Twice daily bathing with SALINE SOLUTION (with foreskin retracted) Clotrimazole cream (1% BID x7 days) Refractory -> Stop Clotrimazole and start Fluconazole PO or Nystatin Cream

PCN G Benzathine (just 1x) PCN Allx -> Doxy

Penile & Urethral DOs Flashcards by Shay S

What is the Coronal Sulcus?

rim of the glans penis

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What is Balanitis & Balanoposthitis? How do they differ?

Balanitis = Inflammation/Infx of Glans penis
Balanoposthitis = Glans + Foreskin

MCC: poor hygiene in an uncircumcised male -> Candida (MALE YEASTY)

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MCC of Balanitis & Balanoposthitis?

Poor hygiene in an uncircumcised male -> Candida (MALE YEASTY)

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Which dermatologic conditions can cause Balanitis & Balanoposthitis?

Lichen Sclerosis (chronic progressive inflammation and skin thinning -> SCC risk)
Lichen Planus
Psoriasis
Eczema (irritants, condoms), Allx Rxn

Lichen Sclerosis used to be called “balanitis xerotica obliterans (BXO)”

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Balanitis & Balanoposthitis may be the 1st sign of undiagnosed _____

Immunocompromised states such as DM are HIGH Risk Factors

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Dx?
Pt presents with glans/foreskin -> red, burning, itchy, +/- red papules “Satellite lesions”, +/- cottage cheese like discharge

Balanitis or Balanoposthitis

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Candida Balanitis Tx

Twice daily bathing with SALINE SOLUTION (with foreskin retracted)
Clotrimazole cream (1% BID x7 days)

Refractory -> Stop Clotrimazole and start Fluconazole PO or Nystatin Cream

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What is Lichen Sclerosus?

“balanitis xerotica obliterans (BXO)”

chronic atrophic dermatitis
white atrophic plaques on glans/foreskin that get bigger over time -> turn into a large sclerotic mass w/adhesions, Phimosis, Meatal Stenosis

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Lichen Sclerosus Tx:
- Mild?
- Mod/Severe (Phimosis, Meatal Stenosis)?

“balanitis xerotica obliterans (BXO)”

Mild -> Topical Steroids (Clobetasol) q night
MOD/SEVERE -> CIRCUMCISION

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SS progression of HSV

Prodromal (tingling, burning, itching) -> PAINFUL RED VESICLES/ULCERS -> CRUSTING

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Balanitis/Balanoposthitis -> HSV Dx

1. PCR of Lesion sample
2. Antibody tests (HSV-1/2, IgM, IgG)

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Balanitis/Balanoposthitis -> HSV Tx

Acyclovir, Valacyclovir, Famciclovir

dosing differs (initial vs subsequent episodes)

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Primary Syphilis ET & SS

ET: STI Spirochete (Treponema Pallidum)
SS: SINGLE CHANCRE -> FIRM, PAINLESS, +/- LAD 2-6wk after exposure

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Primary Syphilis Dx
- Screen?
- Confirm?

SCREEN -> NON-Treponemal Test (RPR, VDRL)
CONFIRM -> TREPONEMAL Test (TP-EIA)

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Primary Syphilis Tx

PCN G Benzathine (just 1x)
PCN Allx -> Doxy

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HPV ___ & ___ = Genital warts

6 & 11

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HPV “Genital Warts”
- SS?
- WU?

SS: FLESH-COLORED CAULIFLOWER LESIONS
WU: CLINICAL Dx, STI WU (bc high risk), +/- Bx (CA?)

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HPV “Genital Warts” #1 Tx

IMIQUIMOD (ALDARA) CREAM - 3xWk before bed, wash in AM
If not better by 16wk -> Derm refer

+/- Cryotherapy, Trichloroacetic acid, Sx excision, Lazer

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Circinate Balanitis ET

REACTIVE ARTHRITIS (REITER SYNDROME)
Infx ** (#1 CHLAMYDIA)** -> systemic SS -> Can’t Pee (Urethritis/Balanitis), Can’t See (Conjunctivitis), Can’t Bend at the knee (Arthritis)

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Circinate Balanitits: Penile SS

PAINLESS, small red SHALLOW ULCERS on glans/foreskin

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Circinate Balanitis Tx

Tx underlying ET (Chlamydia) +/- Topical Steroids

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Complications of Balanitis/Balanoposthitis?

Scarring
Phimosis/Paraphimosis
Urethral Stricture
SCC

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Balanitis/Balanoposthitis Tx if NO identifiable ET?

Saline solution bath 2xday
Empiric Yeasty (Candida Balanitis) Tx -> Clotrimazole 1% BIDx7days (Alt -> Fluconazole PO, Nystatin Cream)
if no improvement -> Hydrocortisone 1% BIDx7days
IF ALL ELSE FAILS -> Refer derm or urology for poss Bx

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1 Risk for Penile Cancer

HPV 6, 16, 18

Others: older 60yo, Uncircumcized, HIV, Smoking, UTI, Injury, Urethral stricture, Inflammation

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Majority of Penile CA =

SCC

When to suspect penile CA

* Painless, Palpable lump/ulcer +/- inguinal LAD - Presumable Infx/inflammation thats FAILING STEROID/ABX Tx

Pt presents with penile painless, palpable lump/ulcer. They have been taking Steroids and ABX for over 1mo for a presumable infection that has not gone away. You should suspect what?

