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S2 E094 Male genitalia, Studying for test questions and understanding the PANCE

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Erectile dysfunction

Clinical Presentation

  •   Usually a routine physical exam and direct questioning

Labs, Studies and Physical Exam Findings

  •   History is especially important here in order to rule out psychological causes
  •   U/S with doppler
  •   MRA

Treatment

  •   Exercise
  •   Phosphodiesterase type 5 inhibitors
    •   Tadalafil (Cialis)
    •   Vardenafil (Levitra)
    • Alprostadil
  •   Penile implants

Hypospadias/Epispadias

Hypospadias is a relatively common defect where the urethra ends on the underside of the penis.  Surgical correction may be necessary, but is often a cosmetic issue.

Epispadias is a rare defect where the urethra ends on top of the penis.

Paraphimosis

  •   The foreskin is trapped behind the glans of the penis and can not be reduced
  •   Typically this is caused by a medical practitioner who fails to reduce the foreskin after examination or placement of a catheter.

Treatment

  •   If it can not be reduced the band of the foreskin must be cut

Phimosis

  •   The foreskin can not be retracted over the glans of the penis
  •   This may be normal into adolescents

Treatment

  •   Steroid cream
  •   Circumcision

Benign Prostatic Hyperplasia (BPH)

  •   Advancing age is a risk factor.  90% of men older than 80 will have BPH

Clinical Presentation

  •   Getting up multiple times overnight to urinate (nocturia)
  •   Hesitancy
  •   Decreased urine flow
  •   Incomplete bladder emptying
  •   Frequency

Labs, Studies and Physical Exam Findings

  •   History is important to rule out other possible causes
  •   Smooth, firm enlarged prostate on rectal exam generally in the middle lobe
  •   Neurologic exam
  •   Urine culture will be negative
  •   Serum prostate specific antigen (PSA)
  •   U/S

Treatment

  •   Behavior modification
  •   Decrease fluids before bed
  •   Decrease alcohol and caffeine consumption
  •   Routine voiding schedule
  •   Medications
    •   Alpha blockers – relax smooth muscle.  Side effects include hypotension
      •   Prazosin
      •   Terazosin
  •   5 alpha reductase inhibitors – These block production of DHT which causes BPH
    •   Finasteride
    •   Dutasteride
  •   Surgery
  •   Transurethral resection of the prostate (TURP)
  •   Prostatectomy

Testicular Torsion

  •   Highest incidence at puberty

Clinical Presentation

  •   Severe acute abdominal pain
  •   Nausea and vomiting are possible

Labs, Studies and Physical Exam Findings

  •   The affected testes are firm and tender and usually a little higher
  •   Cremasteric reflex
    •   Unilateral absence of is 99% sensitive
    •   Lightly stroke the superior medial thigh and the cremaster muscle should pull the testis up on the side that was stroked.
  •   Prehn’s sign (pain relief with elevation of the testis) is not entirely helpful as it is + in testicular torsion and epididymitis
  •   U/S with doppler

Treatment

  •   Manual detorsion of the testis – opening a book
  •   Surgical emergency

Spermatocele

  •   Benign cyst within the scrotum which contains spermatozoa

Clinical Presentation

  •   A routine physical exam
  •   Typically painless though may be palpable or uncomfortable if very large

Labs, Studies and Physical Exam Findings

  •   These will transilluminate if large enough
  •   May be palpable on physical exam
  •   U/S

Treatment

  •   Most commonly these are left alone
  •   Spermatocelectomy

Hydrocele

  •   A collection of serous fluid within the scrotum

Clinical Presentation

  •   A routine physical exam
  •   Typically painless though may be palpable or uncomfortable if very large

Labs, Studies and Physical Exam Findings

  •   These will transilluminate if large enough
  •   May be palpable on physical exam
  •   U/S

Treatment

  •   Surgical removal

Varicocele

  •   This is an enlargement of the venous structures within the scrotum

Clinical Presentation

  •   Aching in the scrotum
  •   Patient feels something within the scrotum

Labs, Studies and Physical Exam Findings

  •   A bag of worms on palpation
  •   Will not transilluminate
  •   U/S

Treatment

  •   Varicocele is not necessarily a problem in itself, but may cause decreased sperm count due to elevated temperature.
  •   Removal the venous plexus.  Treatment results are questionable.