Hello and welcome to the Physician Assistant Exam Review Podcast. I know, I know, you’ve always wanted to know about penile disorders. Well, today is your day. We’re going to be covering penile disorders today, and don’t worry, testicular disorders will be next week. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, where I’ve been behind the mic for almost 15 years, helping students just like you who are feeling lost, struggling, just finding that the information isn’t sticking the way that they want it to be. And we’ve been doing this now, like I said, for a long time, helping PA students, helping NP students, helping pharmacy students start to organize information in their brains in a way that makes it available on test day.

That’s really the goal, right? I was talking with someone, one of my surgical techs this week, who was saying when she trains new techs, her goal for them, and she states this clearly, is to not get kicked out of the room. Let me say that again. Her goal for them isn’t to do a good job during the case, not to know everything, not to have every piece of equipment ready. It’s to not get kicked out of the room. Because if you don’t get kicked out of the room, if the surgeon doesn’t kick you out, it means you get to come back and you get to do a better job next time. And you get to learn and you get to do a better job next time.

I said that’s exactly how I teach my PA students. Goal number one is to stay in school, right? If you can’t stay in school, the rest of it doesn’t matter. So, goal number one has to be stay in school. Goal number two is to do amazing on your on your exams. Do the best you possibly can on your exams. Goal number three is to learn as much as you can.

Then it’s pass, then it’s graduate, then it’s pass the PANCE, then it’s becoming practitioner, then it’s become a great practitioner, but it’s in that order. So, that’s a lot of the way that we deal with the information in this particular show. We do it with that framework in mind. Like I said, today we’re going to do penile disorders. Hopefully that’ll stand out for you. These shouldn’t be too terribly difficult. But before we talk about that, I just wanted to mention that this is going to be on Wednesday the 26th.

So first of all, Happy Thanksgiving. Thanksgiving will be tomorrow. And really important to take some time, practice some gratitude, Enjoy some time away from your studies. I hear from so many students who are just grinding and grinding and grinding, and you definitely need some time away. On top of that, I’m going to be hosting the first week in December, three high-impact sessions to reboot your system for studying, for test-taking, and for peak performance and anxiety management. I’m going to host it the first week in December, but it’s going to go on sale Black Friday, where you’re going to get the lowest possible price. Then it’ll be available through the weekend.

But at the end of Cyber Monday, at the end of Monday at 12 p.m., you won’t be able to register anymore because we’re going to start on Tuesday and I don’t want anybody coming in late. It’s just going to screw up all the backend stuff for me. It’s really complicated when people come in after I close things down or after I’m getting ready to record that kind of stuff. So those are going to be live sessions. They will be recorded. But if you’re there at the live, then you can get your questions answered. We can walk through things.

That’s a whole lot more fun. And those will be the following week. You can get information for that at physicianassistantexamreview.com/blackfriday, where you can find all of that.

All right. So for starters, like we always do, let’s jump in and get started with our priming questions. What is it called when the urethral opening is on the ventral side in a newborn boy? What is it called when the urethral opening is on the ventral side in the newborn boy? What is the name for foreskin stuck behind the glans after catheterization? What’s the name for when the foreskin gets stuck behind the glans after catheterization? Painful urination and inability to retract the foreskin due to scarring indicates what diagnosis?

Painful urination and inability to retract the foreskin due to scarring Indicates what diagnosis? An older man with nighttime urination, weak stream, and straining likely has what condition? An older man with nighttime urination, weak stream, and straining likely has what condition? Lastly, difficulty maintaining erections, but preserved morning erections suggest what condition?

All right, so penile disorders is what we’re covering today, which is erectile dysfunction, hypospadias and epispadias, paraphimosis and phimosis, priapism, and then benign prostatic hyperplasia.

All right, so let’s jump in with erectile dysfunction. This is the inability to achieve or maintain an erection firm enough for intercourse. This is very common prevalence with increasing age, may be vascular, neurologic, hormonal, hormonal medication-induced, or psychogenic. And one of the places that they may ask you about this is what’s causing it, right? And it’s, a lot of these seem to be, maybe they’ll be treatment-based, but a lot of them aren’t. A lot of them are going to be just diagnosis. If you look at how they’re set up, we’re asking about risk factors for these things.

