Male genital conditions

Introduction

• Maldevelopment of firm posterior fixation of the tunica vaginalis risks torsion
• Testicular nodularity or firmness is cancer until proven otherwise
• Epididymis lies posterolaterally
• Horizontally aligned testes in standing position are at greater risk of torsion

Scrotal oedema

• Simple, isolated scrotal oedema is relatively rare
• May develop secondary to insect bites, contact dermatitis or idiopathic (young boys)
• Idiopathic scrotal oedema
  • Presents in boys 3-9yo as unilateral pain with scrotal/perineal and inguinal swelling and erythema
  • Episodes resolve within 1-4 days
  • USS shows thickened scrotal wall, increased peritesticular flow and reactive hydrocoele
  • Diagnosis of exclusion

Scrotal abscess

• Important to differentiate scrotal skin abscess (e.g. folliculitis) vs. intrascrotal
• Scrotal wall abscess needs I&D, sitz baths  and healing from base up
• Antibiotics only if surrounding cellulitis or immunosuppressed
• If suspected intrascrotal, need USS and urology referral

Fournier gangrene

• Necrotising fasciitis of perineum
• Diabetic and chronic alcoholism are greatest risk factors
• Need aggressive fluid resus, Meropenem 1g q8h + vancomycin 30mg/kg IV then 15mg/kg BD + Lincomycin 600mg TDS
• Mortality approaches 40%
• Consider in any immunocompromised patient with pain out of proportion or extending beyond confined area of infection

Balanoposthitis

• Usually due to poor hygiene or external irritation with subsequent Candida infection
• Recurrent balanoposthitis can be the sole presenting sign of diabetes
  • Some authors suggest testing for this in all presentations
• Cleansing with mild soap, dry thoroughly, clotrimazole ointment +- steroid ointment
• If bacterial infection suspected (warm, erythema, oedema and spreading to penile shaft) – Fluclox or Cephalexin required

Phimosis

• Inability to fully retract foreskin
• Due to infection, poor hygiene or previous scarring
• Topical steroid applied to foreskin for 4-6 weeks has 70-90% success in avoiding circumcision

Paraphimosis

• True urological emergency with inability to replace foreskin
• Glans oedema and venous engorgement results in arterial compromise and gangrene
• Compression of glans may allow reduction – can wrap in elastic bandage tightly for 5 minutes
• If impaired perfusion exists and no urology service, anaesthetise top of constricting band and incise with iris scissors

Entrapment injuries

• In zipper
  • Cleanse with povidone-iodine
  • Infiltrate 1% lignocaine
  • Apply mineral oil to zipper to see if comes loose
  • Cut zipper away from clothing to make it easier to handle
  • Cut sliding bar of zipper and zipper teeth
  • Bottom bar of zipper can also be cut and then unzipped from below

Penile fracture

• Tunica albuginea of one or both corpus cavernosa ruptures due to direct trauma to erect penis
• Can be associated with partial or complete urethral rupture or deep dorsal vein injury
• Acutely swollen, flaccid, discoloured (eggplant) and tender
• Retrograde urethrogram can assess urethral integrity
• Haematoma evacuation and suture apposition of disrupted tunica albuginea are required

Peyronie disease

• Progressive curvature with erections, painful and may result in erectile dysfunction and failure to penetrate during intercourse
• Thickened plaque on dorsum involving tunica albuginea of both corpora bodies
• Needs urology referral as OPD

Priapism

• Urological emergency
• Persistent, usually painful, pathological erection
• Urinary retention may evolve
• Impotence is seen in 35% of cases following treatment
• Low-flow priapism is by far the most common
  • More common, painful and diagnosed by aspiration of dark, acidic blood from corpus cavernosum
  • Far greater risk of impotence and ischaemia
  • Indicated by aspirated blood pH <7.25, pO2 <30 and pCO2 >60mmHg

Priapism

• Causes
  • Intracavernosal injections for impotence (papaverine, prostaglandin E1), oral agents for hypertension (hydralazine, prazosin, CCB), SSRI’s, phenothiazines, cocaine, EtOH, THC or oral agents for erectile dysfunction
  • Most in children are due to sickle cell (65%) vs. 25% in adults
  • Haemoglobinopathies, Fabry’s disease, chronic granulocytic leukaemia, hypercoagulable states and trauma
• High-flow
  • Non-ischaemic priapism. Rare, often painless and usually due to traumatic fistulae between cavernosal artery and corpus cavernosum
  • Treated with embolisation

Priapism

• Treatment
  • Narcotic analgesia
  • Terbutaline 0.5mg SC in deltoid q30min
  • Penile block – 5mL lignocaine 1% SC at base of penis at 1030 and 0130
  • Corpora cavernosum aspiration of 20-30mL with butterfly at 10 and 2 o’clock then irrigation with saline +- phenylephrine 100mcg bilaterally

Epididymal cyst/spermatocoele

• Localised fullness in head of epididymis
• Epididymal cyst is <2cm vs. spermatocoele >2cm
• Spermatocoeles do not transilluminate as contain opalescent sperm

Acute scrotal pain

• DDx
  • Testicular torsion
  • Appendiceal torsion
  • Epididymitis
  • Orchitis
  • Incarcerated hernia
  • Trauma
  • Vasculitis
  • Prostatitis

