Erectile Dysfunction, Foreskin, Scrotal Lumps, etc

Question 1

What are the causes of Erectile dysfunction?

Answer 1

Vascular

Neurological
(diabetes, spinal injury, parkinsons, cva)

Venogenic/cavernosal

Hormonal
eg. low testosterone

Medication
(antidepressants, b-blockers, etc)

Psychological

Question 2

Why is it important to assess CVS risk in men with ED?

Answer 2

ED is a sensitive marker of early vascular disease

Could potentially mitigate risk of MI, CVA, etc.

Question 3

What management is used to treat ED?

Answer 3

Psychosexual counselling if it is psychological

PDE5 inhibitors eg. sildenafil
(contraindicated if on nitrates for ischaemic heart disease)

treat low testosterone if needed

Intracavernosal prostaglandin injections

Vacuum tumescence device

Inflatable penile prosthesis

Question 4

What is the difference between physiological and pathological/scarred phimosis?

Answer 4

Phimosis is the inability to retract the foreskin (distal prepuce) proximally over the glans penis.

Pathalogical = inability to retract foreskin proximally over glans penis in postpubertal males, or in patients in whom scarring has developed from chronic infection and inflammation (balanoposthitis) etc

Congenital = in children younger than 3 years of age

Question 5

What is a paraphimosis?

Answer 5

A condition where the foreskin of the uncircumcised penis is retracted and left behind the glans penis.

This leads to vascular engorgement and oedema of the distal glans.

a medical emergency!!!

Question 6

How do you tell if ED is organic or psychological?

Answer 6

If it is gradual onset = organic
sudden onset = psychological

Presence of early morning erections show it is psychological

Question 7

What are some common risk factors for Fournier’s Gangrene?

Answer 7

Diabetes Mellitus

Obesity

Immunocompromise eg. HIV

Atherosclerosis

Smoking

Drug and alcohol abuse

Malignancy

Question 8

What is the treatment for Fournier’s

Answer 8

Strong IV antibiotics

emergency surgical debridement to remove dead tissue and stop infection from spreading. (and then sometimes skin grafting/plastics)

Question 9

Define Peyronie’s disease

Answer 9

Plaques of scar tissue form under the skin of the penis.

These can cause the penis to bend or become indented during erections.

They usually form on the top side, causing the penis to bend upwards.

Usually caused by minor trauma = injury to tunica albuginea = scar tissue formation.

Question 10

What are the clinical features of an indirect inguinoscrotal hernia

Answer 10

when inguinal hernia passes into the scrotum via the external inguinal ring, initially at the internal ring (indirect) or through Hesslebach’s triangle (direct).
They run along the spermatic cord as they pass into the scrotum.

Presentation:

• you cannot “get above” an inguinal hernia within the scrotum (cannot palpate its superior surface)
• cough may exacerbate swelling
• may disappear upon lying flat

***needs to be assessed for strangulation or obstruction

Question 11

What are the clinical features of a hydrocele

Answer 11

= abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis

Presents as:

• painless, fluctuant swelling
• transilluminates
• either unilateral or bilateral
• can grow quite large and cause discomfort when sitting/walking

***hydroceles and epididymal cysts will transilluminate

Question 12

What are the clinical features of an epididymal cyst

Answer 12

(Also known as spermatoceles)
= benign fluid-filled sacs arising from epididymis

Present as:

• smooth fluctuant nodule
• found above and separate from testis
• transilluminate
• often multiple
• often middle aged men

Surgery can lead to infertility in young men so usually avoid treatment

Question 13

What are the clinical feature of testicular cancer?

Answer 13

• unilateral painless lumps arising from the testis
• firm irregular fixed mass
• does not transilluminate - commonly 20-40 year olds
• Metastasis can present as weight loss, back pain (retroperitoneal), dyspnoea (lungs)

Question 14

What is the definition, clinical features and treatment of a varicocele?

Answer 14

= abnormal dilation of the pampiniform venous plexus within the spermatic cord.

Present as:

• a lump feeling like a “bag of worms”
• a “dragging sensation”
• may disappear when lying flat
• usually found on left side as spermatic vein drains directly into left renal vein

***can cause infertility and testicular atrophy by increasing intra-scrotal temp so men should be sent for semen analysis

***red flags = right sided, acute onset, remain when lying flat

Treatment:
embolisation or surgical ligation of spermatic veins

Question 15

Risk factors for testicular cancer

Answer 15

Cryptorchidism (undescended testes)

Previous testicular malignancy

FHx

Kleinfelter’s syndrome

Question 16

Investigations for testicular cancer

and what NOT to do

Answer 16

Investigation

• urgent scrotal US for diagnosis
• staging via chest-abdo-pelvis CT with contrast
• tumour markers (BHCG, AFP, LDH)

NO trans-scrotal percutaneous biopsy as it can cause seeding of cancer

Question 17

Treatment for testicular cancer

Answer 17

Treatment

• Royal Marsden Classification
• if high suspicion of testicular cancer, radical inguinal orchidectomy is required (removes testes and spermatic cord)
• Pre-treatment fertility assessment as chemo and radiation can impair fertility
• Chemotherapy or radiotherapy for metastatic

Question 18

What are the types of testicular cancer?

Answer 18

Germ cell tumours
(Seminomas or Non-seminomatous GCTs)
= Usually malignant

Non germ cell tumours
(Leydig cell or Sertoli cell tumours)
= usually benign

Question 19

What are the clinical features of epididymitis?

Answer 19

= inflammation of the epididymis
= most commonly bacterial origin eg. STI
(treated with oral antibiotics and analgesia)

Presents as:

• unilateral
• acute onset scrotal pain
• may be swelling, erythematous overlying skin
• may have systemic symptoms like fever

Question 20

What are the clinical features and treatment of testicular torsion?

Answer 20

= spermatic cord and its contents twists within the tunica vaginalis, compromising blood supply to the testicle = ischaemia
(Bell clapper deformity results in a higher risk)

Presents as:

• sudden onset
• severe unilateral scrotal pain
• nausea, vomiting
• very tender, swollen testis with loss of cremasteric reflex.
• affected testis has a horizontal lie and is higher

Treatment:
scrotal exploration and fixation of both testes (bilateral orchidopexy)