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Testicular Disorders & Erectile Dysfunction


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Testicular Disorders & Erectile Dysfunction

  1. 1. Testicular Disorders and Erectile Dysfunction Patrick Carter MPAS, PA-C Clinical Medicine I March 4, 2011
  2. 2. Objectives For each of the following diseases describe the etiology, epidemiology, pathophysiology, risk factors, signs and symptoms, diagnostic work-up, and treatment:  Testicular torsion  Hypogonadism  Hypospadias  Epispadias  Cryptorchidism  Hydroceles  Varicoceles  Erectile dysfunction
  3. 3. Testicular Torsion
  4. 4. Testicular Torsion General considerations  Ischemic Urologic Emergency  Typical sudden onset of pain  May have intermittent torsion & pain  Color flow Doppler
  5. 5. Testicular Torsion Epidemiology  Bimodal Peak  Neonatal Period  Age 12-18 years  Left side more common  Usually preceding physical exertion or trauma but may be spontaneous
  6. 6. Testicular Torsion Signs and symptoms  Sudden, severe pain  Swollen & Tender testis  Testes in affected side lies higher in scrotum & Transverse position  Absent cremasteric reflex  Nausea & vomiting  NO FEVER
  7. 7. Testicular Torsion
  8. 8. Pediatric Testicular Torsion
  9. 9. Testicular Torsion Treatment  Immediate urologic consultation  Prepare patient for the OR  Doppler ultrasound if it will not delay surgery  Detorsion may be attempted if the patient is seen within a few hours of onset  ―Open book‖ method  Pain relief should be immediate  Do not delay operative intervention, since testicular infarction will occur within 6 to 12 h after torsion
  10. 10. Testicular Torsion Prognosis  Less than 6 hours – salvage rate is excellent  Beyond 6 hours – salvage rate becomes worse  After 48 hours – salvage rate is zero
  11. 11. Testicular Torsion Clinical Pearls  Patients may report similar, less severe episodes that spontaneously resolved in the recent past  Half of all torsions occur during sleep  Abdominal or inguinal pain is sometimes present without pain to the scrotum
  12. 12. Hypogonadism
  13. 13. Hypogonadism Etiology  Insufficient testosterone secretion by testes (MOST COMMON)  Decreased gonadotropin secretion by pituitary  EtOH, Cushing’s, chronic illnesses Clinical features  Decreased libido, ED, fatigue, depression
  14. 14. Hypogonadism Signs  Diminished sexual hair growth  Decreased testicular mass  Loss of muscle mass Diagnostic studies  Morning serum testosterone level  LH and FSH  LH and FSH is high in patients with testicular dysfunction and low in patients with pituitary disorders
  15. 15. Hypogonadism Management  Evaluation for prostate cancer  Testosterone replacement  Oral  IM  Transdermal
  16. 16. Hypospadias
  17. 17. HypospadiasClassificationsA. Glandular (opening proximal to glans)B. Coronal (opening at coronal sulcus)C. Penile ShaftD. PenoscrotalF. Perineal
  18. 18. Hypospadias Testing  Patients with ―Penoscrotal‖ and ―Perineal‖ openings should be considered to have potential intersex problems and should be karotyping to establish genetic sex Treatment  Surgical repair preferred before school age  Over 150 procedures
  19. 19. Epispadias
  20. 20. EpispadiasUrethra is displaceddorsally
  21. 21. Epispadias Classification  Glandular – opens on dorsal aspect of glans  Penile – borad and gaping on dorsum of penile shaft  Penopubic – junction with groove extending through glans Females will have bifid clitoris & separation of labia. Most are incontinent Penile & Penopubic will usually have urinary incontinence Surgery is required to correct incontinence
  22. 22. Cryptorchidism
  23. 23. CRYPTORCHIDISMDEFINITION:A condition in which one or both testes fail to descendinto the scrotum.FACTS & FIGURES• Most common congenital condition involving the testes• 3% of all full-term males at birth• 20% of all premature males at birth• Less than 1% of males by 3 months of age
  24. 24. CRYPTORCHIDISMCLINICAL:No testis detected with palpation of scrotum.CONCERNS:• Impaired fertility• Risk of testicular cancer 35-50% higher than in men who have descended testesDX:• CT scan• Ultrasound
  25. 25. CRYPTORCHIDISMTREATMENT:Administration of HCG (given IM biweekly),which may initiate descent.Referral to urologist by 6 months, surgery by age1 or 2 at the latestOrchiopexy DOES NOT reduce risk of cancer, butdoes facilitate examination and early detection
  27. 27. Hydrocele
  28. 28. HYDROCELEDEFINITION: A collectionof fluid within the tunicavaginalisMost common cause ofScrotal Swelling!•Common in infancy•Associated with 10% of testicular tumors
  29. 29. HYDROCELECLINICAL:•Painless swelling•Readily transilluminated•Feels like “weight in testes”CAN OCCUR WITH:•Epididymitis•Trauma•Hernia•Tumor
  30. 30. HYDROCELEREMEMBER:• No scrotal erythema• No pain• Transilluminates• Any Age• No Infertility• No Dysuria• No Systemic Symptoms
  31. 31. Varicocele
  32. 32. VARICOCELEDEFINITION:Dilation of veins withinthe Spermatic cord(Pampiniform plexus)
  33. 33. VARICOCELECLINICAL:Soft, irregular painlessmass posterior andanterior to testes.Swelling can collapsewith lying down, canrefill with standingupright.
