Bates Chapter 13 - Male Genitalia and Hernias

Acute Epididymitis

An acutely inflamed epididymis is indurated, swollen, and notable tender, making it difficult to distinguish from the testis. Scrotum may be reddened and the vas deferens inflamed. Causes include infection from Neisseria gonorrheae, Chlamydia trachomatis, E coli, and pseudomonas, trauma, and autoimmune disease.

Carcinoma of the Penis

An indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious.

Direct Inguinal Hernia

Arises more medially to the indirect inguinal hernia due to weakness in the floor of the inguinal canal. Associated with straining and heavy lifting.

Evaluating a Possible Scrotal Hernia

Ask the patient to lie down. If the mass returns to the abdomen by itself, it is a hernia. If you can get your fingers above the mass in the scrotum, suspect a hydrocele. Listen to the mass for bowel sounds. If findings suggest a hernia, gently try to reduce it, unless the mass is tender or the patient reports nausea/vomiting.

High Risk for HIV

Men with male sex partners, individuals with multiple sex partners, past or present injection drug users, persons who exchange sex for money or drugs, and sex partners of persons who are HIV-infected, bisexual, or injection-drug users. The presence of any STI warrants testing for coinfection.

Indirect Inguinal Hernia

Most common, occurs in all ages and in both sexes. Originates above inguinal ligament, near its midpoint (the internal inguinal ring). May be palpated in the scrotum. Comes down the inguinal canal and touches the fingertip.

Acute Orchitis

Testis is acutely inflamed, painful, tender, and swollen. May be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections, usually unilateral.

Screening for HIV and AIDS

Identifying early HIV and initiating combined ART decreases risk of progressing to AIDS. Grade A recommendation for HIV screening of adolescents and adults from age 15 to 65 years and screening for all pregnant women. CDC universal HIV testing for adolescents and adults ages 13 to 64 years. CDC recommends opt out approach. Annual testing for high-risk groups.

Indirect Inguinal Hernia

If the peritoneal lining remains an open channel to the scrotum it can give rise to this hernia. This develops at the internal inguinal ring, where the spermatic cord exits the abdomen.

Common Scrotal Swellings

Indirect inguinal hernias, hydroceles, scrotal edema, and, rarely, testicular carcinoma. Tender painful scrotal swelling is present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia. Swellings containing serous fluid, such as hydroceles, light up with a red glow, or transilluminate. Those containing blood or tissue, such as a normal testis, a tumor, or most hernias, do not.

Induration

Induration along the ventral surface of the penis suggests a urethral stricture or possibly a carcinoma. Tenderness in the indurated area suggests periurethral inflammation from a urethral stricture.

Balanitis, Balanoposthitis

Inflammation of the glans; inflammation of the glans and prepuce.

Femoral Hernia

Least common. More common in women than in men. Below the inguinal ligament. Appears more lateral than an inguinal hernia. Can be hard to differentiate from lymph nodes. Never into the scrotum. Inguinal canal is empty.

Reduced or Absent Ejaculation

Less common. Affects middle-aged or older men. Possible causes are medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with ejaculation is usually psychogenic.

Direct Inguinal Hernia

Less common. Usually in men older than 40 years, rare in women. Originates above inguinal ligament, close to the pubic tubercle (near the external inguinal ring). Rarely palpated in the scrotum. Bulges anteriorly and pushes the side of the finger forward.

Inguinal Canal

Lies medial to and roughly parallel to the inguinal ligament and forms a tunnel for the vas deferens as it passes through the abdominal muscles. Inguinal hernias are caused by loops of bowel forcing their way through the inguinal canal.

Erectile Dysfunction

May be from psychogenic causes, especially if early morning erection is preserved. May reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes.

Palpating the Vas Deferens

May feel thickened or beeded if chronically infected. A cystic structure in the spermatic cord suggests a hydrocele of the cord.

Cough Test

To examine for an inguinal hernia. Invaginate the scrotal skin. Find the triangular slit-like opening of the external inguinal ring. Ask the patient to cough and palpate for a distinct bulge or mass that moves against your stationary finger during the cough. This bulge suggests a direct inguinal hernia. This warrants surgical evaluation. Incarceration is rare and is more common with indirect hernias.

Scrotal Hernia

Usually an indirect inguinal hernia that comes through the exteranal inguinal ring, so the examining fingers cannot get above it within the scrotum.

