The penis
• Phimosis: scarring of the prepuce which will
not retract without fissuring
– may be so tight as to cause urinary obstruction
– sometimes congenital, also occurs later in life as a
result of balanitis xerotica obliterans (pliant
foreskin becomes thickened and will not retract)
– increased susceptibility to carcinoma.
– Treatment is by circumcision.
• Paraphimosis :When the tight foreskin is retracted, it may
sometimes be difficult to return and a paraphimosis results.
• venous and lymphatic return from the glans and distal
foreskin is obstructed &even more pressure within the
obstructing ring of prepuce.
• ice bags, gentle manual compression and injection of a
solution of hyaluronidase in normal saline may help to reduce
the swelling. circumcision if careful manipulation fails. A
dorsal slit of the prepuce under local anaesthetic may be
enough in an emergency.
• Inflammations
• Balanoposthitis
– Inflammation of the prepuce is known as posthitis; inflammation of
the glans is balanitis. If two structures are often involved -
balanoposthitis. Skin conditions such as lichen planus and psoriasis
,Drug hypersensitivity reactions can affect the skin of the penis.
– In mild, the only symptom is itching and some discharge. In more
severe, the glans and foreskin are red-raw and pus exudes.
– Balanoposthitis is associated with penile cancer, diabetes and
phimosis.
– Monilial infections are quite common under the prepuce.
– Treatment is by broad-spectrum antibiotics and local hygienic
measures.
• STDs: Genital herpes , Lymphogranuloma venereum , Granuloma
inguinale , Condylomata acuminata (syn. genital warts)
Other abnormalities
• Chordee is a fixed bowing of the penis due to hypospadias or, rarely, chronic
urethritis. Erection is deformed and sexual intercourse may be impossible.
Treatment is usually surgical.
• Peyronie’s disease: a relatively common cause of deformity of the erect penis.
On examination, calcified hard plaques of fibrosis can be palpated in the
tunica of one or both corpora cavernosa& causes the erect penis to bend,
often dramatically, towards the side of the plaque. The aetiology is uncertain,
but it may be a result of past trauma — there is an association with
Dupuytren’s contracture.
– Treatment is difficult. Some cases continue to progress. Others seem to
remit after 3—5 years.or placing nonabsorbable sutures in the corpus
cavernosum opposite the plaque
• Persistent priapism. The penis remains erect and becomes painful. sickle cell
disease or leukaemia, an abnormally prolonged bout of otherwise normal
sexual activity, malignant disease in the corpora cavernosa or the pelvis.
Priapism is rarely seen as a consequence of spinal cord disease.
– Treatment. An underlying cause should be excluded & aspiration of the
sludged blood in the corpora cavernosa
Hypospadia
• Urethral meatus opens on the ventral
side of penis proximal to the tip of the glans
penis.
• Classically defined as an association of three
anatomic abnormality of penis
– ventral opening of the urethral meatus
– ventral curvature of penis[Chordee]
– ventrally deficient fore skin hooded ]
Classification
• Glandular
• Coronal
• Pineal shaft
• Penoscrotal
• Perineal
About 70% are distal penial or coronal
Circumcision is contraindicated
Symptom and sign
New born seldom have symptom.
Older and adult
1.chordee,prevent sexual intercourse
2.voideing in sitting position, infertility
3.deficent or absent ventral foreskin hooded]
• Meatus may be stenotic-exam,calibrate
• Increase incidences of undescended testis-exam.scrotum
• Penoscrotal and perineal hypospadia often have bifid scrotum
and ambiguous genitalia
Principle of hypospadia repair
Preschool age, in most cases <2yr
• Correction of the penile chrodee
• Reconstruction of ‘missing urethra
[urethroplasty]
• Fashioning of
.urethral meatus [meatoplasty]
.ventral part of glans [glanuloplasty]
.the mucosal collar and skin cover of ‘penile shaft
EPISPADIAS
Abnormal dorsally opening urethral meatus
Deformities
dorsal urethral meatus,dorsal chordee,deficient dorsal foreskin, short penis
ASSOCIATED CONDITIONS
urine incontenence,vesaicourethral reflex, symphysis diastasis
inguinal hernia
• CLASSIFICATION
GLANULAR
PENlLE
PENOSCROTAL
Isolated epis is less common;most occur in association with bladder extrophy i.e open ant.
