M

CH17 Male Reproductive System

Fournier’s Gangrene

  • Definition: a rare, rapidly progressing polymicrobial necrotizing fasciitis of the external genitalia and perineum.
  • Risk factors:
    • Diabetes
    • Trauma to urethral/penile area
    • Use of SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin)
  • Presentation:
    • Abrupt onset of severe pain, redness, and swelling in perineal region
    • Systemic findings: fever, tachycardia, hypotension
    • Rapid progression; skin may turn black (gangrene)
    • Can involve scrotum and penis
  • Management:
    • Surgical emergency
    • Requires surgical debridement and IV antibiotics
    • Refer to emergency department (ED)

Paraphimosis

  • Definition: foreskin cannot be returned to its original position due to swelling of the glans penis.
  • Presentation: swollen, reddened, painful glans; highest incidence in uncircumcised infants/toddlers
  • Urgency: emergency; may cause ischemic changes if untreated
  • Management:
    • Acute decompression with a small slit in the foreskin under topical anesthesia
    • Severe cases may require circumcision; refer to ED
  • Predisposing factor: phimosis (tight foreskin that cannot retract to expose glans)

Priapism

  • Definition: prolonged, painful erection lasting ≥2–4 hours not related to sexual stimulation
  • Two types: ischemic and nonischemic
  • Epidemiology: bimodal distribution; peak in children 5–10 years and adults 20–50 years
  • Etiology:
    • Idiopathic or secondary priapism (medications, disease states)
    • Most common adult cause: intracavernosal injections for erectile dysfunction
    • High-risk factors: sickle cell disease (high risk for ischemic), high doses of ED drugs, cocaine use, quadriplegia
  • Ischemic priapism: urologic emergency
  • Refer to ED for management

Prostate Cancer

  • Demographics: more common in older men; higher risk with African American ethnicity; obesity and family history are risk factors
  • Presentation: may be asymptomatic; back pain and rectal/perineal discomfort with obstructive voiding symptoms possible
  • Screening considerations: more common in men >50; screening guidelines suggest individualized decisions for ages 55–69; PSA/DRE as part of evaluation
  • Exam findings:
    • Painless, hard fixed nodules or indurated areas on the prostate on DRE
    • Elevated PSA > 4.0 ext{ ng/mL}
  • Diagnosis: biopsy of prostatic tissue (often via transrectal ultrasound) – consult urology
  • Management considerations: refer to urologist if PSA > 4.0 ext{ ng/mL}; individualize screening; many cancers are slow-growing; watchful waiting common
  • Note on prognosis: most cancers are not aggressive; watchful waiting/monitoring commonly used

Testicular Cancer

  • Epidemiology: most common solid malignancy in males aged 15–35 years
  • Presentation: nodule or heaviness in one testis; one larger testicle; tenderness; may present with new hydrocele due to tumor pressing on vessels
  • Common course: usually painless; metastasis may cause symptoms
  • Prognosis: among the most curable solid neoplasms; 5-year survival rate approximately 95 ext{%}
  • Diagnostic/testing:
    • Ultrasound: solid mass in testicle
    • Biopsy or management typically involves orchiectomy; in practice, orchiectomy is both diagnostic and therapeutic
  • Management: refer to urology for biopsy/orchiectomy

Testicular Torsion

  • Presentation: acute onset of severe testicular pain with extremely swollen, red scrotum; may have nausea/vomiting
  • Exam:
    • Affected testicle positioned higher and closer to the body
    • Absent cremasteric reflex
  • Urgency: urologic emergency; call ED
  • Diagnostics: preferred initial test in ED is Doppler ultrasound with color flow
  • Treatment: manual detorsion or surgical detorsion with fixation (orchiopexy)

Torsion of Appendix Testis

  • Presentation: abrupt onset of blue-colored round mass on testicular surface; called a “blue dot” sign
  • Anatomy: appendix testis is a small pedunculated structure attached to the testicular surface (anterior superior region)
  • Exam: cremasteric reflex is present
  • Epidemiology: torsion of appendix testis rarely occurs in adults; most cases in children 7–14 years (mean ~10.5 years)

