The document discusses several male genital disorders including testicular torsion, hypogonadism, hypospadias, epispadias, cryptorchidism, hydroceles, varicoceles, and erectile dysfunction. For each condition, it describes the etiology, signs and symptoms, diagnostic evaluation, and treatment options. The document provides clinical details to help identify these conditions and manage patients.

1. Testicular Disorders and
Erectile Dysfunction
Patrick Carter MPAS, PA-C
Clinical Medicine I
March 4, 2011

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. Testicular Torsion

4. Testicular Torsion
 General considerations
 Ischemic Urologic Emergency
 Typical sudden onset of pain
 May have intermittent
torsion & pain
 Color flow Doppler

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. 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. Testicular Torsion

8. Pediatric Testicular Torsion

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. 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. 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. Hypogonadism

14. 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

15. 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

16. Hypogonadism
 Management
 Evaluation for prostate cancer
 Testosterone replacement
 Oral
 IM
 Transdermal

17. Hypospadias

18. Hypospadias
Classifications
A. Glandular (opening proximal to
glans)
B. Coronal (opening at coronal sulcus)
C. Penile Shaft
D. Penoscrotal
F. Perineal

19. 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

20. Epispadias

21. Epispadias
Urethra is displaced
dorsally

22. 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

23. Cryptorchidism

24. CRYPTORCHIDISM
DEFINITION:
A condition in which one or both testes fail to descend
into 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

26. CRYPTORCHIDISM
CLINICAL:
No testis detected with palpation of scrotum.
CONCERNS:
• Impaired fertility
• Risk of testicular cancer 35-50% higher than in
men who have descended testes
DX:
• CT scan
• Ultrasound

27. CRYPTORCHIDISM
TREATMENT:
Administration of HCG (given IM biweekly),
which may initiate descent.
Referral to urologist by 6 months, surgery by age
1 or 2 at the latest
Orchiopexy DOES NOT reduce risk of cancer, but
does facilitate examination and early detection

28. CRYPTORCHIDISM

29. Hydrocele

30. HYDROCELE
DEFINITION: A collection
of fluid within the tunica
vaginalis
Most common cause of
Scrotal Swelling!
•Common in infancy
•Associated with 10% of
testicular tumors

31. HYDROCELE
CLINICAL:
•Painless swelling
•Readily transilluminated
•Feels like “weight in testes”
CAN OCCUR WITH:
•Epididymitis
•Trauma
•Hernia
•Tumor

32. HYDROCELE
REMEMBER:
• No scrotal erythema
• No pain
• Transilluminates
• Any Age
• No Infertility
• No Dysuria
• No Systemic Symptoms

33. Varicocele

34. VARICOCELE
DEFINITION:
Dilation of veins within
the Spermatic cord
(Pampiniform plexus)

35. VARICOCELE
CLINICAL:
Soft, irregular painless
mass posterior and
anterior to testes.
Swelling can collapse
with lying down, can
refill with standing
upright.

36. VARICOCELE
CLINICAL:
May feel like a “weight in
the testes” or “bag of
worms”
FACTS & FIGURES:
> 15 years old
More common on left side
(95%)

37. VARICOCELE
REMEMBER:
• 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

38. Erectile Dysfunction

39. 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

40. 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

41. 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

42. Erectile Dysfunction
 General Considerations
 Psychogenic causes
 Anxiety related
 Due to a new partner
 Unreasonable expectations about
performance
 Emotional disorders

43. Erectile Dysfunction
 Causes of Organic ED
 Vascular
 Endocrine
 Neurologic
 Medications
 Alcoholism
 Postsurgical changes

44. 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

45. 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

46. 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
(Peyronie's disease)

47. 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

48. Peyronie’s Disease

49. Peyronie's Disease

50. 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)

51. 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

52. 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

53. Erectile Dysfunction
 Treatment Procedures
 Direct injection of vasoactive substances
into the penis
 Prostaglandin E, papaverine, or a combination

54. 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

55. Erectile Dysfunction
 Therapeutic
Procedures
 Vacuum
constriction device
 Behaviorally
oriented sex
therapy for men
with no organic
dysfunction

56. Questions?