitis

inflammation of the glans

Balanoposthitis

inflammation of the glans and prepuce

Hypospadias

congenital ventral displacement of the meatus on the penis

Epispadias

congenital dorsal displacement of the meatus on the penis

Purulent, cloudy, or yellow discharge

gonococcal urethritis

Scanty white or clear discharge

nongonococcal urethritis

The quality of discharge is a useful clue but is _______________________ to diagnose a specific type of urethritis.

insufficient

A definitive diagnosis of a specific type of urethritis requires

gram stain and culture

On the dorsal side of the penis, plaques of _____________________ can sometimes be palpated under the skin on the right or left aspect of the shaft in the ________________

Peyronie disease; corpora cavernosa

Urethral strictures most commonly occur in the _______________, but induration or firmeness along the ventral surface of the penis suggests a urethral stricture or possibly a ______________.

proximal urethra; carcinoma

Inspection of the scrotum may reveal

- scrotal nevi

- hemangiomas

- telangiectasias

- STIs including condyloma or ulcers from herpes and chancroid (painful)

- syphilis and lymphogranuloma venereum (painless)

- associated inguinal lymphadenopathy

Cryptorchidism (an undescended testicle)

poorly developed scrotum on one or both sides

Common scrotal swellings

- indirect inguinal hernia

- hydroceles

- scrotal edema

- rarely, testicular carcinoma

Erythema and mild excoriation

fungal infection

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

epidermoid cysts (common, frequently multiple, benign)

tender painful scrotal swelling

acute epididymitis

acute orchitis

testicular torsion

strangulated inguinal hernias

Any painless nodule on the testis raises the possibility of _________________, a potentially ____________ cancer with peak incidence between the ages ________________.

testicular cancer; curable; 15 and 34 years

Lymph drainage from the testes parallels ________________ from the the renal vein and inferior vena cave, the primary site of lymph node involvement in testicular cancer.

retroperitoneal venous flow

The vas deferens, if chronically infected, may feel

thickened or beaded

A cystic structure in the spermatic cord suggests a

hydrocele of the cord

The left testicular vein empties into the

left renal vein

The right testicular vein empties into the

inferior vena cava

A bulge suggests a

groin hernia

Groin hernias in women often

do not have visible bulge

Femoral hernias most commonly present

inferior to inguinal ligament and medial to the femoral artery

Direct inguinal hernia

bulge near the external inguinal ring

Indirect inguinal hernia

bulge near the internal inguinal ring

distinguishing the type of hernia is difficult with sensitivity and specificity of

74% and 96%

Ultrasonography of the groin may be particularly useful in

clinically doubtful cases

Hernias warrant surgical evaluation, especially when

symptomatic or incarcerated

Chance of incarceration is low, estimated at ______________ per year and 10 x more common with ________________

0.3-3%; indirect hernias

A hernia is ____________________ when its contents cannot be returned to the abdominal cavity

incarcerated

A hernia is _______________ when the blood supply to the entrapped contents is compromised

strangulated

Suspect strangulation in the presence of

tenderness, nausea, vomiting

If you can place your fingers above the mass, it is probably not a hernia, and you should suspect the presence of a

hydrocele

During the valsalva maneuver. a temporary increase in the diameter of the spermatic cord indicates filling of abnormally dilated spermatic veins draining the testis, suggesting a

varicocele

What may help distinguish a hydrocele from an intestine-containing hernia?

transillumination of the scrotal mass

IF the light shines through as a red glow

mass is cystic

If the light is blocked by the mass

solid

Scrotal masses containing blood or tissue, such as a normal testis, a tumor, or most hernias

do not transilluminate

If the mass disappears by returning to the abdomen itself while laying down (reducible), it is likely an

indirect inguinal hernia

Risk factors for testicular carcinoma

- cryptorchidism (high risk in the undescended teste)

- history of carcinoma in the contralateral testicle

- mumps orchitis

- inguinal hernia

- hydrocele in childhood

- positive family history

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

genital warts (condylomata acuminata)

Genital Warts: Causative Organism

- HPV 6, 11

- carcinogenic subtypes rare, approx 5-10% of all anogenital warts

Incubation period for genital warts

weeks to months; infected contact may have no visible warts

_____________ can arise on penis, scrotum, groin, thighs, anus; usually asymptomatic, occasionally causing itching and pain

genital warts

_________________ may disappear without treatment

Genital warts

Small scattered or grouped vesicles, 1-3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks

Genital Herpes Simplex

Genital Herpes Simplex: Causative Organism:

usually HSV2 (90%, DS DNA virus)

Incubation for genital herpes simplex

2-7 days after exposure

Primary episode of ____________ may be asymptomatic; recurrence usually less painful, shorter duration

genital herpes simplex

- fever

- malaise

- headache

- arthralgias

- local pain

- edema

- lymphadenopathy

associated with genital herpes simplex

Genital herpes simplex needs to be distinguished from

genital herpes zoster (older patients with dermatomal distribution) and candidiasis

Small red papule that becomes a chancre, a painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening. Borders are raised and indurated. Chancre heals within 3-8 weeks.

Primary syphilis

How long does it take for a chancre of primary syphilis to heal?

3-8 weeks

Painless or painful? Chancre of primary syphilis

painless

Primary Syphilis: Causative Organis,

treponema pallidum, a spirochete

Incubation period for primary syphilis

9-90 days after exposure

Someone with primary syphilis may develop inguinal lymphadenopathy within _______________. Lymph nodes are rubbery, nontender, mobile.

7 days

_____________ patients with primary syphilis develop secondary syphilis while chancre still present. This suggests coinfection with HIV

20-30%

Primary syphilis needs to be distinguished from

genital herpes simplex, chancroid, granuloma inguinale from klebsiella granulomatis (rare in US, 4 varients)

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

Chancroid

Chancroid: Causitive Organism

haemophilus ducreyi, an anaerobic bacillus

Incubation period for chancroid

3-7 days after expoaure

Painful inguinal adenopathy; suppurative buboes in 25% of patients

chancroid

Chancroid needs to be distinguished from

primary syphilis, genital herpes simplex, lymphogranuloma venereum, granuloma inguinale from klebsiella granulomatis (both rare)

Hypospadias

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