PANCE Blueprint Genitourinary (5%)

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

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

ReelDx Virtual Rounds (Paraphimosis)

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