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Male Genital Problems

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Male Genital Problems Tintinalli s Ch 95 Testes and Epididymis Testicular torsion on exam: Firm, tender, high riding in scrotm testis Epididymis may be displaced ... – PowerPoint PPT presentation

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Title: Male Genital Problems


1
Male Genital Problems
  • Tintinallis Ch 95

2
Anatomy
  • Penis
  • Two corpora cavernosa
  • Erectile bodies
  • Encased in tunica albuginea
  • Corpus spongiosum
  • Surrounds urethra
  • Blood supply internal pudendal art.,
  • Lymphatics inguinal nodes

3
Penis
4
Anatomy
  • Scrotum
  • Dartos Fascia similar to Campers fascia
  • Scarpas Fascia similar to Colles Fascia
  • Blood supply femoral internal pudendal art.
  • Lymphatics inguinal femoral nodes

5
Scrotum and testis
6
Anatomy
  • Testes
  • Avg 4-5 cm length, 3 cm width depth
  • Suspended by spermatic cord
  • Encased in tunica albuginea
  • Enveloped in Tunica Vaginalis attaching testes to
    posterior scrotal wall
  • Anchor gubernaculum

7
Anatomy
  • Testes
  • Maldevelopment of tunica vaginalis Risk of
    torsion
  • Potential space btwn viscera and tunica vaginalis
    space for hydrocele development
  • Blood Supply thru spermatic cord
  • Internal spermatic external spermatic Art.
  • Lymphatics drain to external, common iliac,
    periaortic nodes

8
Anatomy
  • Epididymis
  • Single, fine, tubular structure
  • 4-5 m long compressed into 5 cm
  • Promotes sperm maturation motility
  • Appendix epididymis testis
  • NO function

9
Anatomy
  • Vas Deferens
  • Distinct muscular tube
  • Extends into spermatic cord from tail of
    epididymis, crosses behind the bladder
  • Joins the seminal vesicles forming ejaculatory
    ducts

10
Anatomy
  • Prostate
  • Originates in the 3rd month of development
    continuing to grow throughout life
  • Young males, may not be palpable on rectal
  • In elderly men, can enlarge to obstruct urine
    flow

11
Physical Examination
  • Visual inspection
  • Fully retract foreskin to inspect glans, coronal
    sulcus, preputial areas for ulceration or
    malignancy
  • Note position of urethral meatus
  • Discharge?
  • Shaft inspection
  • Palpate for plaques, cysts, early abscesses

12
Physical Examination
  • Supine or standing positions can be used
  • Testes should be checked
  • Nodularity or firmness carcinoma until proven
    otherwise
  • Alignment, when standing
  • Horizontal increased risk of torsion
  • Epididymis
  • Posterolateral of testis
  • Tender with palpation, even when normal

13
Physical Examination
  • Prostate
  • Normal prostate exam causes discomfort
  • Heart- shaped contour
  • Consistency similar to tip of nose
  • Carcinogenic Prostate similar to bony chin

14
Physical Examination
  • Inguinal Canals
  • Examine while standing
  • Check for hernias, spermatic cord varicoceles
  • UA
  • In uncircumcised male, retract fore skin and wash
    glans before collecting midstream specimen

15
Common GU Disorders Scrotum
  • Scrotal Edema
  • Insect/human bites
  • Contact Dermatitis
  • Idiopathic Scrotal Edema, boys 3-9 y/o
  • Unilateral pain, scrotal/penile/perineal/inguinal
    swelling erythema
  • U/S thickened skin, increased peritesticular
    blood flow, reactive hydrocele
  • Recurrent 10-20
  • Episode resolves 1-4 days
  • Scrotal contiguous w/ penile Edema
  • Fluid Overload, CHF, Anasarca

16
Common GU Disorders Scrotum
  • Scrotal Abscess, determine
  • Localized to scrotal wall
  • i.e. Hair follicle abscess
  • ID, sitz baths
  • Originates from intrascrotal structures
  • Needs U/S evaluation
  • Retrograde Urethrogram
  • Referral to Urologist

17
Common GU Disorders Scrotum
  • Fournier Gangrene
  • Polymicrobial, synergistic, necrotizing infection
    of perineal SQ fascia and male genitalia
  • Origin rectum, skin, urethra
  • Benign infection becomes virulent, leading to
    end-artery thrombosis necrosis
  • Diabetic Male, immunocompromised hosts highest
    risk

18
Common GU Disorders Scrotum
  • Fournier Gangrene
  • Mortality 20
  • Prompt recognition
  • Aggressive fluid resuscitation
  • Abx coverage g-, g, anaerobic
  • Surgical debridement
  • Urologic consultation periurethral involvement,
    Urinary tract involvement
  • Hyperbaric Oxygen Tx