So risk factors for ED would be anything that’s going to cause a vascular issue. So diabetes, hypertension, cardiovascular disease, smoking, obesity. Then we’re going to get to low testosterone, maybe SSRIs, beta blockers, thiazides, spironolactone, and lastly, pelvic surgery like a prostatectomy. So previous surgery, definitely an indication here. Clinical presentation, difficulty achieving or maintaining an erection, right? That’s sort of what it is. Morning erections may be preserved in psychogenic ED.

So if you’re still getting erections, but have trouble for intercourse, maintaining it, that’s maybe two different factors, right? It might be psychogenic versus a cardiovascular issue. Gradual onset suggests organic disease. Sudden onset suggests psychogenic issues. Here, the question stem is likely going to describe a man with diabetes or some kind of vascular disease reporting difficulty maintaining erections. Largely, this is a clinical diagnosis. You can do some basic labs like a fasting glucose or A1C or a lipid panel, those kind of things, but again, it’s mostly clinical.

You can do a serum testosterone, and you may consider cardiovascular evaluation because ED may precede coronary disease. So if a person has erectile dysfunction, you may want to look into the rest of their cardiovascular system. Treatment lifestyle is going to be number one, right? So weight loss, exercise, smoking cessation, reducing alcohol is a good one. Medications would be your phosphodiesterase 5 inhibitors. So sildenafil, tadalafil. Contraindications would be nitrates, right?

What’s the problem with nitrates and your phosphodiesterase 5 inhibitors? Severe hypotension. Hypotension, right? Severe hypotension. You may do for a treatment, replace testosterone. And then there are injections or penile prosthesis you can do as you get further down that road.

Exam keys here. Again, there’s just not a whole lot of information in these. It’s really going to be major things you’re going to be tested on. And then one or two of them may pop up, so I’m trying to cover it for you. But it’s tough to come up with how these questions are going to come.

Exam keys, gradual onset plus vascular risk factors, you’re thinking organic erectile dysfunction. Preserved morning erections, you’re thinking psychogenic erectile dysfunction. First line drug therapy is going to be PDE5 inhibitors. Watch out for the nitrates there and evaluate for underlying cardiovascular disease. Next is hypospadias and epispadias. Hypospadias is when the urethral meatus opens on the ventral surface of the penis, so on the underside. Epispadias is when the meatus opens on the dorsal surface, so this is much less common and a much bigger problem.

These are congenital issues, so they come up with newborns. Risk factors are family history, maternal estrogen exposure, low birth weight or prematurity, and may be associated with cryptorchidism, so keep that in mind. Clinical presentation. You’re going to see that abnormal location of your urethral meatus, especially when the infant urinates. Ventral penile curvature, so you can get a chordee, which can occur with hypospadias. Abnormal urinary stream, like I said, that’s going to be the first thing. When I was in the, literally yesterday, I was up doing a C-section on the sixth floor, and immediately after birth, this kid just starts peeing all over the neonatologist.

The question stem would likely describe a newborn boy with the urethral opening on the underside of the penis or difficulty directing urine, that kind of thing. This is again clinical diagnosis, not a whole lot of studies you’re going to have to do here. It’s pretty obvious. The major thing here is do not circumcise, because you may want to use that foreskin for surgical repair. You’re also going to want to check for an undescended testes, because again, they can go together. Treatment here is going to be surgical repair, ideally between 6 and 12 months of age. And again, the epispadias is a more complex repair.

I don’t think you need to know a whole lot more than that. Your keys for the exam here is know the difference between hypospadias and epispadias and know that don’t circumcise these children, and the repair is going to be between 6 and 12 months. Phimosis and paraphimosis is next. Phimosis is the inability to retract the foreskin skin over the glans of the penis. So you can’t pull the foreskin back. This can be physiological in young boys or pathological from scarring and chronic inflammation and infection and poor hygiene. So you sort of have to determine which is going on here.