Normal Findings (Spermatogenesis and Male Reproductive Organs)

  • Spermatogenesis
    • Ideal temperature for sperm production: 1^{
      ^ ext{o}}C to 2^{
      ^ ext{o}}C below core body temperature
    • Sperm production begins in late puberty (Tanner stage IV) and continues for life
    • Sperm production occurs in seminiferous tubules
    • Sperm maturation time: 64 days
  • Testes
    • Cryptorchidism increases risk of testicular cancer
    • Testosterone/androgens stimulated by LH
    • Spermatogenesis stimulated by testosterone and FSH
    • Left testicle typically hangs lower than the right
  • Prostate gland
    • Heart-shaped; grows throughout life
    • Produces PSA and prostatic fluid; prostatic fluid is alkaline to support sperm survival in the vagina (which is acidic)
    • Up to 60 ext{%} of 60-year-old men have BPH (benign prostatic hyperplasia)
    • BPH can lead to enlargement and lower urinary tract symptoms
  • Epididymis
    • Coiled tube at posterior aspect of testis; stores immature sperm; sperm maturation takes about 3 ext{ months}; resembles a beret on the upper pole of the testes
  • Vas Deferens (Ductus Deferens)
    • Transports sperm from epididymis toward the urethra; cut/clipped during vasectomy
  • Cremasteric reflex
    • Testicle elevates toward the body when ipsilateral inner thigh is stroked or pinched
    • Absent in testicular torsion
  • Scrotal transillumination
    • Useful for evaluating cryptorchidism, hydrocele, spermatocele, and scrotal masses
    • Hydrocele transilluminates (glow); testicular tumor does not (solid)
    • Varicocele does not transilluminate

Acute Bacterial Prostatitis

  • Definition: acute infection of the prostate, usually gram-negative organisms; infection ascends via urethra with possible concomitant cystitis or epididymitis
  • Epidemiology: tends to occur in young and middle-aged men
  • Most common organisms: Enterobacteriaceae (e.g., Escherichia coli, Proteus)
  • Age-related management note: in men <35, treat like gonococcal/chlamydial urethritis
  • Classic case: fever/chills with suprapubic/perineal pain; dysuria, frequency, nocturia; cloudy urine
  • Exam: DRE reveals extremely tender, warm, boggy prostate; may have bladder infection or epididymitis
  • Objective findings: firm, edematous, tender prostate; risk of bacteremia with vigorous palpation
  • Labs:
    • CBC: leukocytosis with left shift
    • UA: pyuria, hematuria, bacteriuria
    • Urine culture and sensitivity (C&S): obtain after gentle prostatic massage
  • Diagnosis: based on symptoms plus edematous, tender prostate
  • Treatment:
    • Outpatient empiric therapy: ciprofloxacin ext{ (Ciprofloxacin)} ext{ 500 mg PO BID} or trimethoprim-sulfamethoxazole ext{ (TMP-SMX) DS}, BID
    • Narrow antibiotic once culture results identify organism class
    • Prolonged antibiotic course to ensure eradication
    • Sexually active men <35 or those with high-risk sexual behavior: cover gonorrhea and chlamydia
    • Supportive care: antipyretics, stool softeners (e.g., Colace), sitz baths, hydration
    • Hospitalize if septic or toxic