bladder wall
Management
• Epispadia: Primary genital repair in the new born period, followed later by
bladder neck reconstruction(at 3 to_5 yrs of age)
Genital repair at1yr of age + bladder neck reconstruction (3_5yrs)
• Extrophy: start repair of abdomenal wall & pelvic one since birth
Testis & scrotum
• Ectopic testis:- . Its main hazard is a liability to injury but is usually fully
developed
– at the superficial inguinal ring;
– in the perineum;
– at the root of the penis;
– in the femoral triangle.
– Contralateral scrotum
• Incompletely descended testis
– one or both testes in 4 % full-term infants and in 30 % preterm. About 50 % reached
into the scrotum during the first month of life but full descent after that was
uncommon. The incidence in later childhood and puberty is thus around 2%
– normal until the age of 6 years but by puberty the testis is flabby and poorly developed
which halt spermatogenesis and limit the production of androgens
Undescended testis
• Testicular retraction
• Cannilicular testis
• Intra-Abdominal testes
• Ectopic testicle
• Absent testicle
Clinical features
– unilateral on the right in 50 % and on the left in 30 %, both 20 %
– The testis may be:
• intra-abdominal, lying extraperitoneally usually just above the internal
inguinal ring;
• in the inguinal canal, where it may or may not be palpable. When both testes
are impalpable, the condition is known as cryptorchidism (hidden testes)
• in the superficial inguinal pouch, where it must be distinguished from the
much more common retractile testis which may be found in the same
condition
•
• Hazards of incomplete descent are:
– sterility in bilateral cases;
– pain due to trauma;
– an associated indirect inguinal hernia
– torsion;
– epididymo-orchitis , is extremely rare
– atrophy of an inguinal testis that can occur even before puberty,
possibly due to recurrent minor trauma;
– increased liability to malignant disease even if they have been
brought down surgically.35 times that in a normally positioned testis.
• Surgical treatment
– before the age of 2 years.= Orchidopexy
– Orchidectomy for atrophied testis with normal contralateral
• Varicocele are abnormal tortuosities and dilations of the
testicular veins within the spermatic cord & a varicose
dilatation of the veins(the pampiniform plexus) draining the
testis. On physical examination, they feel like a “bag of
worms.”
– much more common on the left side
– Surgical treatment of varicoceles is indicated for
diminished testicular growth in adolescents, infertility, or
significant symptoms
• Spermatoceles are benign cystic dilations involving the tail of
the epididymis or proximal vas deferens
Hydrocele
• generally are asymptomatic fluid collections around the testicle(b/n parietal &
viseral tunica albuginia)
• Classified into:
– Communicating(Primary): b/se of patent processes vaginalis & common in children & young adults
– noncommunicating hydroceles may be idiopathic or may occur secondary to epididymitis, orchitis,
testicular torsion, torsion of the appendix testis or appendix epididymis, trauma, or tumor. These
conditions must be excluded in children and adolescents with hydrocele
• Diagnosis:physical examination and transillumination of the scrotum that demonstrates a
cystic fluid collection. Communicating hydroceles are often reducible; noncommunicating
hydroceles are not. Doppler ultrasonography may be necessary to evaluate the testicle and
rule out a primary cause.
• Treatment: Surgical repair is indicated for hydroceles in newborns that persist beyond one
year of age, for communicating hydroceles, and for idiopathic hydroceles that are
symptomatic or compromise the skin integrity
• For secondary treat the cause
• Mild epididymitis usually with a 1- to 2-day onset of unilateral testicular pain
and swelling associated with dysuria or urethral discharge.