Risk factors are that poor hygiene, recurrent infections, diabetes, which can lead to recurrent infections. Is kind of why that gets tied in there. Clinical presentation again, difficulty retracting the foreskin, ballooning of foreskin during urination, pain or irritation in pathological cases. Here the question stem would likely describe a boy or adult male who cannot retract his foreskin, and sometimes with recurrent infections. This too will be a clinical diagnosis. You’re going to want to rule out infection because when you see this, it may be swollen, it may be red, it may be tender, that kind of thing. So in children, again, this may be physiologic, so reassurance is okay.

Pathologic, if you believe it to be pathologic, topical corticosteroid cream, gentle stretching, and then if you’re really in trouble here, circumcision for refractory cases or recurrent infections.

Exam keys here again pretty straightforward. Inability to retract the foreskin is phimosis. Treating with topical steroids is first, then circumcision. Paraphimosis is a urologic emergency.

Okay, good to know. Paraphimosis is a urologic emergency. This is the retracted foreskin becomes trapped behind the glans causing venous congestion and possible arterial compromise. Risk factors are improper foreskin retraction during catheterization or exam. It’s definitely uncommon, but I’ve had concerns about this when patients have come down and having the foreskin retracted and then not put back when a patient’s been catheterized. If it’s retracted for too long, you can run into this problem. And then poor hygiene.

Phimosis is also a risk factor. Clinical presentation, painful swollen glans with tight constricting band of foreskin behind the glans. Edema, discoloration, and the question stem here would likely describe acute penile pain and swelling after the foreskin was left retracted. Diagnostics here, this is going to be clinical, right? We’re not going to be imaging. We don’t need an MRI. You don’t need anything.

This is a clinical diagnosis. This is first step is immediate manual reduction and lubrication with compression. So you’re going to try to reduce that foreskin. Really straightforward and obvious stuff here, right? If this foreskin is trapped behind the glans, goal number one is to manually reduce it. If unsuccessful, you may need to surgically slit that foreskin in order to relieve the pressure. And then you may wind up with a full circumcision once swelling resolves.

Obviously, this can lead to ischemia and necrosis. That is bad.

Exam keys, painful swollen glans, retracted foreskin, Stuck behind the corona. This is paraphimosis, emergency reduction required. Our last penile issue before we get to BPH is priapism. This is painful erection lasting more than 4 hours unrelated to sexual activity. So, we have 2 main types. This is ischemic and non-ischemic. So an ischemic is low blood flow, right?

Most common painful, this is an emergency. Non-ischemic is high flow, usually post-trauma, less painful. Risk factors here, sickle cell disease, trazodone comes up as a major one, antipsychotics, and then your PDE5 inhibitors. Much less common than your trazodone or your antipsychotics, but still on the list. Leukemia or other hematological diseases, cocaine or alcohol use, and then perineal trauma. Clinical presentation. Ischemic, rigid, painful shaft, glans may stay soft.

Non-ischemic, this is partially rigid, minimally painful after trauma. The question stem here is likely going to say something like, painful erection in a patient, probably going to have something in there with like sickle cell or trazodone as part of their presentation or part of their history. Again, this is going to be a clinical diagnosis. We’re not getting x-rays. There’s nothing to ultrasound here. If you’re not sure, you can just stick a small needle into the penis and remove some of the blood. If it’s ischemic, you may find some dark, low oxygenated blood.

Treatment. Ischemic is an emergency, right? So this is immediate aspiration of trapped blood. You can do an injection of phenylephrine directly into the penis. Pain medication would be nice. And if they have sickle cell opposite, we’re going to treat that. In non-ischemic disease, we’re going to do observation.

We’re going to do ice. Gentle compression may help. And then your exam keys here. Painful erection greater than 4 hours is ischemic priapism. This is an emergency, so we’re going to aspirate and phenylephrine. You’re going to watch for sickle cell and trazodone. Those are the classics.

Our last one for the night is BPH. We’ve mentioned BPH a couple times as we move through this. When we talk about… what’s the word I’m looking for. When we have obstructive disorders… I’m completely blanking here on… What was the first thing we covered?