Acute Epididymitis

  • Most common cause of scrotal pain in adults; etiology depends on age and STI risk
    • <35 years: more likely STI (chlamydia, gonorrhea)
    • >35 years: usually gram-negative organisms (e.g., E. coli)
  • Classic case: acute unilateral swollen, red scrotum; tenderness at posterior epididymis; may have hydrocele and UTI symptoms; fever possible
  • Prehn’s sign: relief of pain with scrotal elevation
  • Cremasteric reflex: positive
  • Labs:
    • CBC: leukocytosis
    • UA: pyuria, hematuria, nitrites
    • Urine culture and sensitivity
    • NAAT for gonorrhea and chlamydia
  • Treatment:
    • STI risk without anal intercourse: ceftriaxone 500 ext{ mg IM} + doxycycline PO BID imes 10 ext{ days}; treat partner
    • STI risk with anal intercourse: ceftriaxone 500 ext{ mg IM} + levofloxacin 500 ext{ mg PO daily} imes 10 ext{ days}
    • Low STI risk: fluoroquinolone (e.g., levofloxacin 500 ext{ mg PO daily} imes 10 ext{ days}) or TMP-SMX DS 1 ext{ tablet PO BID} imes 10 ext{ days}
    • Pain management: NSAIDs (ibuprofen, naproxen) or acetaminophen with codeine for severe pain
    • Scrotal elevation, ice packs; bedrest for a few days
    • Stool softeners if constipated
    • Refer to ED if septic, severe pain, abscess

Balanitis / Balanoposthitis

  • Definition: candidal infection of the glans penis; balanoposthitis includes foreskin involvement
  • Risk factors: uncircumcised status, diabetes, immune compromise; SGLT2 inhibitors increase risk of balanitis and UTI
  • Classic case: redness, pain, tenderness, pruritus of glans and/or foreskin; shallow ulcers; curd-like discharge; reactive arthritis can accompany and worsen symptoms
  • Treatment:
    • Improve perineal hygiene; saline baths BID
    • Topical antifungal therapy: azole creams (clotrimazole 1%, miconazole 2%) BID for 7–14 days
    • Treat partner if candidiasis present

Benign Prostatic Hyperplasia (BPH)

  • Epidemiology: very common in aging men; prevalence rises with age
    • ~60 ext{%} at age\,60; ~80 ext{%} at age\,80
  • Assessment: use AUA/IPSS urinary symptom score to grade severity
  • Classic symptoms: gradual development of LUTS (weak stream, hesitancy, dribbling, nocturia, incomplete emptying)
  • Objective findings:
    • DRE: enlarged, smooth, rubbery prostate; size may be palpated
    • PSA often elevated in BPH and/or cancer; interpret with context
  • Treatment:
    • Lifestyle: reduce caffeine/alcohol, limit evening fluids, avoid diuretics if possible
    • First-line: alpha-1 adrenergic antagonists (e.g., tamsulosin, terazosin, doxazosin)
    • ED with BPH: PDE-5 inhibitors as alternative initial therapy
    • For overactive bladder symptoms: anticholinergics or beta-3 agonists (watch for urinary retention risk)
    • Disease modification to slow progression: 5-alpha-reductase inhibitors (finasteride); typically 6–12 months to see effect
    • Herbal therapy (saw palmetto): mild or insufficient evidence; not routinely recommended
    • Combination therapy for persistent symptoms despite monotherapy
    • Medication considerations: some drugs worsen LUTS (anticholinergics, sympathomimetics); examples include antihistamines, decongestants, caffeine, atropine, TCAs
  • Tips:
    • Finasteride inhibits type II 5-alpha-reductase; can shrink prostate and lower PSA (PSA doubles while on therapy; if stopping, PSA returns to baseline)
    • Prostate shrinkage around 50% during therapy while on finasteride; monitor PSA doubling appropriately

Chronic Bacterial Prostatitis

  • Definition: chronic (>6 weeks) or recurrent bacterial prostatitis; may follow acute bacterial prostatitis or occur sporadically
  • Etiology: usually E. coli; nonbacterial prostatitis is culture-negative
  • Classic case: weeks of suprapubic/perineal discomfort with irritative voiding symptoms; may have low-grade fever; sometimes asymptomatic
  • Exam: variable; prostate may feel normal, or show hypertrophy, tenderness, edema, or nodularity
  • Labs:
    • UA, urine C&S, PSA
    • PSA elevated in about 25 ext{%} of cases
    • Transurethral ultrasound to measure prostate volume
  • Treatment:
    • First-line: fluoroquinolone such as ciprofloxacin 500 ext{ mg PO BID}
    • Alternatives: TMP-SMX DS, one tablet PO BID
    • Duration: 4–6 weeks

