Abnormal Findings (Chapter 24: Male Genitourinary System)

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1

Urinary Problems

Urethritis (Urethral Discharge and Dysuria)

Infection of urethra causes painful, burning urination or pruritus. Meatus edges are reddened, everted, and swollen with purulent discharge. Urine is cloudy with discharge and and mucus shreds.

Cause determined by cultures: (1) gonococcal urethritis has thick, profuse, yellow or gray-brown discharge; (2) nonspecific urethritis (NSU) may have similar discharge but often as scanty, mucoid discharge.

Of these, about 50% are caused by chlamydia infection. The cause is important to differentiate because antibiotic treatment is different.

2

Urinary Problems

Renal Calculi

Renal stones (crystals of Ca oxalate or uric acid) form in kidney tubules and then migrate and become urgent when they pass into ureter, become lodged, and obstruct urine flow.

Cause abrupt sever flank pain with radiation to the groin or abdomen, nausea and vomiting, restlessness, gross or microscopic hematuria.

3

Urinary Problems

Acute Urinary Retention

Abrupt inability to pass urine with bladder and lower abd pain. Much more common in men due to bladder outlet obstruction such as BPH. Must catheterize to relieve acute discomfort; then manage underlying problem

4

Urinary Problems

Urethral Stricture

Pinpoint, constricted opening at meatus or inside along urethra.

Occurs congenitally or secondary to urethral injury. Gradual decrease in force and caliber of urine stream is most common symptom. Shaft feels indurated along ventral aspect of site of stricture.

5

Male Genital Lesions

Tinea Cruris

A fungal infection in the crural fold, not extending to scrotum, occurring in post-pubertal males ("jock itch") after sweating or wearing layers of occlusive clothing. It forms a red-brown half-moon shape with well-defined borders

6

Male Genital Lesions

Genital Herpes - HSV-2 Infection

Clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans, foreskin, or anus.

These rupture for form superficial ulcers. May have mild tingling before outbreak or shooting pain in buttock or leg.

A STI, the initial infection lasts 7-10 days and is treated with oral acyclovir. The virus remains dormant indefinitely; recurrent infections last 3-10 days with milder symptoms

7

Male Genital Lesions

Genital Warts

Soft, pointed, moist, fleshy, painless papules may be single or multiple in a cauliflower-like patch.

Color may be gray, pale yellow, or pink in White males and black or translucent gray-black in Black males. They occur on shaft of penis, behind corona, or around the anus where they may grow into large, grapelike clusters

8

Male Genital Lesions

Syphilitic Chancre

Begins withing 2-4 weeks of infection as a small, solitary, silvery papule that erodes to red, round, or oval, superficial ulcer with a yellowish serous discharge.

Palpation reveals a nontender indurated base that can be lifted like a button between the thumb and the finger.

Lymph nodes enlarge early but are nontender.

This is an STI easily treated with penicillin G; but untreated it leads to cardiac and neurologic problems and blindness.

9

Male Genital Lesions

Carcinoma

Begins as red, raised, warty growth or as an ulcer with watery discharge. As it grows, may necrose and slough. Usually painless.

Almost always on glans or inner lip of foreskin and following chronic inflammation. Enlarged lymph nodes are common.

10

Penis Abnormalities

Hypospadias

Urethral meatus open on the ventral (under) side of glans or shaft or at the penoscrotal junction. A groove extends from the meatus to the normal location at the tip.

This congenital defect is important to recognize at birth. The newborn should not be circumcised because surgical correction may need to use foreskin tissue to extend urethral length

11

Penis Abnormalities

Priapism

Prolonged painful erection of penis without sexual stimulation and unrelieved by intercourse or masturbation, most common in men in 30s and 40s. A rare condition but when lasting 4 hours or longer can cause ischemia of penis, fibrosis of tissue, erectile dysfunction.