I can’t think of the word. And we have an urinary incontinence due to obstruction, right? That’s what I’m going to do. So we talked about BPH very early on as we go through GU. It’s earlier in the blueprint, but because it’s a small section, I couldn’t find a good place to put it, so I put it in here. The definition here is it’s a non-cancerous enlargement of the prostate leading to bladder outlet obstruction. This is important.

A non-cancerous enlargement of the prostate leading to bladder outlet obstruction. This is extremely common in older men, and it causes lower urinary tract symptoms. Risk factors, advancing age, family history, obesity, metabolic syndrome. It can be associated with erectile dysfunction and medications like antihistamines or anticholinergics. Clinical presentation is obstructive symptoms, so you get a weak stream, hesitancy, straining, dribbling. Incomplete emptying is a big one here. You can also get irritative symptoms.

You get frequency, urgency, and nocturia because if you’re not completely emptying the bladder, you’re going to have frequency. You’re going to have nocturia, right? That just makes sense. You can also get acute urinary retention. And in this case, the question stem is going to say something like an older man with gradually worsening urinary hesitancy, a weak stream, and nocturia getting up maybe three, four times overnight, that kind of thing. Your diagnostics here is a digital rectal exam. You’re going to feel a smooth, enlarged, rubbery prostate.

You’re going to want to do a UA to rule out infection or hematuria. You might want to do a PSA. You might check, again, if you have issues with incomplete emptying, the patient’s complaining and things like that, you can do a post void residual, so you can check how much urine is still in the bladder after they void. Treatments. Step one is going to be lifestyle stuff, right? So, same as always. We’re going to reduce evening fluids to help with that nocturia Limit caffeine and alcohol.

Avoid decongestants and anticholinergics. And then timed voiding. We talked about this earlier, but planning it out. Medications, alpha blockers are the first line here, right? Most people seem to remember that. These help to relax the smooth muscle and help with symptom relief. 5-alpha reductase inhibitors like finasteride or dutasteride.

Finasteride, dutasteride, you get to mock my mispronunciations once again. These can shrink the prostate best for large prostates. They are slow to work. And then step three is surgical procedural options. So if you’re not getting any symptom relief, if you’re getting recurrent UTIs, if you’re getting stones, renal insufficiency, then your TURP is going to be your gold standard. It’s really going to be the answer that they’re looking for here.

Exam keys. This is an older man with a weak stream and nocturia with a smooth and large prostate. That’s going to be BPH. Alpha blockers give the fastest relief. 5-alpha reductase inhibitors shrink prostate and lower PSA. Acute urinary retention. Immediate catheterization is going to be the answer there.

And if they have recurrent issues, complications, you’re going to move to a TURP. Make sense? Beautiful.

All right, so that brings us to the end of the section I want to cover on penile disorders and BPH. Beautiful, beautiful. We’re on our way through GU. We actually only have one more show for GU. That’s next week, which we’ll be doing testicular disorders, urethral disorders, and kidney stones. I think that’ll all fit into one show. I’ll do the notes and be sure of it, but I think that’s going to be the case.

What I wanted to talk about today was as far as the study tip goes before we get into the priming questions. Was an idea I came across just yesterday. I was listening to a podcast, and someone mentioned a comedian. And I sent out an email, actually yesterday morning, with her name. I can’t think of it off the top of my head. I should have written it down, but I didn’t. And she was describing being on social media and what it does to her brain.

And she used the term, I have type 2 ADHD. And I thought that was absolutely perfect, that she absolutely nailed it. I’m talking to so many students, and I’m watching my children, who are presenting with or talking about ADD symptoms, trouble focusing, trouble sitting, trouble getting through an entire movie, that kind of thing. Not flinching to check their phone every two seconds. And what I’ve thought for a long time is that this isn’t that they have ADD or ADHD. It’s that they have induced the similar symptoms because of those quick dopamine cycles of being on the screens, of video games, of Instagram, of whatever short-form videos you’re watching, checking email, checking Facebook, checking Instagram, checking all of these things repetitively, checking the news repetitively. Feeling those alarm bells go off as you read the headlines.

Wondering why you get twitchy. Wondering why you can’t focus. Wondering why you can’t fall asleep. And it seems a lot like ADD. And the symptoms are similar. But it’s not about how your brain is wired. It’s about what you’re doing to it and the habits you’re creating.