19
Common GU Disorders Penis
  • Balanoposthitis (both)
  • Balanitis inflammation glans penis
  • Posthitis inflammation foreskin
  • Recurrent episodes can be only sign DM
  • Candida, Gardnerella, anaerobes
  • Tx mild soap, adequate drying, antifungal
    creams/po Rx, circumcision
  • Tx if suspect bacterial infection Broad spectrum
    axbx, 1st or 2nd gen Cephalosporin

20
Common GU Disorders Penis
  • Phimosis
  • inability to retract foreskin prox. post. to
    glans
  • Causes
  • Infection, poor hygiene, injury with scarring
  • Tx circumcision traditional
  • Topical steroids for 4-6 weeks
  • 70-90 effective
  • Avert circumcision

21
Common GU Disorders Penis
22
Common GU Disorders Penis
  • Paraphimosis
  • Urologic Emergency
  • Inability to reduce the proximal edematous
    foreskin distally over the glans
  • Increasing edema can lead to arterial compromise
    and gangrene

23
Common GU Disorders Penis
24
Common GU Disorders Penis
  • Paraphimosis Tx
  • (Local anesthetic block may be used)
  • Compression of glans may reduce edema
  • Tightly wrap glans in 2 in elastic bandage
  • 5 minutes
  • Expressing edema out of glans
  • Punture glans several times w/22g to 25g needle
  • Superficial Dorsal Incision of band

25
Common GU Disorders Penis
  • Entrapment Injuries
  • String, metal rings, wire, and hair
  • Penile Hair-tourniquet syndrome
  • Usu. 2-5 y/o circumcised boys
  • Hair may be invisible in swollen coronal sulcus
  • May involve urethral or dorsal Nerve compression
  • Check retrograde urethrogram penile Artery
    doppler before discharge
  • Remove object with ingenuity care

26
Common GU Disorders Penis
  • Fracture of Penis
  • Acute tear/rupture corpus cavernosa tunica
    albuginea
  • Acute swelling, Flaccid, Discolored, Tender
  • Hx trauma with intercourse/sexual activity
  • Sudden snapping sound
  • Usu. 30-40 y/o
  • Tx Retrograde urethrogram
  • Surgical hematoma evacuation, suture disrupted
  • tunica albuginea

27
Common GU Disorders Penis
  • Peyronie Disease
  • Progressive penile deformity
  • Curvature with erections Painful
  • May lead to erectile dysfunction unsuccessful
    vaginal penetration during intercourse
  • Thickened plaque on shaft of penis
  • usu. dorsally involves tunica albuginea of
    corpora bodies
  • Tx
  • Reassurance pain usually improves with time
  • Urologic referral
  • Assoc. with Dupuytrens contracture of hand

28
Common GU Disorders Penis
  • Priapism
  • Urologic Emergency, Consult required
  • Persistent, Painful, Pathologic erection
  • Both corpus spongiosum engorged with stagnant
    blood
  • Urinary retention may develop
  • Impotence may develop, 35 pts

29
Common GU Disorders Penis
  • Priapism Causes
  • Rx
  • Intracavernosal injections - Papaverine,
    prostaglandin E1
  • Oral HTN Rx - Hydralazine, prazosin, Ca Ch.Blk.
  • Psych - Chlorpromazine, trazodone, thioridazine
  • Hematologic disorders (see in Children)
  • Sickle Cell

30
Common GU Disorders Penis
  • Priapism
  • High-flow, rare
  • Non ischemic, nonpainful
  • Traumatic fistula b/w cavernosal art. corpus
    cavernosum
  • Dx by Doppler
  • Tx w/ embolization
  • Low-flow
  • Ischemic, Painful
  • Dx by dark acidic intracavernosal blood aspirate

31
Common GU Disorders Penis
  • Priapism Tx
  • Analgesia
  • Terbutaline 0.25 to 0.5 mg SQ in deltoid
  • Repeat q20 - 30 min. prn
  • Pseudoephedrine 60 120 mg po
  • Use within 4 hrs onset
  • Sickle Cell Pts
  • Simple or exchange transfusions

32
Common GU Disorders Penis
  • Carcinoma
  • Rare,1 in 100,000 reported malignancies
  • 5th to 6th decades of life
  • Uncircumcised males
  • Nontender ulcer or warty growth beneath foreskin,
    on glans or coronal sulcus
  • Often hidden by phimotic foreskin

33
Testes and Epididymis
  • Testicular Torsion
  • Potential infarction infertility
  • Peak incidence _at_ puberty
  • Occurs at any age
  • Results from maldevelopment of fixation btwn
    tunica vaginalis and posterior scrotal wall
  • Horizontally aligned testis at greater risk

34
Testes and Epididymis
  • Testicular torsion on exam
  • Firm, tender, high riding in scrotm testis
  • Epididymis may be displaced
  • Cremasteric reflex absent
  • Torsion vs epididymitis
  • NOT distinguished by Prehn Sign (Elevation of
    testis causing relief OR exacerbation of pain)

35
Testes and Epididymis
  • Testicular Torsion
  • Radiology images
  • Color-flow doppler U/S
  • Radionuclide scintigraphy
  • Either is useful if promptly available
  • If cannot be excluded by Hx/PE/Radiology
  • Emergent Urologic Consultation
  • Surgical Exploration
  • Tx OPEN THE BOOK!

