1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 52 Disorders of the Male Genitourinary System

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Male Genitourinary System and Their Effects Disorders –Structural defects –Inflammation –Neoplasms Affect –Urine elimination –Sexual function –Fertility

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Hypospadias and Epispadias Congenital disorders of the penis Hypospadias The termination of the urethra is on the ventral surface of the penis. Categorized as glandular (involving the glans penis), penile, or perineoscrotal –Epispadias The opening of the urethra is on the dorsal surface of the penis.

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Phimosis and Paraphimosis Phimosis –Tightening of the prepuce or penile foreskin that prevents its retraction over the glans Paraphimosis –The foreskin is so tight and constricted that it cannot cover the glans.

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Peyronie Disease Definition –A localized and progressive fibrosis of unknown origin that affects the tunica albuginea Manifestations –Painful erection, bent erection, and the presence of a hard mass at the site of fibrosis

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis of Erectile Dysfunction Careful history (medical, sexual, and psychosocial) Physical examination Laboratory tests aimed at determining what other tests are needed to rule out organic causes of the disorder

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Components Involved in an Erection Autonomic nervous system Neurotransmitters and endothelial relaxing factors The vascular smooth muscle of the arteries and veins supplying the penile tissue The trabecular smooth muscle of the sinusoids of the corpora cavernosa

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Erectile Dysfunction Definition –The inability to achieve and maintain an erection sufficient to permit satisfactory sexual intercourse Psychogenic causes –Performance anxiety –A strained relationship with a sexual partner –Depression –Overt psychotic disorders such as schizophrenia

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Erectile Dysfunction (cont.) Organic causes –Neurogenic –Hormonal –Vascular –Drug-induced –Penile-related etiologies

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Mechanisms Causing Priapism Low-flow (ischemic) priapism –There is stasis of blood flow in the corpora cavernosa with a resultant failure of detumescence High-flow (nonischemic) priapism –Involves persistent arterial flow into the corpora cavernosa

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Classifications of Priapism Primary priapism –The result of conditions such as trauma, infection, and neoplasms Secondary priapism –Hematologic conditions such as leukemia, sickle cell disease, and thrombocytopenia –Neurologic conditions such as stroke, spinal cord injury, and other central nervous system lesions –Renal failure

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors for Generalized Penile Arterial Insufficiency Hypertension Hyperlipidemia Cigarette smoking Diabetes mellitus Pelvic irradiation

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The foreskin is so tight and constricted that it cannot cover the glans is a condition known as _____________. −A. phimosis −B. paraphimosis −C. hypospadia −D. epispadia

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. paraphimosis Rationale: Paraphimosis is a condition suffered by uncircumcised males.

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question The following conditions are _________________ types of priapism. –A. hematologic conditions such as leukemia, sickle cell disease, and thrombocytopenia –B. neurologic conditions such as stroke, spinal cord injury, and other central nervous system lesions –C. renal failure –D. primary or secondary

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. primary or secondary Rationale: Primary or secondary conditions as they are not directly related to penile function.

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Balanitis and Balanoposthitis Balanitis –An acute or chronic inflammation of the glans penis Balanoposthitis –Inflammation of the glans and prepuce –Usually encountered in males with phimosis or a large, redundant prepuce that interferes with cleanliness and predisposes to bacterial growth in the accumulated secretions and smegma

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Signs of Penile Cancer Invasive carcinoma of the penis begins as a small lump or ulcer. If phimosis is present, there may be painful swelling, purulent drainage, or difficulty urinating. Palpable lymph nodes may be present in the inguinal region.

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Risk Factors for Cancer of the Penis Balanitis xerotica obliterans Increasing age Poor hygiene Smoking Human papillomavirus (HPV) infections Ultraviolet radiation exposure Immunodeficiency states

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cryptorchidism (Undescended Testes) Occurs when one or both of the testicles fail to move down into the scrotal sac The testes develop intra-abdominally in the fetus and usually descend into the scrotum through the inguinal canal during the 7th to 9th months of gestation. The undescended testes may remain in the lower abdomen or at a point of descent in the inguinal canal.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Consequences of Cryptorchidism Infertility Malignancy Testicular torsion (10x increased risk) The possible psychological effects of an empty scrotum

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Disorders of the Scrotum and Testes Hydrocele Hematocele Spermatocele Varicocele Testicular torsion

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Epididymitis Definition –Inflammation of the epididymis Types torsion –Sexually transmitted infections associated with urethritis –Primary nonsexually transmitted infections associated with urinary tract infections and prostatitis Causes –Bacterial pathogens

24. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis of Epididymitis Laboratory findings usually reveal an elevated white blood cell count. Urinalysis and urine culture are important. The cause can be differentiated by Gram stain examination or culture of a midstream urine specimen or a urethral specimen. Doppler ultrasound may be useful, revealing increased blood flow to the affected testis.

25. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Orchitis Mumps virus Definition –An infection of the testes Causes –Can be precipitated by a primary infection in the genitourinary tract –The infection can be spread to testes through the bloodstream or the lymphatics.

26. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Neoplasms Scrotal cancer –Exposure to tar, soot, and oils –Poor hygiene –Chronic inflammation –HPV Testicular cancer

27. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins TNM Classification for Testicular Cancer Stage I: tumor confined to testes, epididymis, or spermatic cord Stage II: tumor spreads to retroperitoneal lymph nodes below the diaphragm. Stage III: metastases outside the retroperitoneal nodes or above the diaphragm

28. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cell Types in Seminoma The nonseminoma tumors include embryonal carcinoma, teratoma, choriocarcinoma, and yolk cell carcinoma derivatives. Nonseminoma tumors usually contain more than one cell type and are less differentiated than seminomas. Embryonal carcinomas are the least differentiated of the tumors, with the totipotential capacity to differentiate into other nonseminomatous cell types.

29. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Types of Prostatitis Acute bacterial prostatitis Chronic bacterial prostatitis Chronic prostatitis/chronic pelvic pain syndrome –Inflammatory prostatitis –Noninflammatory prostatitis

30. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Benign Prostatic Hyperplasia Age-related, nonmalignant enlargement of the prostate gland Characterized by the formation of large, discrete lesions in the periurethral region of the prostate rather than the peripheral zones, which commonly are affected by prostate cancer Static Dynamic

31. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following is associated with the mumps virus? −A. Epididymitis −B. Prostatitis −C. Scrotal cancer −D. Orchitis

32. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer D. Orchitis Rationale: Orchitis can occur following a bout of the mumps.

33. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Diagnosis and Treatment of Prostate Cancer Biopsy Gleason Score Tumor markers Prostate cancer Watchful waiting Surgery Radiation therapy High intensity focused ultrasound Chemotherapy Cryosurgery Hormonal therapy Combination

34. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Methods of Staging Tumors CT scans of the chest, abdomen, and pelvis Ultrasonography for detection of bulky inferior nodal metastases Lymphangiography Radiographic methods to detect metastatic spread

35. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Prostate Tumor Grading System T1: Primary-stage tumors are asymptomatic and discovered on histologic examination of prostatic tissue specimens. T2: Tumors are palpable on digital examination but are confined to the prostate gland. T3: Tumors have extended beyond the prostate. T4: Tumors have pushed beyond the prostate to involve adjacent structures.

36. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Protective Against Prostate Cancer Dietary factors such as lycopene, selenium, and vitamin E Chemoprevention (using drugs to prevent disease) with the 5α-reductase inhibitor Finasteride, was recently shown to prevent the development of prostate cancer in men without BPH.