Male Repro

Injuries/Trauma

Anterior Urethral Injury

• The Presence of the following prompt further evaluation via retrograde urethrography:
• Blood at meatus
• Hematuria
• Difficulty Voiding
 

• RETROGRADE URETHROGRAPHY MUST BE DONE BEFORE ANY ATTEMPT OF CATHETARIZATION AS IT CAN RESULT IN COMPLETE TRANSECTION OF THE URETHRA

Testicular Torsion

• Dx → Testicular Torsion
• Other presentation:
• INFANT with Unilateral Cryptorchidism + ACUTE ABDOMEN + inconsolable to lower abdominal palpation

Penile Fracture (PF)

• Caused by blunt trauma to erect penis (most commonly during sexual intercourse)
• Rupture of tunica albuginea → snapping sound + sudden onset pain followed by loss of erection & appearance of shaft hematoma

• EMERGENCY
• IF (Blood at meatus - Hematuria - Dysuria - Urinary Retention):
• FIRST ⇒ Retrograde Urethrography (as 20% are associated with Anterior urethral injury)
• THEN ⇒ Urgent surgical repair of tunica albuginea

Inflammatory Conditions/Infections

Acute Epididymitis

• Posterior unilateral testicular pain THAT IMPROVES with elevation of testes

• CA:
• < 35 years ⇒ Chlamydia & Gonorrhea
• ≥ 35 years ⇒ E.coli

Balanitis & Balanoposthitis

• Balanitis ⇒ Inflammation of glans penis

• Balanoposthitis ⇒ Balanitis + foreskin inflammation

• Causes:
• Infection (Candida is HY, STI, Flora)
• Irritation (poor hygiene, contact dermatitis)

• Evaluation ⇒
• IF thick, whitish discharge ⇒ KOH preparation for candida
• IF urethral discharge ⇒ STI screening

• TTT:
• Foreskin hygiene + Sitz baths
• If candida → Topical antifungals + Screen for DM (if no hx of recent abx use or diaper)

Sexual Disorders

Erectile Dysfunction (ED)

• 1st Line ⇒ PDE-5 inhibitors
• CONTRAINDICATED with Nitrates
• USED CAUTIOUSLY with alpha blockers (taken 4 hours apart & lowest dose of each drug)

Priapism

• Persistent Painful erection in the absence of sexual stimulation

• Causes:
• Primary (Idiopathic)
• Secondary
• Meds: Alpha-1 antagonists, SSRIs, Trazadone, PDE-5 inhibitors, Simulants (Cocaine, Methylphenidate)
• Diseases: SCD, Leukemia
• Surgery: Perineal/Trauma
• Neurogenic Lesions: Cauda Equina Syndrome

• TTT ⇒ Medical EMERGENCY
• Aspiration of blood from corpora cavernosa
• Intracavernous injection of phenylephrine (vc & emptying of blood)
 

PROSTATE

Acute Bacterial Prostatitis

• “ANTERIOR TENDERNESS ON PR” is buzzy

• Fever, Lower UTI symptoms + Tender & swollen prostate, causing difficulty voiding or acute retention
• TTT → Suprapubic catheterization (NORMAL Catheters → ascending infection from prostate→ Sepsis OR Rupture of inflamed prostate)
• THEN → Fluroquinolones OR TMP for 6 weeks

Chronic Bacterial Prostatitis

• NO fever, Lower UTI symptoms + PAINLESS prostate BUT pain with ejaculation is present + bacteria in urinalysis (from prostate)

Chronic NON-Infectious Prostatitis/Chronic Pelvic Pain Syndrome

• Symptoms:
• Pain in pelvis/perineum/genitals +/- back radiation
• Irritative Symptoms (urgency-hesitancy)
• Hemotospermia/Pain with ejaculation

• Dx → EXCLUSION

• Management:
• Alpha-1 antagonists
• 5-alpha reductase inhibitors
• Antibiotics (especially if hx of UTIs)

BPH + Lower UTI symptoms

• Do PSA in patients with BPH & lower UTI symptoms UNLESS life expectancy is < 10 years.

• TTT
• First Line ⇒ Alpha Blockers
• If persistent symptoms, intolerance (hypotension) ⇒ 5-alpha reductase inhibitors

TUMORS

Leydig Cell Tumor

• Produces testosterone OR estrogen

Testicular Cancer

• sometimes the initial presentation is → RETROPERITONEAL LYMPH NODES

• Diagnosis:
• Scrotal US (hypoechoic solid ⇒ Seminoma; Cystic + Calcifications ⇒ NSGCT)
• Makers
• Radical Inguinal Orchiectomy (CONFIRMS & DEFINITIVE TTT)
• FNA & Biopsies are associated with worse outcomes & increases chance of recurrence/spread
 

PEDS

Hypospadias

• Degree:
• Mild → meatus on glands/shaft
• SEVERE → meatus on scrotum/perineum +/- underdeveloped penis with small glans OR severe penile curvature (chordee)
• *** Urethral meatus extending to the corona ⇒ Urological Evaluation with deferred circumcision

• Evaluation:
• Mild → NONE
• Severe → Karyotyping & Pelvic US (to see repro organs & differentiate sexual conditions)
• If associated with non-genitourinary abnormalities → Renal & Bladder US (to evaluate for Syndromes “WAGR/CHARGE SYNDROMES”)

Cryptorchidism

Management Algo

• Orchiopexy is optimally performed before age 1 to reduce risk of complications
• Like (Seminoma - Torsion - Infertility)
• After orchiopexy however, incidence of infertility (if done before 1 year) & torsion DECREASES
• Seminoma is still increased in BOTH affected & contralateral testes

Hydrocele

• Usually resolves spontaneously after 1 year of age, so observation & reassurance in Newborns

MISC

• Cardioselective beta blockers (eg, metoprolol) can cause ED, but a large systemic review of randomized controlled trials confirmed that the overall incidence is low (<1%/yr). 
• Given that these medications decrease mortality in patients with a history of acute MI, they should be continued unless the patient is completely intolerant or experiences severe side effects.

• Varicocele is painless

• Groin Hernia presents as intermittent sharp pain during activity (in a person with predisposition, construction worker)

Indications of Cystoscopy:

1. Hematuria (Gross or Microscopic with RF of malignancy “smoking”) {NOT NEEDED IF GN HEMATURIA}

2. Infections (recurrent UTIs - nonresponsive to ttt)

3. Obstructive Symptoms (Strictures - Stone)

4. Irritative Symptoms WITH NO INFECTION

5. SUS of Malignancy (Abnormal Urine Cytology - Abnormal Bladder Imaging)

Fournier Gangrene

• Rapid Onset Skin infection of lower abdomen + scrotum + perineum WITH CREPITUS + SYSTEMIC MANIFESTATIONS (FEVER + HYPOTENSION)

• Risk Factors: (uncontrolled) DM & Obesity

• Can progress to sepsis, acidemia, renal insufficiency, and coagulopathy

• Management:
• INITIALLY ⇒ ABX + FLUIDS
• DEFINITIVE ⇒ SURGERY ASAP