Penile CA

Penile CA Dx

- Lesion Bx (incisional or punch) - Inguinal lymph node eval -> CT, MRI, CT/PET, or Inguinal US +/- US FNA)

Order a ____ for pt with sussy penis CA that also has bone pain, HIGH Ca, HIGH Alk Phosph

Bone Scan

Tx for EARLY STAGE Penile CA & PeIN (pre-malig lesion)

**Organ sparing procedures** * Topical (5-FU, Imiquimod) * Rad * Mohs Sx * Laser Ablation * Partial excision

Tx for LATER STAGE Penile CA

* Partial/Total **PENECTOMY** (Reroute urethra to perineum) ## Footnote +/- Inguinal lymph node dissection +/- ADD Chemo/Rad

Tx for Physiologic Phimosis

1. **REASSURANCE**, self-resolve by **16yo** 2. If does not go away with age -> **STEROIDS + STRETCH EXERCISES** 3. REFRACTORY -> **CIRCUMCISION**

#1 ET for Pathologic Phimosis

Lichen Sclerosus (BXO) ## Footnote Any Trauma, Inflammation, Infx

Tx for Pathological Phimosis

- **CIRCUMCISION** (MC INDICATION FOR ADULT CIRCUMCISION) - Preputioplasty (Sx release scar tissue) - Preputial Balloon Dilation (widen the ring while saving the prepuce)

#1 ET for Paraphimosis

**IATROGENIC** Foreskin Manipulation (Urine Cath) ## Footnote - Injuries (self, sex, piercings, GU procedures) - Partial Phimosis

Paraphimosis occurs when the foreskin is stuck behind the ___________

Coronal Sulcus

Paraphimosis Tx: If NO signs of necrosis?

**MANUAL REDUCTION** 1. Pain control -> dorsal penile block, topical, procedural sedation 2. DECR Swelling -> Granulated sugar, Compression dressing, Manual circumferential compression 3. Manual reduction (pull it back on). If fails -> try puncture technique 4. DO NOT retract foreskin for 1 week | AVOID ICE for pain control bc it vasoconstricts = BAD

Paraphimosis Tx: IF Manual Reduction FAILS or Signs of NECROSIS (Blue)

**DORSAL SLIT PROCEDURE** +/- Circumcision later on ## Footnote cut constricting band and replace it

Tx for Penile Constriction Tourniquet

1. Superficial -> Dissolve the hair (Nair, Magic Shave, Veet) 2. Use forceps to unwind it or cut the hair

#1 organism -> Simple Acute Cystitis (UTI) in Men

E. coli

Red flags for complicated UTI

* Flank pain, CVA tenderness = PYELO * Pelvic/Perineal pain = Prostitis * Systemic SS = Pyelo, Prostitis, Sepsis -> DO PROSTATE EXAM

You suspect a UTI in a mean who also presents with systemic ss. Next step?

Do a prostate exam

#1 Dx order for man with likely UTI

UA Culture ## Footnote all men get a UA culture bc it gets complicated very fast

1st line Tx options for Simple UTI in men

Bactrim, Macrobid, or Beta-lactams x7 days

Tx for Simple UTI in men if SEVERE SS or possible prostate involvement

Ciprofloxacin x 5 days

Men with persistent and/or recurrent cystitis should be WU for...

* Predisposing factors (BPH, Other Urinary tract obstruction) * Chronic Prostatitis

#1 organism -> Urethritis

Neisseria Gonorrhea

Discharge Consistency if... - Gonorrhea -> - Chlamydia ->

- Gonorrhea -> Purulent - Chlamydia -> CLEAR

Dx for urethritis

Clinical Dx NAAT - STI specific

Urethritis Tx

**Presumptive Tx both GONORRHEA & CHLAMYDIA** * Gonorrhea -> CEFTRIAXONE 500mg IM x1 * Chlamydia -> DOXYCYLINE 100mg PO BID x7 days

Suspect ______ infx if Urethritis is persistent/fails meds

Mycoplasma genitalium

Tx for confirmed Mycoplasma genitalium Infx -> Urethritis

Moxifloxacin

WU for Penile Frx and Urethral Injuries

* Inital -> US * Retrograde Urethrogram (RUG)

Penile fractures occur when the _______ layer of the penis thins during erection and then ruptures d/t direct trauma

Tunica Albuginea

Order a _____ for poss Urethral Injury

RUG Retrograde urethrogram

Retrograde urethrogram for possible urethral injury is (+) for extravasation. What does this mean?

contrast is outside of the urethra = Urethral injury confirmed ## Footnote Partial = some dye in the bladder Complete = NO dye in the bladder!!!!

Should you avoid cathing if there is urethral injury?

AVOID Urethral bladder caths. However, you MUST DO A SUPRAPUBIC CATH TO DRAIN THE BLADDER ASAP

Urethral strictures are MC in which age group and by which mechanism?

Males 55yo+ Idiopathic, Iatrogenic, Trauma, Inflammation

55yo Male presents with weak stream, incomplete bladder emptying, urinary spraying, and says he "doesn't cum like he used to" #1 DDx?

Urethral Stricture

Urethral Stricture WU - order ___ to Screen - order ____ to CONFIRM Dx

* SCREEN = UROFLOWMETRY * Dx CONFIRM = (RUG) Retrograde Urethrogram

Penile & Urethral DOs Flashcards

- Balanitis & Balanoposthitis - Penile CA - Phimosis & Paraphimosis - Penile Constriction Tourniquet - Hypospadias & Epispadias - Simple Acute Cystitis in Men - Urethritis - Penile Fracture - Urethral Injury - Urethral Stricture (60 cards)