Structural Abnormalities - Men's Health
What are the classifications of hypospadias?
1.Glandular: opening on proximal glans penis 2.Coronal: opening at the coronal sulcus 3.Penile shaft 4.Penoscrotal 5.Perineal **70% are distal penile or coronal**
What causes hydrocele?
Can occur as result of inflammatory condition : Reactive hydrocele: usually acute or maybe more painful •Epididymitis •Orchitis •Testicular tumor
How do you diagnose torsion of appendix testes?
Clinical diagnosis Scrotal US: low echogenicity of the torsed appendage with a central hypoechogenic area •Can usually differentiate the appendage from the testicle
•Painless scrotal swelling •Soft, pear-shaped, fluid-filled cystic mass ANTERIOR to the testicle and epididymis •May complain of dull ache or heaviness
Hydrocele PE: TRANSLUMINATES when light is shown through testicle •Will enlarge (worsen swelling) with Valsalva if it is a communicating type
Complications of cryptorchidism
Increased risk of: •Malignancy: testicular: seminomas •Infertility: over 75% of untreated bilaterally cryptorchid men, normal fertility if surgically treated •Inguinal Hernia •Testicular Torsion
How do you diagnose spermatocele?
Scrotal Ultrasound
Treatment of epispadias
Surgical correction •To correct incontinence •Straighten the penis by removing the chordee •Extend urethra out onto the glans penis
•Acute onset of scrotal, inguinal or lower abdominal pain (usually <6 hours) •Nausea and vomiting may be present
Testicular torsion
•Chronic obstructive voiding symptoms •Weak urinary stream •Incomplete bladder emptying WITH a hx of recurrent UTIs, urinary spraying, or dysuria
a urethral stricture
What is a orchiopexy?
fixation of an undescended testis in the scrotum
Most common cause of PAINLESS scrotal swelling
hydrocele •Most occur in older patients •Develop gradually
•Difficulty directing stream of urine or spraying •Curvature (chordee) can prevent sexual intercourse •Increased risk of UTIs •May cause ED
hypospadias •Physical exam: ventral urethra, dorsal hooded prepuce (abnormal foreskin, but circumcision not recommended at birth), chordee, may also have cryptorchidism
•Severe penile pain •Swelling •Erythema •Constriction causes edema and venous engorgement of the glans, which can lead to arterial compromise with subsequent tissue necrosis
paraphimosis
•Edema, erythema and tenderness of the prepuce and the presence of purulent discharge usually cause the patient to seek medical attention
phimosis
•Painless, cystic testicular mass •>2cm to be considered a spermatocele •Round, soft, fluctuant mass that is superior, posterior and separate from the testicle. (it is the head of the epididymis)
spermatocele PE: Freely movable •Will transilluminate
•"Blue dot" sign: infarcted and necrosed appendage can sometimes be seen through the scrotum as a bluish discoloration •Can be difficult to distinguish from testicular torsion
torsion of appendix testes •May have point tenderness •May have a reactive hydrocele
•Usually painless, but may have a dull ache or heaviness •May feel a "bag of worms" in the scrotum SUPERIOR to the testicle
varicocele PE: May be enlarged when patient is upright or with Valsalva •Less apparent when patient is supine or when testicle is elevated
•Febrile UTIs in infants •Hydronephrosis on fetal US •Frequent, recurrent UTI •May have prolonged enuresis
vesicoureteral reflux enuresis --> involuntary urination, especially by children at night
How do you diagnose testicular torsion?
•CLINICAL diagnosis •Testicular doppler US (surgery should not be delayed if clinical evident) --> reduced or absent testicular blood flow on affected side •Emergency surgical exploration: definitive diagnosis
What are risks for phimosis?
•Can occur at any age •Chronic balanoposthitis may lead to this condition Children under 2 have a relatively narrow opening that gradually widens
What causes hypospadias?
•Congenital anomaly •Also seen with penile curvature and abnormal foreskin development •Increased risk seen with estrogen and progestins given during pregnancy
What is epispadias?
•Congenital anomaly that results in abnormal DORSAL placement of the urethral opening
How do you diagnose a urethral stricture?