Can occur as a side effect of some medications and street drugs; with sickle-cell trait or disease; with leukemia in which increased numbers of WBCs produce engorgement; with malignancy; from local trauma; or as a result of spinal cord injuries with ANS dysfunction

12

Penis Abnormalities

Phimosis

Non-retractable foreskin forming a pointy tip with a tiny orifice. Foreskin is advanced and so tight that it is impossible to retract over glans. May be congenital or acquired from adhesion secondary to infection. Poor hygiene leads to retained dirt and smegma, which increases risk for inflammation, calculus formation, obstructive uropathy

13

Penis Abnormalities

Paraphimosis

Foreskin is retracted and fixed. Once retracted behind glans, a tight or inflamed foreskin cannot return to its original position. Constriction impeded circulation, so glans swells.

A medical emergency; the constricting band prevents venous and lymphatic return from the glans compromises arterial circulation

14

Penis Abnormalities

Epispadias

Meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis.

Rare; less common than hypospadias but more disabling because of associated urinary incontinence and separation of public bones

15

Penis Abnormalities

Peyronie Disease

Hard, nontender, subcutaneous plaques palpated on dorsal or lateral surface of penis. May be single or multiple and asymmetric.

Associated with painful bending of the penis during erection. Plaques are fibrosis of covering of corpora cavernosa.

Usually occurs after 45 years. Its cause is trauma to the erect penis (e.g., unexpected change in angle during intercourse). More common in men with DM, gout, Dupuytren contracture of palm

16

Scrotum Abnormalities

Cryptorchidism

S: empty scrotal half

O: inspection - in true maldescent, atrophic scrotum on affected side; palpation - no testis

A: absent testis

True cryporchidism - testes that have never descended. Incidence at birth is 3-4%; one half of these descend in first month. Incidence with premature infants is 30%; in the adult, 0.7-0.8%. True undescended testes has a histologic change by 6 years, causing decreased spermatogenesis and infertility. Also increases risk for testicular cancer.

17

Scrotum Abnormalities

Small Testis

S: none

O: palpation - small and soft (rarely may be firm)

A: small testis

Small and soft (<3.5 cm) indicates atrophy as with cirrhosis or hypopituitarism, following estrogen therapy, or as a sequelae of orchitis. Small and firm (<2 cm) occurs with Klinefelter's syndrome (hypogonadism)

18

Scrotum Abnormalities

Testicular Torsion

S: excruciating unilateral pain in testicle of sudden onset, often during sleep or following trauma; may also have lower abd pain, nausea and vomiting, no fever

O: inspection - red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening; palpation - cord feels thick, swollen, tender; epididymis may be anterior; cremasteric reflex absent on side of torsion

Sudden twisting of spermatic cord. Occurs in late childhood, early adolescence; rate after age 20 years. Torsion testis on wall of scrotum allows testis to rotate. The anterior testis rotates medially toward the other testis. Blood supply is cut off, resulting in ischemia and engorgement. An emergency requiring surgery; testis can become gangrenous in a few hours

19

Scrotum Abnormalities

Epididymitis

S: severe pain of sudden onset in scrotum, relived by elevation (positive Prehn sign); also rapid swelling, fever

O: inspection - enlarged scrotum; reddened; palpation - exquisitely tender; epididymis enlarged, indurated; hard to distinguish from testis. Overlying scrotal skin may be thick and edematous; lab - WBCs and bacteria in urine

A: tender swelling of epididymis

Acute infection commonly caused by prostatitis; after prostatectomy because of trauma of urethral instrumentation; or from chlamydia, gonorrhea, or other bacterial infection. Often difficult to distinguish between epididymitis and testicular torsion

20

Scrotum Abnormalities

Varicocele

S: dull pain; constant pulling or dragging feeling; or may be asymptomatic

O: inspection - usually no sign; or bluish color through light scrotal skin; palpation - when standing, feel soft, irregular mass posterior to and above testis; collapses when supine, refills when upright; feels distinctive, like a "bag of worms"; testis on side of varicocele may be smaller due to impaired circulation

A: soft mass on spermatic cord

Dilated, tortuous varicose veins in the spermatic cord caused by incompetent valves, which permit reflux of blood; 90% left-sided, perhaps because left spermatic vein is longer and inserts at a right angle into left renal vein. Occurs in 15% by age 15 years. Screen at early adolescence; obtain scrotal ultrasound; early Tx important to prevent potential infertility when an adult.