Testicular torsion

• 1/4000 males under 25 annually
• Bimodal distribution with extravaginal torsion in perinatal period and intravaginal torsion in puberty
• May occur post-mild trauma (4-8% of cases) or at periods of testicular growth (puberty)
• Fair number occur during sleep when cremasteric relaxation allows torsion
• Firm, tender, often high-riding and horizontal lie
• Epididymis may be displaced and not in usual posterolateral lie
• Unilateral absence of cremasteric reflex is 99% sensitive 
• Relief with elevation (Prehn sign – positive for epididymitis) does not reliably distinguish epididymitis and torsion

Testicular torsion

• Excellent salvage rates if <6 hours
• No clinical or lab parameters can reliably ascertain duration of ischaemia
  • So no matter how long symptoms have existed, need urgent consult
• Doppler USS is useful in equivocal cases
  • Positive if absent or clearly reduced ipsilateral intratesticular blood flow
  • Negative if blood flow increased or normal
  • 88% sensitive and 90% specific

Testicular torsion

• Manual detorsion
  • Local anaesthetic relieves discomfort of procedure but also removes clinical endpoint
  • Medial to lateral motion (like opening a book)
  • 540 degrees on initial attempt
  • Any relief of pain is positive
  • If pain worsens, this suggests detorsion should be performed in the opposite direction
• Always consider in young boys with abdominal pain, vomiting, 

Appendageal torsion

• Appendix testis, appendix epididymis, paradidymis (organ of Giraldes) and vas aberrans can all tort
• In prepubertal boys, these appendices tort more than testes
• Present similarly but without systemic vomiting, nausea
• Blue dot sign
  • Seen with early appendix epididymis or appendix testis torsion
• If blood flow intact to testicle, then surgical exploration can be avoided
• Usually self-limited and managed with analgesics, bed rest, scrotal support and reassurance of resolution within 3-5 days

Epididymitis/orchitis

• Usually gradual onset
• Young boys – Sterile reflux – coliforms if congenital anomalies
• Young men <40 – STI
• Homosexual men – Consider fungal UTI + STI
• Men >40 – E. coli and Klebsiella
• Elderly men – Consider associated BPH or urethral stricture
• Rare causes include Melioid, extrapulmonary TB, syphilis and brucellosis
• Presents with pain in lower abdomen, inguinal canal, scrotal or testicular pain in that order due to retrograde spread of inflammation
• Can be difficult to differentiate clinically from torsion
• May get reactive hydrocoele

Epididymo-orchitis

• Investigations
  • Urine MCS +- first-pass PCR +- urethral swab if discharge depending on risk profile
  • USS scrotum if considering torsion
• Management
  • UTI: As per UTI guidelines
  • STI: As per STI guidelines (Cef 500mg stat IV + Azithromycin 1g week apart + serology for other STI’s and PASH follow-up)
  • If febrile, toxic, septic – Admit for consideration of abscess
  • Avoid straining as promotes retrograde inflammatory cycle
  • Urology follow-up

Orchitis

• Isolated orchitis (without epididymitis) is quite rare
• Typically seen in association with systemic infection e.g. mumps, EBV, coxsackie, varicella or echovirus
• Mumps presents unilaterally in 70% of cases, followed by contralateral spread in 1-9 days

Urethral strictures

• In young people, STI’s result in bulbous strictures
• In older patients, post-endoscopy meatal stenosis or localised urethral strictures are more common
• >150-200mL post-void residual is pathological
• Retrograde urethrography can define site and severity of stricture
• If 2-3 gentle attempts at IDC insertion fail, obtain urology consult

Haematospermia

• Trauma, tumor with erosion, inflammation or infection of male ejaculatory system can cause this
• Trauma during sexual intercourse is the most common cause
• Not uncommon after vigorous sexual activity
• Refer all to urology
• Those over 40 are at higher risk of cancer and should be told this

Varicocoele

• Left > Right due to nutcracker effect of left renal vein between aorta and SMA
• Can get larger over time
• 20% of post-pubertal males
• Bag of worms
• Asymptomatic, dull aching pain worse sitting up, atrophy of left testicle and decreased fertility are all possible
• Bilateral in 33%
• Unilateral right varicocoele suggests right IVC obstruction e.g. RCC  CT abdo with contrast

Hydrocoele

• Collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis
• May be secondary to acute pathology e.g. torsion, epididymitis

Testicular cancer

• Most common solid tumor of men 18-40
• Usually painless mass
• Firm, non-tender nodule or mass that does not transilluminate (although reactive hydrocele may occur)
• USS is first line + Alpha fetoprotein and beta-hCG
• Normal serum values do NOT rule out testicular cancer

Testicular cancer

• Germ cell tumors (90%)
  • Seminoma
  • Non-seminomatous germ cell tumors
    • Embryonal carcinoma
    • Choriocarcinoma
    • Yolk sac tumor
    • Teratoma
    • Mixed
  • Spermatocytic tumor
• Sex cord stromal tumors
  • Sertoli cell, Leydig cell, Granulosa cell, mixed
• Mixed germ/stromal
• Adnexal tumors
• Carcinoid/lymphoma/metastatic

Last Updated on October 9, 2020 by Andrew Crofton