Tumor of the Testis

Usually appears as a painless nodule. As it grows and spreads, it may seem to replace the entire organ. The testicle feels heavier than normal.

Varicocele of the Spermatic Cord

Varicocele refers to gravity-mediated varicose veins of the spermatic cord, usually found on the left. It feels like a soft bag of worms in the spermatic cord above the testis and if prominent appears to distort the contours of the scrotal skin. Collapses in the supine position, so exam should be both supine and standing. If does not collapse, suspect a left spermatic vein obstruction within the abdomen.

Male Lymphatics

When you find an inflammatory or possibly malignant lesion on the surface of the penis or the scrotum, assess the inguinal nodes for enlargement or tenderness.

Checking for a Variocele

With patient standing, palpate the spermatic cord about 2 cm above the testis. Have the patient bear down against a closed glottis for about 4 seconds. (Valsalva maneuver). A temporary increase in the diameter of the spermatic cord indicates filling of abnormally dilated spermatic veins draining the testis.

Hydrocele

A nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can palpate above the mass within the scrotum.

Spermatocele and Cyst of the Epididymis

A painless, movable cystic mass just above the testis suggests a spermatocele or an epididymal cyst. Both transilluminate. The former contains sperm, and the latter does not, but they are clinically indistiguishable.

Phimosis

A tight prepuce that cannot be retracted over the glans. Retractions is necessary to detect chancres and carcinomas. Smegma is a normal cheesy, whitish material which may accumulate under the foreskin.

Paraphimosis

A tight prepuce that, once retracted, cannot be returned. Edema ensues.

TSE

Best performed standing after a warm bath or shower. Check for swelling in mirror. Feel scrotal sac to locate testicle. Use one hand to stabilize and the other to feel or roll the testicle feeling the entire surface. The epididymis is a soft, tube-like structure at the back of the testicle that collects and carries sperm. It's normal for one to be larger or lower.

Strangulated Hernia

Blood supply to the entrapped contents is compromised. Suspect in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.

Chancroid

Red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins, contains necrotic exudate, has a friable base. Caused by Haemophilus ducreyi, an anaerobic bacillus. Incubation 3-7 days. Painful inguinal adenopathy.

Tuberculous Epididymitis

Chronic inflammation of tuberculosis produces a firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens.

Premature Ejaculation

Common, especially in young men.

Epidermoid Cysts

Common, often multiple, benign dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium on the scrotum.

Hypospadias

Congenital ventral displacement of the meatus on the penis.

Incarcerated Hernia

Contents cannot be returned to the abdominal cavity.

Risk Factors for Testicular Cancer

Cryptorchidism, hx of carcinoma in the contralateral testicle, mumps orchitis, an inguinal hernia, a hydrocele in childhood, positive family history.

Male Sexual Function

Depends on normal levels of testosterone, arterial blood flow from the internal iliac artery to the internal pudenal artery and its pernile artery and branches, and intact neural innervation from a-adrenergic and cholinergic pathways. Erection from venous engorgement of the corpora cavernosa results from two types of stimuli. Visual, auditory, or erotic cues trigger sympathetic outflow from higher brain centers to the T11 through L2 levels of the spinal cord. Tactile stimulation initiates sensory impulses from the genitalia to the reflex arcs and parasympathetic pathways through the pudenal nerve.

Low Libido Causes

Depression, endocrine dysfunction, or side effects of medications.

LGBT Patients Have Higher Rates of...

Depression, suicide, anxiety, drug use, sexual victimization, and risk of infection with HIV and STIs.

Tips for Taking the Sexual History

Explain why you are taking the sexual history. Convey that you understand that this information is highly personal, and encourage the patient to be open and direct. Relate that you gather this history from all your patients. Affirm that you conversation is confidential.

Hydrocele

Forms in the the potential space between the parietal and visceral layers of the scrotum

Male Sexual Development

GRH from the hypothalamus stimulates pituitary secretion of luteinizing hormone and follicle-stimulating hormone. LH acts on interstitial Leydig cells to promote synthesis of testosterone, which is converted in target tissues to 5a-dihydrotestosterone This triggers pubertal growth of the male genitalia, prostate, seminal vesicles, and secondary sex characteristics such as facial and body hair, musculoskeletal growth, enlargement of the larynx with low-pitched voice. FSH regulates sperm production by the germ cells and Sertoli cells of the seminiferous tubules.