I can feel it in myself when I get worse on those days, right? I’ll get up and I’ll check the news. I’ll get up and I’ll check my email. I’ll check Instagram to see how the latest post was doing. I have DMs, right? And then I’ll check my email again and then I’ll check in on the 33 Days to Pass the PANCE members and make sure they don’t have any questions. By the time I finish that, maybe I pick up my phone, play a two, three minute game.

Then all of a sudden it’s time to say, oh, maybe someone sent me something else on Instagram. So I have to go back and check it again. Then maybe somebody sent an email. So I have to go back and check it again. And it’s over and over and over. And as you go through this cycle multiple times, you feel worse and worse and worse and worse. And your focus gets less and less and less, and it’s harder to maintain.

So, I love the way that she used that term, type 2 ADHD, to describe it, because I think that’s exactly what’s going on. And the way to battle this, something I’ve been working on and not doing a good job of, by the way, is a technique I heard someone else talk about. I’m trying to struggle for the name of the individual I heard that from, too, but suddenly I’m blanking on that, too. But it’s the idea of saying no to yourself. Of creating the habit of impulse control. And this individual talked about making it a point to get to 25 no’s a day. How many times can you say no to yourself in a day?

Oh, maybe I should just go check the refrigerator. Nope. Oh, maybe I should check Instagram. Nope. I’m just going to pick up my phone to check the weather because that’s really important. Nope, take a break. Don’t need to check it.

Because how many times you check the weather and wind up 15, 20 minutes, an hour later, not sure why you picked up your phone in the first place. So I thought that was a great technique, a great takeaway that you can use is keep an eye out for some of those things that your brain ticks off and makes them seem like they’re super important and they’re really not. And just say no and try to get to a place where you’re controlling those impulses. I thought those were some cool ideas, not my own, but some good ideas.

All right, let’s talk about the priming questions. What is it called when the urethra opening is on the ventral side in a newborn boy? Ventral side opening for the urethra. This is hypospadias. What’s the name for when the foreskin gets stuck behind the glans, especially after something like catheterization. This is paraphimosis. Painful urination and inability to retract the foreskin due to scarring indicates what diagnosis?

That would be phimosis. Older man with nighttime urination, weak stream, and straining likely has what condition? BPH. Difficulty maintaining erections but preserved morning erections suggest what condition? Erectile dysfunction, but I added the caveat of psychogenic, although I didn’t really ask that straight up. So maybe you missed it, but it should be psychogenic erectile dysfunction. Awesome.

All right, well, thank you so much for participating. Thank you so much for being part of the community. I really do appreciate that. Again, I’m going to be hosting something really special the first week in December for the Black Friday PA Student Reboot Program. It’s going to be three nights, all recorded, but it’s much better if you’re there live. You’re going to get the best possible price on Black Friday. The only way, well, You can go to physicianassistantexamreview.com/blackfriday.

That’s how you’re going to find out about it. If you sign up for the early bird email list, then I’ll definitely shoot you an email so you’ll know when it’s coming. And then over the weekend, it will still be available, but it goes away on Monday because we start on Tuesday. Everything will be recorded, so don’t worry about it. Not designed to interfere with your work, designed to speed up your work, get you some better scores. Really, the point here is that the next cohort of 33 Days to Pass the PANCE doesn’t start until February. And I had a bunch of people reach out to me and say, like I can’t wait till February.

I’ve got stuff. I’ve got my exam in January. I’ve got things. I can’t wait that long. So, I was trying to come up with how can I help those people in this window before that February cohort kicks off. So, I figured, why don’t I do this three-night session where I go through a lot of the same material as quickly as I possibly can and get you the biggest impact I can get you in a shorter, tighter time frame. Make sense?

All right. Great.

Fantastic. Well, have a great day. I look forward to talking to you next week, but definitely go to physicianassistantexamreview.com/blackfriday to check that out. And if it’s for you, definitely love to have you and would enjoy you showing up to the lives, asking questions, participating. It’s the best way to learn and get the most out of it.

All right. Take care. I’ll talk to you next week.