36
Testicular torsion detorsion
37
Testes and Epididymis
  • Torsion of appendages
  • Four nonfunctional appendages
  • Testis Appendix 90
  • Epididymis Appendix 8
  • Paradidymis and vas aberrans
  • Twist more often than testis

38
Testes and Epididymis
  • Torsion of appendages Early
  • Pain intense near head of epididymis or testis
  • Tender palpable nodule
  • Blue dot sign, pathognomonic
  • If U/S shows normal testicular blood flow
  • pt avoids surgery
  • appendage calcifies/degenerates 10-14 days

39
Testes and Epididymis
  • Torsion of appendages Late
  • Testicular swelling increased
  • Doppler equivocal
  • Urologic Consultation needed
  • Surgical Exploration to exclude testis torsion

40
Testes and Epididymis
  • Epididymitis
  • Pain usually gradual onset
  • Inflammation can spread to testis causing
    epididymoorchitis (Must r/o torsion/abscess)
  • Initial exam isolated firmness nodularity of
    globus minor
  • Positive Prehn sign Pt with transient relief of
    pain in recumbent position with scrotal elevation
  • Later developing into large, tender scrotal mass

41
Testes and Epididymis
  • Epididymitis occurance
  • Young boys coliform bacteria
  • Often congenital anomalies lower urinary tract
  • lt35 y/o adults STDs, urethral strictures
  • Homosexual males fungal infections, STDs
  • gt40 y/o men E. coli Klebsiella
  • Older men with epididymitis secondary to UTI
    needs evaluation for underlying pathology

42
Testes and Epididymis
  • Epididymitis
  • Bacterial infection most common cause
  • UA pyuria 50 of pts
  • Negative, does NOT r/o epididymitis
  • Urine Cx S send in children or older men
  • Cx for GC/Chl if urethral D/C present
  • Doppler U/S r/o torsion, hydrocele

43
Testes and Epididymis
  • Epididymitis
  • Age lt35-40 think GC/Chl
  • Ceftriaxone 250mg IM, plus doxycycline 100mg po
    bid x 10 days
  • Ofloxacin 300mg po bid x 10 days
  • Age gt35-40 think g- bacilli
  • Cipro 500mg po bid x 10-14 days
  • Levofloxacin 250mg po qd x 10-14 days
  • TMP/SMX 160/800mg (DS) po bid x 10-14 days
  • Adjust for CxS results

44
Testes and Epididymis
  • Orchitis
  • Rare
  • Inflammation of testis
  • Testicular tenderness, swelling
  • Dx with HP
  • U/S r/o testicular torsion or abscess
  • Tx symptomatic and disease specific

45
Testes and Epididymis
  • Orchitis Causes
  • Systemic infections
  • Mumps unilateral 70 pts, spreads to
    contralateral day 1-9days
  • Viral illnesses (coxsackie, Epstein-Barr,varicell
    a, echovirus)
  • Bacterial assoc. w/ epididymitis
  • Immunocompromised pts.
  • Mycobacteriosis
  • Cryptococcosis
  • Toxoplasmosis
  • Candidiasis

46
Testes and Epididymis
  • Testicular Malignancy
  • Any Asymptomatic testicular mass, firmness or
    induration
  • 10 present with pain Secondary to hemorrhage
    within tumor
  • ANY unexplained testicular mass must be
    approached as possible tumor
  • Urgent Urological Referral needed

47
Testes and Epididymis
  • Think testicular CA metastasis if
  • Unexplained supraclavicular LAD
  • Abdominal mass
  • Chronic nonproductive cough from lung mets
  • Do testicular exam, may find primary tumor

48
Acute Prostatitis
  • Bacterial inflammation prostate
  • Sx/Sx
  • Low back pain
  • Perineal, suprapubic or genital discomfort
  • Obstructive urinary sx/sx, freq, urg, dysuria
  • Perineal pain with ejaculation
  • Fever or chills

49
Acute Prostatitis
  • Risks
  • Lower Urinary tract obstruction
  • Acute epididymitis or urethritis
  • Unprotected rectal intercourse
  • Phimosis
  • Intraprostatic ductal reflux
  • Catheter use