Infections Transmitted through Oral-Penile Route

Gonorrhea, chlamydia, syphilis, and herpes.

Peyronie Disease

Palpable, nontender, hard plaques found just beneath the skin, usually along the dorsum of the penis. Patient complains of crooked, painful erections.

Counseling about Sexual Practices

Patient counseling should be interactive and combine information about general risk reduction with personalized messages based on the patient's personal risk behaviors. Client-centered. Correct use of male condoms is highly effective in preventing the transmission of HIV, HPV, and other STIs.

Genital Herpes Simplex

Small scattered or grouped vesicles, 1-3 mm in size on glans or shaft of penis. May appear as erosions. Caused by HSV 2. Incubation 2-7 days. Associated with fever, malaise, headache, arthralgias, local pain and edema, lymphadenopathy. Need to distinguish from genital herpes zoster and candidiasis.

Scrotal Edema

Pitting edema may make the scrotal skin taut; seen in heart failure or nephrotic syndrome.

Palpating for a Femoral Hernia

Place your fingers on the anterior thigh in the region of the femoral canal. Ask the patient to strain down or cough.

Penile Discharge

Profuse yellow signals gonococcal urethritis. Scanty white or clear signals nongonococcal urethritis. Definitive diagnosis requires Gram stain and culture.

Painless Testicular Nodule

Raises the possibility of testicular cancer, a potentially curable cancer with a peak incidence between the ages of 15-34 years. Lymph drainage from the testes parallels retroperitoneal venous flow from the renal vein and inferior vena cava, the primary site of lymph node involvement in testicular cancer.

Testicular Cancer

Rare, highly treatable when detected early. More common in white young men. Risk factors are family history, HIV infection, and history of cryptorchidism. Men should seek attention for: painless lumps swelling or enlargement in either testicle, pain or discomfort in a testicle or in the scrotum, feeling of heaviness or sudden fluid collection in the scrotum, or a dull ache in the lower abdomen or groin.

Disseminated Gonorrhea Symptoms

Rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms.

Chlamydia and Gonorrhea Screening

Recommended as routine for sexually active women age 24 and younger. Most new STI cases are chlamydia, but gonorrhea and syphilis are increasing.

HPV Vaccine

Routine quadrivalent HPV vaccination in males age 11 or 12 and through age 21 years if not vaccinated previously. Can prevent HPV related diseases such as genital warts, anal cancer, and penile cancer, can reduce HPV transmission to female sex partners and lower risk of oropharyngeal cancers.

Genital Warts

Single or multiple papules or plaques of variable shapes. Caused by HPV subtypes 6 and 11. Incubation can be weeks to months. Can arise on penis, scrotum, groin, highs, anus. Usually asymptomatic but may cause itching and pain.

Small Testis

Small firm testes usually less than or equal to 2 cm suggest Klinefelter syndrome. Small soft testes suggesting atrophy are seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism. May also follow orchitis.

Primary Syphilis

Small red papule that becomes a chancre, a painless erosion of to 2 cm in diameter. Base is clean, red, smooth, and glistening, borders raised and indurated. Heals within 3-8 weeks. Caused by Treponema pallidum. Incubation 9-90 days. Inguinal lymphadenopathy. Lymph nodes rubbery, nontender, mobile. 20-30% develop secondary syphilis.

Pubic or Genital Excoriations

Suggest lice (crabs) or sometimes scabies in the pubic hair.

Cryptorchidism

The testis is atrophied and lies outside the scrotum in the inguinal canal, abdomen, or near the pubic tubercle. It may also be congenitally absent. There is no palpable left testis or epididymis in the unfilled scrotum. Markedly raises the risk of testicular cancer.

Torsion of the Spermatic Cord

Torsion, or twisting, of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is often retracted upward in the scrotum. The cremasteric reflex is nearly always absent on the affected side in boys or men with torsion Most common in neonates and adolescents, but can occur at any age. Surgical emergency because of obstructed circulation.

Penile Growths/Sores

Ulcer in syphilitic chancre and herpes. Warts from human papillomavirus, swelling of scrotum in mumps orchitis, scrotal edema, and testicular cancer. Pain in testicular torsion, epididymitis, and orchitis.

Penile Discharge

Yellow signals gonorrhea. White signals non-gonococcal urethritis from Chlamydia.