  34. 34. VARICOCELECLINICAL:May feel like a “weight inthe testes” or “bag ofworms”FACTS & FIGURES: > 15 years oldMore common on left side(95%)
  35. 35. VARICOCELEREMEMBER:• No scrotal erythema• No pain (usually)• DOES NOT transilluminate• Most common after puberty• No dysuria• No systemic symptoms• In older men = think bladder/renal tumor• CAN CAUSE INFERTILITY
  36. 36. Erectile Dysfunction
  37. 37. Erectile Dysfunction Essentials of Diagnosis  Most causes are organic and not psychogenic  Increasing incidence with older age  Variety of treatment available, with multiple oral agents
  38. 38. Erectile Dysfunction General Considerations  Inability to maintain an erect penis with sufficient rigidity to allow sexual intercourse  Loss of erections occurs from arterial, venous, neurogenic, or psychogenic causes  Associated with concurrent medical problems (hypertension, diabetes mellitus), or radical pelvic or retroperitoneal surgery  Look for concomitant cardiovascular disease
  39. 39. Erectile Dysfunction General Considerations  Antihypertensive medications  Centrally acting sympatholytics (methyldopa, clonidine, reserpine) can cause loss of erection  Beta Blockers & Thiazide Diuretics are common  Androgen deficiency causes both loss of libido and erections and lack of emission by decreasing prostatic and seminal vesicle secretions
  40. 40. Erectile Dysfunction General Considerations  Psychogenic causes  Anxiety related  Due to a new partner  Unreasonable expectations about performance  Emotional disorders
  41. 41. Erectile Dysfunction Causes of Organic ED  Vascular  Endocrine  Neurologic  Medications  Alcoholism  Postsurgical changes
  42. 42. Erectile Dysfunction Clinical findings  History  Erectile dysfunction should be distinguished from problems with ejaculation, libido, and orgasm  Degree of the dysfunction—chronic, occasional, or situational  Timing of dysfunction  Determine whether the patient ever has any normal erections, such as in early morning or during sleep
  43. 43. Erectile Dysfunction Clinical findings  History  Inquire about hyperlipidemia, hypertension, neurologic disease, diabetes mellitus, renal failure, adrenal and thyroid disorders, and depression  Trauma to the pelvis, pelvic surgery, or peripheral vascular surgery  Use of drugs, alcohol, tobacco, and recreational drugs
  44. 44. Erectile Dysfunction Clinical findings  Physical examination  Secondary sexual characteristics  Neurologic motor and sensory examination  Peripheral vascular examination  Examination of genitalia, testicles, and prostate  Evaluate for penile scarring, plaque formation (Peyronies disease)
  45. 45. Peyronie’s Disease Dense fibrous plaque that forms on the tunica albuginea – causing a curvature of the erect penis Etiology of the plaque is unknown  May be scar tissue resulting from microscopic tears of the tunica albuginea during intercourse Flaccid penis is usually normal on exam and the curvature is only noted in the erect penis
  46. 46. Peyronie’s Disease
  47. 47. Peyronies Disease
  48. 48. Erectile Dysfunction Laboratory Tests  Complete blood count  Urinalysis  Lipid profile  Serum glucose, testosterone, LH/FSH, and prolactin  Serum testosterone and gonadotropin levels may help localize the site of disease (CNS vs Testes)
  49. 49. Erectile Dysfunction Imaging studies  Cavernosometry (measurement of flow required to maintain erection)  Cavernosography (contrast study of the penis to determine site and extent of venous leak) Nocturnal penile tumescence testing
  50. 50. Erectile Dysfunction Medications  Hormone replacement for androgen deficiency  Alprostadil urethral suppository pellets  PDE-5 inhibitors taken 1 hour prior to anticipated sexual activity  Viagra (sildenafil) 50 mg, Levitra (vardenafil) 5 mg, or Cialis (tadalafil) 10 mg  Contraindicated in patients receiving nitrates  Some patients who do not respond to one PDE-5 inhibitor will respond to another
  51. 51. Erectile Dysfunction Treatment Procedures  Direct injection of vasoactive substances into the penis  Prostaglandin E, papaverine, or a combination
  52. 52. Erectile Dysfunction Surgery  Penile prosthesis: rigid, malleable, hinged, or inflatable  Surgery for disorders of the arterial system  Vascular reconstruction  Endarterectomy and balloon dilation for proximal arterial occlusion  Arterial bypass procedures for distal occlusion
  53. 53. Erectile Dysfunction Therapeutic Procedures  Vacuum constriction device  Behaviorally oriented sex therapy for men with no organic dysfunction
  54. 54. Questions?