•Cystourethroscopy •Retrograde urethrogram (if trauma) •Voiding cystourethrogram •US urethrography
What is a non-communicating hydrocele?
•Derived from fluid from the mesothelial lining of the tunica vaginalis (no connection to abdomen). Never changes
Secondary vesicoureteral reflux
•Due to abnormally high voiding pressure in the bladder that leads to failure of the closure of the UVJ during bladder contraction, usually due to obstruction.
Management of a urethral stricture
•Endoscopic treatment --> dilation, cold knife incision, incision with electrocautery or laser •Intermittent catheter dilation •Surgical reconstruction •Prophylactic antibiotics •Complications: urinary fistula
Treatment of torsion of appendix testes
•Exploratory surgery if uncertain •Local application of ice •NSAIDS
What is the pathophysiology of epispadias?
•Failure of midline penile fusion •Bladder exstrophy: in utero rupture of an overdeveloped cloacal membrane, leading to herniation of the lower abdominal contents
What is the pathophysiology of hypospadias?
•Failure of urogenital folds to fuse during development (by 15 weeks gestation) •Proximal hypospadias is usually associated with additional GU malformations
Causes of paraphimosis?
•Forceful retraction of phimotic foreskin •Usually physiologic or iatrogenic (retraction by caretaker) in young boys and infants •Adolescents and adults: can occur after balanitis or penile inflammation (DM) or after intercourse
What is a varicocele?
•Forms when the VEINS along the spermatic cord become engorged due to valve incompetence •Cystic testicular mass of varicose veins: pampiniform venous plexus ad internal spermatic veins
Prognosis of varicocele
•Generally harmless •Can affect fertility and is most common SURGICAL correctable cause of male infertility (seen in about 30% of male infertility): the increased blood flow increases the scrotal temp causing problems with spermatogenesis
What are the classifications of epispadias?
•Glandular: the urethra opens on the dorsal aspect of the glans (which is broad and flattened) •Penile: the meatus (which is often broad and gaping) is located between the pubic symphysis and the coronal sulcus. A distal groove usually extends from the meatus through the played glans. •Penopubic: the urethral opening is at the penopubic junction, and the entire penis has a distal dorsal groove extending through the glans
vesicoureteral reflux treatment
•Grades I and II --> Observation or antibiotic prophylaxis •Grades III and IV --> Surgical correction
Treatment of phimosis
•If evidence of infection: broad spectrum antibiotics •Proper hygiene, stretching exercises •May use topical steroids •Circumcision is definitive treatment, but after infection has been controlled
Treatment of testicular torsion
•Immediate urologic consultation •Urgent detorsion and orchiopexy within 6 hours of onset of pain to salvage testicle •Irreversible damage after 12 hours •Manual detorsion should be attempted (rotate away from midline- open book) •Orchiectomy if testes is not salvageable
What is phimosis?
•Inability to retract the foreskin over the glans •NOT a surgical emergency (unlike paraphimosis)
What causes a urethral stricture?
•Infections (STI) •Trauma •Instrumentation of urethra •Idiopathic •Congenital: rare
What causes testicular torsion?
•Insufficient fixation of the lower pole of the testis to the tunica vaginalis, leading to increased mobility of the testicle.
What is a spermatocele (epididymal cyst)
•It is a retention cyst of the tubule of the rete testis or the head of the epididymis •Contains a milky fluid and sperm
What is testicular torsion?
•It is a twisting of the spermatic cord that cuts off the arterial blood supply to the testes leading to testicular ischemia and is a surgical emergency
Treatment of cryptorchidism
•It is rare for a cryptorchid testis to descend spontaneously after 6 months of age (70% will descend by 3 months of age) •Surgical correction (orchiopexy) should be performed between 6-12 months of age •Repair inguinal hernia if present
How to diagnose hypospadias
•Karyotyping are indicated to help establish genetic sex •Urethroscopy and cystoscopy are of value to determine whether internal male sexual organs are normally developed •Excretory urography is also indicated to detect additional congenital anomalies of the kidneys and ureters in the proximal types of hypospadias.
Who is at risk for testicular torsion?
