Erectile Dysfunction (ED)

Definition

• Inability to achieve or maintain an erection firm enough for intercourse
• Very common; prevalence increases with age
• May be vascular, neurologic, hormonal, medication-induced, or psychogenic

Risk Factors

• Diabetes
• Hypertension
• Cardiovascular disease
• Smoking
• Obesity
• Low testosterone
• SSRIs, beta-blockers, thiazides, spironolactone
• Pelvic surgery (prostatectomy)

Clinical Presentation

• Difficulty achieving or maintaining an erection
• Morning erections may be preserved in psychogenic ED
• Gradual onset suggests organic disease; sudden onset suggests psychogenic
• The question stem would likely describe a man with diabetes or vascular disease reporting difficulty maintaining erections

Diagnostics

• Clinical diagnosis
• Basic labs: fasting glucose/A1c, lipid panel
• Serum testosterone (morning level) if hypogonadism suspected
• If unclear: nocturnal penile tumescence testing distinguishes psychogenic vs organic
• Consider cardiovascular evaluation because ED may precede coronary disease

Treatment

• Lifestyle: weight loss, exercise, smoking cessation, reduce alcohol
• First-line medication: phosphodiesterase-5 inhibitors (sildenafil, tadalafil)
• Contraindication: nitrates (causes severe hypotension)
• Low testosterone → testosterone replacement when indicated
• Vacuum erection devices, penile injections (alprostadil), or penile prosthesis if refractory

Exam Keys

• Gradual onset + vascular risk factors → organic ED
• Preserved morning erections → psychogenic ED
• First-line therapy → PDE-5 inhibitors
• Never combine PDE-5 inhibitors with nitrates
• Evaluate for underlying cardiovascular disease

Hypospadias and Epispadias

Definition

• Hypospadias: urethral meatus opens on ventral (underside) surface of penis
• Epispadias: urethral meatus opens on dorsal surface (less common)
• Congenital conditions due to abnormal urethral development

Risk Factors

• Family history
• Maternal estrogen exposure
• Low birth weight or prematurity
• Associated with cryptorchidism

Clinical Presentation

• Abnormal location of urethral meatus
• Ventral penile curvature (chordee) may accompany hypospadias
• Abnormal urinary stream
• The question stem would likely describe a newborn boy with a ventral urethral opening or abnormal urine stream

Diagnostics

• Clinical diagnosis on newborn exam
• Do NOT circumcise — foreskin may be needed for repair
• Evaluate for undescended testes if present

Treatment

• Surgical repair at 6–12 months
• Goals: normal urine stream, straight penis, normal appearance
• Epispadias often requires more complex reconstruction

Exam Keys

• Ventral opening = hypospadias
• Do NOT circumcise before evaluation
• Repair at 6–12 months
• Associated with chordee and cryptorchidism

Phimosis

Definition

• Inability to retract foreskin over the glans
• Physiologic in young boys; pathologic from scarring or infection

Risk Factors

• Recurrent balanitis or infections
• Poor hygiene
• Diabetes

Clinical Presentation

• Difficulty retracting foreskin
• Ballooning of foreskin during urination
• Pain or irritation if pathologic
• The question stem would likely describe a child or adult who cannot retract foreskin with recurrent infections

Diagnostics

• Clinical diagnosis
• Rule out infection if erythema or discharge present

Treatment

• Physiologic (children): reassurance
• Pathologic: topical corticosteroid cream and gentle stretching
• Circumcision if recurrent infections or refractory

Exam Keys

• Inability to retract foreskin = phimosis
• First-line: topical steroids
• Circumcision if persistent or infected
• Never forcefully retract in children

Paraphimosis

Definition

• Urologic emergency
• Retracted foreskin becomes trapped behind the glans causing venous congestion and possible ischemia

Risk Factors

• Improper foreskin retraction during catheterization or exam
• Poor hygiene
• Phimosis
• Edema from infection or trauma

Clinical Presentation

• Painful swollen glans
• Tight constricting band of foreskin behind the corona
• Edema and discoloration
• The question stem would likely describe acute penile pain and swelling after foreskin left retracted

Diagnostics

• Clinical diagnosis

Treatment

• Immediate manual reduction with lubrication/compression
• If unsuccessful: dorsal slit
• Circumcision once swelling resolves

Exam Keys

• Painful swollen glans + trapped foreskin = paraphimosis
• Emergency reduction required
• Delay risks ischemia and necrosis

Benign Prostatic Hyperplasia (BPH)

Definition

• Noncancerous enlargement of prostate causing bladder outlet obstruction
• Very common in older men
• Causes lower urinary tract symptoms (LUTS)

Risk Factors

• Age
• Family history
• Obesity or metabolic syndrome
• Erectile dysfunction association
• Medications (antihistamines, anticholinergics)

Clinical Presentation

• Obstructive: weak stream, hesitancy, straining, dribbling, incomplete emptying
• Irritative: frequency, urgency, nocturia
• Acute urinary retention possible
• The question stem would likely describe an older man with hesitancy, weak stream, nocturia

Diagnostics

• DRE: smooth, enlarged, rubbery prostate
• Urinalysis to rule out infection or hematuria
• PSA optional (consider if life expectancy >10 years)
• Post-void residual may be borderline elevated
• Ultrasound/cystoscopy only if hematuria, recurrent infections, or uncertainty

Treatment

Step 1: Lifestyle

• Reduce evening fluids
• Limit caffeine and alcohol
• Avoid decongestants and anticholinergics
• Timed voiding

Step 2: Medications

• Alpha-blockers (tamsulosin, alfuzosin) for fast symptom relief
• 5-alpha-reductase inhibitors (finasteride, dutasteride) shrink prostate; best for large glands
• Combination therapy for moderate/severe symptoms

Step 3: Procedures

• Indications: refractory symptoms, recurrent retention, recurrent UTIs, stones, renal insufficiency
• TURP (gold standard)
• Minimally invasive: laser therapy, UroLift

Exam Keys

• Older man + weak stream + nocturia + smooth enlarged prostate = BPH
• Alpha-blockers give quickest relief
• 5-alpha-reductase inhibitors shrink prostate and lower PSA
• Acute retention → catheterization
• TURP for complications or refractory symptoms