50
Acute Prostatitis
  • Common bacteria
  • E. coli, most common
  • Pseudomonas
  • Klebsiella
  • Enterobacter
  • Serratia
  • Staphylococcus

51
Acute Prostatitis
  • Clinical findings
  • Perineal tenderness, rectal sphincter spasm,
    prostatic bogginess or tenderness
  • Dx
  • Clinical
  • UA, Cx S, may be negative
  • Urethra Cx for GC/Chlamydia

52
Acute Prostatitis
  • Tx
  • Cipro 500mg po bid for 30 days
  • Best, initial Tx
  • TMP/SMX DS 1 po bid for 30 days
  • Lower cure rates
  • Discharges home with urologic F/U
  • Admit when pt
  • Evidence of sepsis
  • Diabetic, immunosuppressed

53
Urethra
  • Urethritis
  • Purulent or mucopurulent urethral D/C
  • Dx usu. clinical
  • Confirm w/Pyuria, bacteriuria in first void
    specimen
  • Causative bacteria
  • N. gonorrhea or C. trachomatis usu.
  • HSV, U. urealyticum, Trich. Less frequent

54
Urethra
  • Urethritis
  • R/O epididymitis, disseminated GC, or Reiter
    syndrome
  • Tx with Abx
  • Ceftriaxone 125 mg IM and Azithromycin 1g po
  • Or Doxycycline 100 mg po bid x 7 days
  • Recurrent think
  • Trich, Tx w/ metronidazole
  • doxycycline resistant U. urealyticum, use
    azithromycin

55
Urethra
  • Urethral Stricture
  • Teenagers/young adults
  • think STD, GC/Chl
  • Bulbous urethral strictures
  • Traumatic, will be at site of injury
  • Older pop.
  • Postendoscopy meatal stenosis
  • Localized strictures

56
Urethra
  • Urethral Stricture
  • D/Dx of nonpassible catheter
  • stricture, sphincter spasm, bladder neck
    contracture, BPH
  • Dx
  • Retrograde urethrography can give location and
    extent of stricture
  • Endoscopy confirms bladder contracture and BPH
    role

57
Urethra
  • Urethra Stricture
  • Emergency Bladder Decompression
  • Suprapubic cystostomy
  • Seldinger technique cystostomy
  • Cystostomy kit for suprapubic indwelling catheter
    insertion
  • Urologic followup in 2-3 days

58
Urethra
  • Urethral Foreign Bodies
  • Bobby pins, long thin paint brushes, ball point
    pens
  • Bloody urine combined with infection and slow,
    painful urination
  • Xray may disclose radiopaque foreign bodies
  • Removal often via endoscopy
  • Once removed, retrograde urethrogram or endoscopy
    needed to evaluated urethra

59
Urinary Retention
  • Bladder Outlet Obstruction
  • Urinary retention
  • Chronic systemic medical illness or carcinoma
  • Motor or sensory deficits
  • Medications sympathomimetic agonists causing
    muscle constriction
  • Long trips, voluntary infrequent voiding coupled
    with borderline obstructive Sx
  • Mechanical causes

60
Urinary Retention
  • Exam
  • Inspect meatus for stenosis
  • Palpate entire length urethra
  • R/O masses, fistulas, abscess
  • Lower abdomen
  • R/O Suprapubic mass
  • Rectal Exam
  • Anal sphincter tone, Size consistency of
    prostate
  • Lrg intravesical prostate feels normal but
    obstructs
  • Lrg nodular prostate may shrink, postvoid
  • U/S for distention/postvoid residual

61
Urinary Retention
  • Catheter
  • Alleviates pain, distress, urinary retention
  • Use Lidocaine lubricant
  • If fail to pass 16fr, try 16 Coude
  • Pass catheter to fullest extent obtaining free
    flow urine
  • Then Inflate balloon
  • Avoid inflating balloon in prostatic urethra

62
Urinary Retention
  • Catheter
  • Rapid decompression
  • Transient gross hematuria may occur
  • Post micuritional/decompression syncope is rare
  • Postobstructive diuresis may occur
  • Hypovolemia and Hypotension develops
  • Monitor hourly I/O, vitals, urine and serum
    electrolytes
  • Dissipates in 24-48 hrs after tubules recover

63
Urinary Retention
  • D/C home
  • Leave indwelling catheter with leg bag
  • Educate pt/family on care and for emergency
    balloon deflation catheter removal
  • Antibiotics if evidence of UTI
  • Urologist consult for F/U and GU eval
  • Observe in ED 4-6 hrs or admit
  • Chronic or insidious urinary retention pts
  • Postobstructive diuresis occurs
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