Cryptorchidism

  • Definition: testicle fails to descend spontaneously by age 4 months
  • Occurrence: up to 30 ext{%} of premature infants; many descend by age 12 months
  • Risks: markedly increases risk of testicular cancer and sterility
  • Examination: empty scrotal sac
  • Management: usually corrected during infancy

Erectile Dysfunction (ED)

  • Definition: inability to produce an erection firm enough for sexual intercourse
  • Epidemiology: ED common with aging; prevalence increases with age
    • ~18 ext{%} of men 50–59; ~37 ext{%} of men 70–79
    • In men >50, more likely to be organic in origin
  • Etiology:
    • Organic: aging, neurologic (Parkinson’s, Alzheimer’s, stroke, MS, spinal cord injury), vascular (hypertension, diabetes, smoking), hormonal (hypogonadism), local penile factors (Peyronie’s disease)
    • Drug-induced: SSRIs (notably paroxetine), antipsychotics, recreational drugs, alcohol, antihypertensives (beta-blockers, thiazide diuretics)
    • Psychogenic: morning erections present; performance anxiety, depression, relationship issues, stress
  • Evaluation:
    • Rule out diabetes (fasting glucose, A1C), thyroid disorder (TSH), morning serum testosterone
  • Treatment:
    • First-line: PDE5 inhibitors
    • Alternatives: vacuum devices, intracavernosal alprostadil, penile implants, testosterone therapy, cognitive-behavioral therapy for psychogenic ED
    • Sildenafil (Viagra) specifics:
    • Dose options: 25, 50, 100 mg; take one dose 30–60 ext{ minutes} before sex; duration ~4 hours; max once per 24 hours
    • Also used for pulmonary hypertension (Revatio)
    • Cautions: do not combine with Revatio or riociguat; careful with alpha-blockers, recent MI, unstable angina; take on an empty stomach; fatty meals and alcohol delay absorption; avoid QT-prolonging drugs
    • Warning: may cause acute non-arteritic anterior ischemic optic neuropathy (NAION); risk higher with diabetes, heart disease, hypertension
    • Vardenafil (Levitra): single dose 30–60 minutes before sex; duration ~4 hours
    • Tadalafil (Cialis): 5–20 mg; long duration up to 36 hours; may be prescribed as daily dose (5–10 mg) for concurrent BPH and ED
    • Contraindications: nitrates; caution with alpha-blockers, recent MI, stroke, major surgery; avoid grapefruit juice; monitor for hypotension
    • Adverse effects: headache, flushing, dizziness, hypotension, nasal congestion, priapism, vision/hearing changes
  • Tips:
    • Distinguish chronic prostatitis vs acute prostatitis
    • SSRIs can cause ED; paroxetine has particularly high risk

Hydrocele

  • Definition: serous fluid within the tunica vaginalis; scrotal exam shows superior/anterior location to testes
  • Epidemiology: most hydroceles are asymptomatic; more common in newborns; most resolve spontaneously
  • Diagnostics/Management:
    • Scrotal transillumination glows; larger glow on affected side
    • If adult new or enlarging hydrocele with pain, order scrotal Doppler ultrasound to rule out tumor, hematoma, rupture, torsion, epididymitis, or orchitis; refer to urology

Peyronie’s Disease

  • Definition: inflammatory fibrotic plaques on the tunica albuginea
  • Clinical features: penile pain with erection, palpable nodules, penile deformity (bent/curved erections)
  • Course: may resolve spontaneously in a minority; many cases worsen over time
  • Psychosocial impact: can cause erectile dysfunction
  • Labs: none; clinical diagnosis
  • Management: refer to urology for evaluation and management

Phimosis and Paraphimosis (overview)

  • Physiologic phimosis: normal in almost all newborn males; foreskin should not be red or swollen; avoid forcible retraction to prevent tearing and scarring
  • Pathologic phimosis: truly nonretractable foreskin due to chronic inflammation/edema; may affect sexual function, voiding, hygiene; refer to urology
  • Paraphimosis: foreskin cannot return to original position due to swelling of glans; glans red, swollen, and painful
    • Highest incidence in uncircumcised infants/toddlers; partial phimosis increases risk
    • Emergency management: small slit in foreskin under topical anesthesia to relieve pressure; circumcision may be needed in severe cases; ED referral