21

Scrotum Abnormalities

Spermatocele

S: painless, usually found on exam

O: inspection - does transilluminate higher in the scrotum than hydrocele, and the sperm may flouresce; palpation - round, freely movable mass lying above and behind testis; if large, feels like a third of testis

A: free cystic mass on epididymis

Retention cyst in epididymis; cause unclear but may be obstruction of tubules. Filled with thin, milky fluid that contains sperm. Most spematoceles are small (<1 cm); occasionally they may be larger and mistaken for hydrocele

22

Scrotum Abnormalities

Early Testicular Tumor

S: painless, found on exam; may have Hx of undescended testicle or familial testicular cancer

O: palpation - firm nodule or harder than normal section of testicle; testicular swelling occurs in most

A: solitary nodule

Most testicular tumors occur between ages 18-35; practically all are malignant. More common in Whites; must biopsy or confirm. Most important risk factor is undescended testis, even those surgically corrected. Early detection important in prognosis, but practice of testicular self-exam is low

23

Scrotum Abnormalities

Diffuse Tumor

S: enlarging testis (most common symptom). When enlarges, has feel of increased weight

O: inspection - enlarged, does not transilluminate; palpation - enlarged, smooth, oivoid, firm; important - firm palpation does not cause usual sickening discomfort as with normal testis

A: nontedner swelling of testis

Diffuse tumor maintains shape of testis

24

Scrotum Abnormalities

Hydrocele

S: painless, swelling, although person may complain of weight and bulk on scrotum

O: inspection - enlarged mass does transilluminate with a pink or red glow; palpation - nontender mass; able to test fingers above mass

A: nontender swelling of testis

Cystic. Circumscribed collection of serous fluid in tunica vaginalis surrounding testis. May occur following epididymitis, trauma, hernia, tumor of testis, or spontaneously in the newborn. Usually resolves during first year; if large or enlarging, may need surgical decompression

25

Scrotum Abnormalities

Scrotal Hernia

S: swelling, may have pain with straining

O: inspection - enlarged, may reduce when supine, does not transilluminate; palpation - soft, mushy mass; palpating fingers cannot get above mass. Mass is distinct from testicle that is normal

A; nontender swelling of scrotum

Scrotal hernia usually caused by indirect inguinal hernia. Requires surgery. Teach patient or boy's parents signs of incarcerated hernia; proceed to ED if these occur before planned surgery

26

Scrotum Abnormalities

Orchitis

S: acute or moderate pain of sudden onset, swollen testis, feeling of weight, fever

O: inspection - enlarged, edematous, reddened; does not transilluminate; palpation - swollen, congested, tense, and tender; hard to distinguish testis from epididymis

A: tender swelling of testis

Acute inflammation of testis. Most common cause is mumps; can occur with and infectious disease;

May have hydrocele that does transilluminate

27

Scrotum Abnormalities

Scrotal Edema

S: tenderness

O: inspection - enlarged, may be reddened (with local irritation); palpation - taut with pitting. Probably unable to feel scrotal contents

A: scrotal edema

Accompanies marked edema in lower half of body (e.g., CHF, renal failure, and portal vein obstruction). Occurs with local inflammation: epididymitis, torsion of spermatic cord. Also, obstruction if inguinal lymphatics produces lymphedema of scrotum

28

Indirect Inguinal Hernia

Course: sac herniates through internal inguinal ring; can remain in canal or pass into scrotum

s/s: pain with straining; soft swelling that increases with increased intra-abd pressure; may decrease when lying dowb

Freq: most common; 60% of all hernias; more common in infants <1 year and males 16-20 years of age

Cause: congenital or acquired

29

Direct Inguinal Hernia

Course: directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum

s/s: usually painless; round swelling close to the pubis in area of internal inguinal ring; easily reduced when supine

Freq: less common; occurs most often in men older than 40 years, rare in women

Cause: acquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, ascites

30

Femoral Hernia

Course: through femoral ring and canal, below inguinal ligament, more often on the right side

s/s: pain may be severe; may become strangulated

Freq: least common, 4% of all hernias, more common in women

Cause: acquired; due to increased abd pressure, muscle weakness, or frequent stooping