PENILE AND URETHRAL DISORDERS

Question 1

1. What is the corpus cavernosum?

2. What is the corpus spongiosum and what runs through it?

Answer 1

1. Corpus cavernosum
   - Two columns of tissue that run along side the penis that helps with erections
2. Corpus spongiosum
   - Column of sponge like tissue that runs along the front and ending at the glans
   - The urethra runs through the spongiosum

Question 2

Disorders of the Urethra

4

Answer 2

1. Urethritis
2. Urethral stricture
3. Meatal stenosis
4. Hypospadius

Question 3

Urethritis

1. What is it?
2. Who is it more common in?
3. Causes? 5

Answer 3

1. An inflammation of the urethra
2. Females greater than males
3. Causes
   - Gonorrhea
   - Chlamydia
   - HPV
   - Herpes simplex
   - Idiopathic

Question 4

Urethritis
Symptoms:
1. Males? 4
2. Females? 4

Answer 4

Symptoms

1. Males
   - Dysuria
   - Itching or burning at the meatus
   - Hematuria/hematospermia
   - Urethral discharge
2. Females
   - Frequency
   - Dysuria
   - SP discomfort
   - discharge

Question 5

Urethritis
1. Dx? 2

2. Tx? (first line and FL alternative)
3. Alternatives? 2

Answer 5

1. Diagnosis
   - UA and culture
   - NAATs
2. Treatment
   - Azithromycin 1g PO single dose
   - Doxycycline 100mg bid x 7 days
3. Alternatives
   - Erythromycin 500mg PO qid x 7 days
   - Levofloxacin/Cipro 500mg PO once daily x 7 days

Question 6

Urethritis

Treatment considerations? 4

Answer 6

1. Treat partner
2. Use condoms
3. Avoid irritants
4. NSAIDs

Question 7

Urethral Stricture

1. What is it?
2. What are the two types?

Answer 7

1. • A fibrotic band of tissue that renders the normal compliant urethral lumen inelastic
   • Narrowing of the urethra with slowing of the urine
2. Two types
   - Anterior: Begins at the bulbar urethra and end at the meatus
   - Posterior: Involves the membranous and prostatic urethra

Question 8

Urethral Stricture
Etiologies?
3

Answer 8

1. Trauma
2. Iatrogenic
3. Infection

Question 9

How would the following cause urethral stricture?

1. Trauma? 2
2. Iatrogenic? 2
3. Infection? 2

Answer 9

1. Trauma
   - Anterior urethra: Straddle injuries and penetrating injuries
   - Posterior urethra: Urethral disruption from pelvic fracture
2. Iatrogenic
   - Catheterization
   - Surgical
3. Infection
   - Gonococcal/Chlamydia

Question 10

Urethral strictures:
1. Presentation? 3

2. Diagnosis? 3

Answer 10

1. Obstructive urinary symptoms
   - Slow stream
   - Decreased caliber
   - Post-void dribbling
2. Dx
   - Catheter
   - Cystoscopy
   - RUG

Question 11

Urethral stricture: Tx? 3

Answer 11

1. Urethral dilation
2. DVIU
3. Urethroplasty

Question 12

Meatal Stenosis

1. What is it?
2. More common in who?
3. Causes? 2
4. Symptoms? 3
5. Dx?
6. Tx?

Answer 12

1. Narrowing of the opening of the urethra at the tip of the penis
2. More common in males
3. Causes
   - Swelling and irritation after newborn circ
   - Idiopathic
4. Symptoms
   - Spraying of stream
   - Bed wetting
   - Dysuria
5. Diagnosis
   - Physical exam
6. Treatment
   - Meatonomy

Question 13

Hypospadius

1. What is it?
2. Occurs between what?
3. Presentation? 3

Answer 13

1. A congenital defect in which the opening of the urethra is on the underside of the penis
2. Occurs between the glands and penile-scrotal junction
3. Presentation
   - Spraying of urine
   - Having to sit down to void
   - Foreskin makes the penis look like it has a “hood”

Question 14

Hypospadius

1. DX?
2. Tx?
3. Tx complications? 2

Answer 14

1. Diagnosis
   - Made usually at time of birth with physical exam
2. Treatment
   -Surgical repair (4-18 months)
   (Magpi and Snodgrass)
3. Complications
   - Meatal stenosis
   - Fistula

Question 15

What are the penile disorders? 5

Answer 15

1. Balanitis
2. Phimosis
3. Paraphimosis
4. Peyronie’s Disease
5. Erectile Dysfunction

Question 16

Balanitis

1. What is it?
2. Who is most affected?
3. Causes? 2
4. Presentation? 3

Answer 16

1. Inflammation of the glans penis
2. Uncircumcised men with poor hygiene most affected
3. Causes
   - Infectious
   - Non-infectious
4. Presentation
   - Pain
   - Irritation
   - Itching/Burning

