PANCE Blueprint Genitourinary (5%)

Penile disorders (PEARLS)

The NCCPA™ PANCE Genitourinary Content Blueprint penile disorders

Erectile dysfunction Hypospadias/epispadias Paraphimosis/phimosis
Description Inability to achieve or maintain an erection sufficient for sexual intercourse A birth defect in which the opening of the urethra is not at the tip of the penis A condition in which the foreskin is retracted behind the glans penis and cannot be pulled back forward
Symptoms Difficulty achieving or maintaining an erection The urethral opening is not at the tip of the penis

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

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

The foreskin is retracted behind the glans penis and cannot be pulled back forward
Causes Vascular disease, neurological disorders, hormonal imbalances, medications, psychological factors Genetics, environmental factors Recurrent retraction of the foreskin, inflammation of the foreskin, trauma to the penis
Treatment Lifestyle changes, medications, surgery Treatment is surgical repair, usually performed before 1-2 years of age Treat with betamethasone topically. If there is no improvement - circumcision
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

© SM 1000 by Adobe Stock

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

Patient with epispadias will present as → a 2-year-old boy is brought to the clinic by his parents due to concerns about abnormal urination. The parents report that the child’s urine stream appears misdirected and sprays upward. On examination, the urethral opening is observed on the dorsal surface (upper side) of the penis, near the base of the glans. The child is diagnosed with epispadias. He is referred to a pediatric urologist who explains that this is a rare congenital condition and discusses the potential for surgical correction to improve the function and appearance of the genitalia, as well as to prevent future urinary issues.
  • 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 (least 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 

Patient with hypospadias 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 (underside) of the penile shaft.
  • The position of the urethral meatus defines the type of hypospadias
    • Glanular - head of the penis (least 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

Hypospadias urinating

Hypospadias and two fistulas

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. The 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 the glans
  • It causes a tourniquet effect and is a medical emergency
  • More acute than phimosis

DX: The diagnosis of paraphimosis is based on 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 a local anesthetic relieves the condition temporarily
    • Circumcision is then done when the edema has resolved
Swelling of the foreskin 4 2

Paraphimosis – is the entrapment of the foreskin in the retracted position

Patient will present with → foreskin in normal position that cannot be retracted.

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 on clinical findings

TX: Treat with betamethasone topically. If there is no improvement - circumcision

Phimosis 001

Phimosis – the foreskin is in the normal position and cannot be retracted

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