•Mainly affects neonates and adolescents, but can occur in older adults as well •Males 10-20 yo at highest risk
Treatment of paraphimosis
•Manual reduction: restore original position of foreskin after reducing edema with cold packs or gentle pressure, compression of the glans •Medications: apply granulated sugar to the glans and prepuce (foreskin): after 20 minutes the osmotic effect will help reduce the edema •Local infiltration of hyaluronidase **Surgical incision/circumcision if unable to reduce**
Where are varicocele most commonly located?
•Most are LEFT SIDED (90%): increased left renal vein pressure transmitted to left gonadal vein) **Usually develops slowly by 3rd decade of life**
What causes phimosis?
•Most common cause is chronic infection from poor local hygiene •Mostly found in uncircumcised males (but excess skin left after circumcision can also cause it)
Primary vesicoureteral reflux
•Most common type •Due to inadequate closure of or incompetent ureterovescil junction (UVJ) that contains a segment of the ureter within the bladder wall •Low grade reflux (grades I and II)
How to diagnose cryptorchidism
•Mostly clinical exam •Scrotal US if determining location in canal
What is a urethral stricture?
•Narrowing of the urethral lumen
Treatment of spermatocele
•None needed unless painful •Surgery if painful
What is a communicating hydrocele?
•Peritoneal/abdominal fluid enters the scrotum via a patent processus vaginalis that failed to close. Changes with position/ valsalva **Almost all hydroceles that are found in children**
Risks of cryptorchidism
•Prematurity •Low birth weight •Maternal obesity or diabetes ** R side is most commonly affected **
What do you do about a varicocele?
•RIGHT sided varicocele needs further evaluation for potential retroperitoneal or abdominal malignancy •Left sided sudden onset of varicocele in older man (>40 yo) may be result of renal cell carcinoma
How to diagnose vesicoureteral reflux
•Renal and bladder US often initial imaging (but may miss significant VUR) •Voiding cystourethrogram imaging test of choice to DIAGNOSE VUR
What is vesicoureteral reflux?
•Retrograde passage of urine from the bladder into the upper urinary tract
What is a hydrocele?
•SEROUS FLUID COLLECTION WITHIN THE LAYERS OF THE TUNICA VAGINALIS OF THE SCROTUM
What would you find on the physical exam for testicular torsion?
•Scrotal swelling •Tender testicle lying in a horizontal plane (bell-clapper deformity) •Testicle may be retracted or "high" riding •NEGATIVE Prehn sign: NO relief with scrotal elevation NEGATIVE (absent) Cremasteric sign on affected side
How do you diagnose varicocele?
•Scrotal ultrasound --> Dilation of the pampiniform plexus >2mm
Treatment of hypospadias
•Should NOT be circumcised at birth, foreskin (prepuce) may be used later to repair the defect •Repair usually recommended by age 2 (arthroplasty) •Many forms of surgical repair •All types of repair also involve straightening the penis by removal of the chordee
How do you diagnose hydrocele?
•Testicular Ultrasound •Rules out testicular tumor or other masses •10% of testicular tumors have a reactive hydrocele as the presenting complaint, so need to rule it out •Ultrasound can help differentiate a hernia from hydrocele (but so can transillumination which is free)
What is cryptorchidism?
•Testis that has NOT descended into the scrotum by 4 months of age •About 3% of full-term and 30% premature male infants have at least 1 undescended testes at birth, but descent is usually complete in the first few weeks of life
What is torsion of appendix testes?
•The epididymis and the testicle often have a vestigial remnant of embryologic ducts known as an appendix testis or appendix epididymis. •Can undergo spontaneous infarction in young boys **Most cases are seen in children 7-14 years**
What is hypospadias?
•The urethral meatus opens on the VENTRAL side of the penis proximal to the tip of the glans penis.
Treatment for hydrocele
•Usually don't require treatment: Watchful waiting •May do elective draining and repair to prevent hernia
What are clinical manifestations of epispadias?
•Will have dorsal curvature of penis and absent dorsal foreskin •Penopubic and penile epispadias will have urinary incontinence (95% and 75% respectively) •Urinary incontinence is a common problem because of maldevelopment of the urinary sphincters
What is paraphimosis?
•the entrapment of a retracted foreskin that CANNOT be returned to the normal position (can't be pulled forward)