Question 17

Balanitis

1. PE findings? 3
2. Dx? 3
3. Tx? 4

Answer 17

1. Physical Exam
   - Erythema/Edema
   - Discharge
   - Ulceration
2. Diagnosis
   - Culture discharge
   - Wet mount
   - Potassium hydroxide
3. Treatment
   - Retraction of foreskin/wash with soap and water
   - Bacitracin if bacterial infection suspected
   - Topical clotrimazole for candidal infection
   - Circumcision

Question 18

Phimosis

1. What is it?
2. In children how may this progress?
3. Causes? 2
4. Complications? 4

Answer 18

1. Inability to retract the foreskin over the glans due to narrowing, constriction, or adhesions
2. In children phimosis may resolve on own
3. Causes
   - Balanitis
   - Poor hygiene
4. Complications
   - Balanitis
   - Paraphimosis
   - Voiding problems
   - Penile carcinoma

Question 19

1. Phimosis
   Presentation? 4
2. Tx? 2

Answer 19

1. Presentation
   - Erythema
   - Itching
   - Discharge
   - Pain with erection and intercourse
2. Treatment
   - Betamethasone cream 0.05% bid
   - Circumcision (alternative)

Question 20

Paraphimosis

1. What is it?
2. Untreated can lead to what?
3. Tx? 2

Answer 20

1. Retracted foreskin becoming trapped proximal to the glans resulting in edema, inflammation, and pain
2. Untreated can lead to ischemia of the glans and eventual gangrene
3. Treatment
   - Firm compression and manual reduction of the foreskin
   - Circumcision

Question 21

Peyronie’s Disease

1. What is it?
2. Usually affects men of what age?
3. Causes? 2
4. How many phases are there?

Answer 21

1. A curvature of the penis, particularly during erections.
   Fibrosis and plaque formation of the tunica albuginea
2. Usually affects men aged 40-70 years old
3. Cause
   - Vascular trauma
   - Injury to the penis
4. Acute and chronic phase

Question 22

Describe the acute (4) and chronic (3) phases of Peyronie’s Disease?

Answer 22

1. Acute: first 18-24 hours
Includes 
-penile pain, 
-some curvature, 
-penile nodule, and 
-inflammation

2. Chronic
Characterized by 
-stable plaque, 
-penile angulation, and 
-loss of erectile ability

Question 23

Peyronie’s Disease

Presentation? 5

Answer 23

Presentation

1. Penile pain
2. Penile angulation
3. Palpable plaque
4. Indentation in the shaft
5. Decreased erectile dysfunction

Question 24

Peyronie’s Disease

1. Tx if dx in the first 6 months? 3
2. Tx after 6 months with a stable plaque? 2

Answer 24

1. Treatment: If diagnosed in first 6 months
   - Vitamin E
   - Ibuprofen
   - Colchicine
2. After 6 month with stable plaque
   - Injection therapy
   - Surgery

Question 25

Peyronie’s Disease What kind of injection therapy? 2

Answer 25

1. Collagenase clostridiu histolyticum (Xiaflex)- Men with palpable plaque and at least 30 degree curvature 2. Verapamil Weekly injections for 6 weeks

Question 26

ED Definition?

Answer 26

Inability to achieve or maintain an erection for satisfactory sexual performance

Question 27

Pathophysiology: Normal erectile response | 5 steps

Answer 27

1. Interaction between neurotransmitter, biochemical, and smooth muscle response 2. Initiated by parasympathetic and sympathetic neuronal triggers 3. Integrate physiologic stimuli of the penis with sexual perception and desire 4. Nitric oxide produced from endothelial cells after parasympathetic stimuli triggers smooth muscle relaxation and arterial influx of blood 5. Compression of venous return follows producing an erection

Question 28

1. ED risk factors? 5 | 2. Dx? 5

Answer 28

1. Risk factors - HTN - Smoking - Diabetes mellitus - Hyperlipidemia - Obesity 2. Diagnosis - International Index of Erectile Function Questionnaire - Fasting serum glucose - Lipid panel - TSH - Testosterone level

Question 29

ED Tx 1. First line? 2. First line medications? 5

Answer 29

Treatment 1. First-line Lifestyle modifications ``` 2. First-line medications Phosphodiesterase type 5 (PDE5) inhibitors -Sildenafil (Viagra) 50-100mg -Tadalafil (Cialis) 5mg daily or 10-20mg -Vardenafil (Levitra) 10-20mg -Avanafil (Stendra) 50-200mg ```

Question 30

ED First-line medications Phosphodiesterase type 5 (PDE5) inhibitors: SE? 5

Answer 30

Side-effects 1. HA, 2. flushing, 3. rhinitis, 4. abnormal vision 5. Do not take with nitrates

Question 31

Second line for ED? 3 Third line for ED? 1

Answer 31

1. Second line - Alprostadil (Caverject) - Vacuum pump device - Muse 125-1000mcg intraurethrally 2. Third-line and last - Inflatable penile prosthesis

Question 32

Where do you want to inject a vasoactive substance in the penis?

Answer 32

Into the corpus cavernosum in a dorsolateral location