Prostate Cancer (Detailed)

  • Global and US context: most common cancer in men worldwide; ~11 ext{%} of US males diagnosed; incidence increases with age; higher risk in African American men
  • Screening considerations: age >55–69 individualized; PSA testing with DRE; discuss risks (bleeding, infection, impotence, procedures, psychological impact) versus benefits; many cancers are slow-growing
  • Objective findings: painless, hard fixed palpable nodule on DRE; PSA > 4.0 ext{ ng/mL}
  • Diagnostic approach: biopsy via transrectal ultrasound
  • Management: refer to urology for PSA > 4.0 ext{ ng/mL} or suspicious findings; management individualized; watchful waiting common for many cases; symptomatic cases may require alpha-blockers, antiandrogens, Lupron, etc.

Spermatocele (Epididymal Cyst)

  • Definition: fluid-filled cyst containing nonviable sperm; located at the head of the epididymis
  • Transillumination: will glow due to fluid contents
  • Fertility impact: does not affect fertility
  • Imaging: ultrasound is the imaging test of choice
  • Treatment: surgical excision if symptomatic or bothersome

Testicular Torsion (revisited)

  • See earlier section under Testicular Torsion for differential features and ED management

Testicular Torsion: Additional Context

  • Bell clapper deformity mentioned as a risk factor where the testicle lies more horizontally
  • Time-critical: early intervention preserves testicular viability

Varicocele

  • Definition: dilated veins in the scrotal sac described as a “bag of worms”
  • Clinical significance:
    • New-onset varicocele can signal testicular tumor or mass compressing venous drainage
    • Unilateral right-sided varicoceles are uncommon and may indicate intrathoracic/abdominal/pelvic tumor compressing venous return
  • Evaluation: ultrasound of the scrotum
  • Treatment: surgical removal of varicoceles if infertile
  • Note: most benign varicoceles are left-sided; unreduced varicocele in the supine position may indicate a mass

Tips and Practical Notes

  • For BPH in patients with hypertension and high blood pressure: start with an alpha-blocker to address blood pressure and LUTS (e.g., terazosin, doxazosin) by relaxing smooth muscles in the prostate and bladder neck
  • Finasteride (Proscar) is a category X drug (teratogenic); requires special handling; not to be handled by pregnant people
  • PSA interpretation with finasteride: prostate size reduction may lower PSA; PSA must be doubled for interpretation while on therapy
  • Distinguish chronic vs acute prostatitis: chronic prostatitis has gradual onset; acute prostatitis presents acutely with fever and tender, swollen prostate (often younger males)
  • SSRIs (notably paroxetine) are associated with ED
  • General clinical approach emphasizes ED workup and pharmaco-therapy options including PDE5 inhibitors, alternative therapies, and lifestyle modifications

Quick Reference Numbers and Key Points (LaTeX-formatted)

  • Temperature difference for spermatogenesis: 1^{
    ^ ext{o}}C to 2^{
    ^ ext{o}}C below core body temperature
  • Sperm maturation duration: 64 days
  • BPH prevalence (age-related): 60 ext{%} at 60, 80 ext{%} at 80
  • Prostate cancer PSA threshold: >4.0 ext{ ng/mL}
  • Prostate cancer 5-year survival (noted earlier): ext{about }95 ext{%}
  • Finasteride effect on prostate size: reduction of approximately 50 ext{%} while on therapy
  • ED medication durations and dosing examples: Sildenafil 30–60 ext{ min} before sex; duration ext{about }4 ext{ hours}; daily tadalafil up to 36 ext{ hours} of activity
  • Antibiotic durations in epididymitis prostatitis scenarios typically range from 7–10 days (for some regimens) or 10 days in combined STI regimens; chronic prostatitis therapy is generally 4–6 weeks
  • Severe pain or septic presentations warrant ED referral and potential hospital admission