PANCE Blueprint Genitourinary (5%)

Penile disorders (PEARLS)

The NCCPA™ PANCE Genitourinary Content Blueprint penile disorders

Erectile dysfunction
Patient will present as → a 60-year-old man who presents to your clinic for evaluation of erectile dysfunction. His wife died 5 years ago and he would like to start dating again. He denies having any life stressors. He reports having no morning or night-time erections. His past medical history includes hyperlipidemia managed with medication and pre-diabetes managed with an active lifestyle and diet.

Occurs when a man can't get or keep an erection firm enough for sexual intercourse

  • Psychological
  • Organic causes include hypertension, neurological problems from diabetes, and hormonal dysfunction
  • Medication side effects
  • Nocturnal penile tumescence used to evaluate sleep erections
  • Do not use with nitrates may cause hypotension

DX: Detailed history and examination, including a DRE and neurologic examination. Assess for signs of PAD

  • Laboratory tests—Obtain a CBC, chemistry panel, fasting glucose, and lipid profile
  • If there is hypogonadism or loss of libido, order serum testosterone, prolactin levels, and thyroid profile
  • Nocturnal penile tumescence—If normal erections occur during sleep, a psychogenic cause is likely. If not, the cause is probably organic.
  • Vascular testing—Evaluate arterial inflow and venous trapping of blood. Tests include intracavernosal injection of vasoactive substances, duplex ultrasound, and arteriography
  • Psychologic testing may be appropriate in some cases

TX: Treat with phosphodiesterase 5 inhibitors Sildenafil (Viagra), Tadalafil (Cialis), Vardenafil (Levitra)

  • Weight loss, smoking and alcohol cessation, hormone replacement and vacuum erection devices, and surgery
Hypospadias/epispadias
Patient will present as → a healthy newborn male is undergoing routine examination, upon examination of the genitalia the urethral meatus is found located proximal to the tip of the glans on the ventral aspect of the penile shaft. (hypospodiasis)

Epispadias is when the urethra opens onto the topside of the penile shaft

  • The position of the urethral meatus defines the type of epispadias
    • Penopubic - at the base of the penis and abdominal wall come together (most severe)
    • Penile - along the shaft of the penis
    • Glanular - near the head of the penis (lease severe)

DX: Diagnosis is usually made during the newborn exam but imaging studies (excretory urogram) can aid in the diagnosis

TX: Treatment is surgical repair, usually performed before 1-2 years of age

  • Do not circumcise - foreskin may be used to reconstruct the urethra

Hypospadias (more common than epispadias) is when the urethra opens onto the bottom (underside) of the penile shaft 

  • The position of the urethral meatus defines the type of hypospadias
    • Glanular - head of the penis (lease severe)
    • Midshaft - middle of the penis
    • Penalscrotal - where the penis and scrotum come together (most severe)

DX: Diagnosis is usually made during the newborn exam but imaging studies (excretory urogram) can aid in the diagnosis

TX: Treatment is surgical repair, usually performed before 1-2 years of age

  • Do not circumcise - foreskin may be used to reconstruct the urethra
Paraphimosis/phimosis
ReelDx Virtual Rounds (Paraphimosis)
Patient will present as → a 31-year-old male who presents to the ED  with penile pain after intercourse. He states that his penis is swollen and very painful. His vital signs are normal. Physical exam is notable for edematous foreskin that does not reduce to its original position.

Paraphimosis is an inability to return the foreskin to its normal position

  • Entrapment of the foreskin behind glans
  • Causes a tourniquet effect and is a medical emergency
  • More acute than phimosis

DX: The diagnosis of paraphimosis is based upon clinical findings

TX: Treat by applying firm circumferential compression to the glans with the hand - may relieve edema sufficiently to allow the foreskin to be restored to its normal position.

  • If this technique is ineffective, a dorsal slit using local anesthetic relieves the condition temporarily
    • Circumcision is then done when edema has resolved

Phimosis is an inability to retract the foreskin

  • Usually resolves by age five
  • Unable to retract the foreskin
  • More chronic than paraphimosis

DX: The diagnosis of paraphimosis is based upon clinical findings

TX: Treat with betamethasone topically, if no improvement circumcision

Nephrolithiasis/urolithiasis (ReelDx + Lecture) (Prev Lesson)
(Next Lesson) Erectile dysfunction (Lecture)
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