• Typically, a painful, indurated epididymis and pyuria. Urinalysis, urine culture,
and CBC count are obtained.Send urethral swabs culture for gonococci and
chlamydiae
• With appropriate antibiotic coverage, these patients can be managed as
outpatients. For patients in whom the etiology is gonococcal or chlamydial,
ceftriaxone (125 to 250 mg intramuscularly) is given in the emergency room,
followed by doxycycline (100 mg orally two times a day for 7 days). In older
men (>35 years of age), enterobacteria are more common, and a
fluoroquinolone, such as ciprofloxacin (500 mg orally two times a day),
provides broad coverage until culture sensitivities can be obtained.
Nonsteroidal analgesics and scrotal elevation can reduce inflammation and
provide symptomatic relief.
• Moderate to severe cases of epididymitis may require hospital admission.
Symptoms usually have been present for several days. Fever and leukocytosis
are present. Broad-spectrum antibiotics and supportive measures of bedrest
with scrotal elevation should be instituted. Ultrasonography can be useful to
rule out abscess formation and assess testicular perfusion
Testicular torsion: often in the peripubertal (12 to 18 years old) age group, although it can occur
at any age.
• C.F: acute onset of testicular pain and swelling, commonly associated with nausea and
vomiting. Some intermittent torsion.
• Physical examination: extremely tender, swollen testicle high riding in the scrotum with a
transverse lie. The cremasteric reflex (elicited by stroking the inner thigh) is absent on the
affected side. In contrast to epididymitis, elevation of the scrotum does not provide relief of
pain (Prehn sign) in torsion. Normal urinalysis and the absence of leukocytosis help to rule
out epididymitis. Testicular torsion is a clinical diagnosis, and if enough suspicions exist, the
patient needs to be explored without delay.
• color Doppler ultrasound can help to confirm or exclude the diagnosis.
• Treatment: urgent scrotal exploration is indicated, Manual detorsion of the testicle may be
attempted in the emergency room, but bilateral orchiopexy is still indicated. Contralateral
testicular fixation should be performed at the time of surgery.
Torsion of testicular appendage (appendix testis)
• Torsion of testicular appendage (appendix testis) can present with symptoms similar to those
of torsion of the testicle, usually in a prepubertal boy. The onset commonly is over 12 to 24
hours.
• Extreme tenderness over the appendage exists, usually on the superior aspect of the testicle.
The “blue dot” sign may be present when the ischemic appendage can be seen through the
scrotal skin. The testicle has a normal position and lie.
Fournier gangrene
• is a severe polymicrobial soft-tissue infection involving the genitals
and perineum; necrotizing fasciitis of this area can occur in women.
• Source: 25% a genitourinary source
25% have an anorectal source
10% have an intra-abdominal source
40% have an unidentified source.
• Risk factors: Diabetic, alcoholic, and other immunocompromised
patients appear to be more susceptible
• The clinical course is one of abrupt onset with pruritus, rapidly
progressing to edema, erythema, and necrosis, often within a few
hours. Fever, chills, and malaise are accompanying signs.
• Physical examination : edema and erythema of the skin of the
scrotum, phallus, and perineal area. This may progress rapidly
to frank necrosis of the skin and subcutaneous tissues, with
extension to the skin of the abdomen and back, reaching as
high as the clavicles and down the thighs. Crepitus in the
tissues suggests the presence of gas-forming organisms.
• Laboratory : CBC, serum electrolytes, creatinine, arterial blood
gas, coagulation parameters, urinalysis, urine, and blood
cultures. A KUB plain film may reveal subcutaneous gas.
• Treatment: -Stabilization
-Broad-spectrum antibiotics that are active
against both aerobic and anaerobic organisms
-Wide débridement is required; orchiectomy is
rarely indicated.
• mortality ranges from 3% to 45%
