Week 21: Male Genitals

An elevated hemiscrotum (elevated testicle) with transverse lie is suggestive of testicular torsion, resulting from twisting and foreshortening of the spermatic cord. A palpable bulge in the inguinal region may be present in the case of inguinal hernia, epididymal tenderness in epididymitis, and scrotal ecchymosis in genitourinary trauma.

A positive prehn sign (relief with lifting of the testicle), indicates epidydimitis. NEGATIVE prehn may suggest torsion (no relief).

This patient is presenting in severe sepsis and Fournier’s gangrene. Empiric antibiotics and medical resuscitation should be administered, but this patient requires emergent surgical debridement for definitive treatment. While hyperbaric oxygen has been used in the treatment of necrotizing fasciitis, it is an adjunctive therapy.

When a child presents with abdominal pain, nausea and vomiting, one must perform a testicular/scrotal exam to rule out acute scrotal or testicular pathologies. In this case, the presence of a swollen right testicle and scrotal pain but negative ultrasound findings is concerning for intermittent testicular torsion. It is important to remember that testicular torsion is a clinical diagnosis, requiring a high index of suspicion, even in the face of early, unremarkable ultrasound findings. Blue-dot sign is typically seen in torsion of the appendix testis. Pain alleviation with testicular elevation is seen in epididymitis. The treatment of testicular torsion starts with manual detorsion, followed by timely surgical detorsion and fixation.

The patient in this case has priapism. Given the history of sickle cell disease, and no preceding trauma, this is likely the ischemic, or low-flow type of priapism. All of the above treatment options are appropriate for low-flow priapism, with the exception of angiography with embolization, which is used for high-flow priapism. Other treatment options for low-flow priapism include intracavernosal aspiration and surgical shunt placement. Urology consultation should be obtained for low-flow priapism.

Testicular pain, swelling, and asymmetric hyperemia of epididymis on ultrasound are suggestive of epididymitis. Epididymitis is a clinical diagnosis, combined with ultrasound examination and urinalysis. The choice of antibiotics follows an arbitrary division at age 35. Younger than 35 years of age, patients are treated with ceftriaxone and azithromycin for presumed Chlamydia and Gonorrhea infection. After 35 years of age, patients are treated with fluoroquinolone for presumed E. coli infection. Analgesics and scrotal elevations should be recommended. Prehn’s sign is a relief of pain with scrotal elevation and is seen in epididymitis, as opposed to no changes in pain in testicular torsion. Emergent urology consultation is not required, but patient may follow up with urology as outpatient.

Amiodarone can cause a chemical epididymitis, which is characterized by testicular pain and swelling. This effect is more common with chronic (greater than 4 months) and high dose (more than 400 milligrams per day) amiodarone use. Amiodarone concentrates in the testicle where is causes lymphocytic infiltration and fibrosis. Unlike patients with infectious epididymitis, patients do not experience fever, pyuria, or leukocytosis.

This patient presents with phimosis and evidence of vascular compromise requiring performance of a dorsal slit procedure. Phimosis occurs when the foreskin of an uncircumcised penis becomes constricted preventing retraction of the prepuce from the glans. It results in urinary outlet obstruction, glans ischemia and infarction. Many cases are physiologic resulting from normal development. Patients typically present with an unretractable foreskin and symptoms consistent with urinary obstruction including decreased urinary stream. Management of phimosis can be difficult. Dilation of the prepuce can be performed using forceps but often does not result relief of phimosis. When there are signs of glans vascular compromise (i.e. discoloration) a dorsal split procedure should be performed. During this procedure, the foreskin is anesthetized and incised dorsally allowing for retraction.

The patient presents with balanitis, which results from inflammation of the glans penis or the glans and foreskin (balanoposthitis). The primary cause is infection, most commonly Candida. Treatment consists of  topical antifungal. Balanitis can also be caused by bacterial agents such as group A beta-hemolytic streptococci. Additionally, it may be secondary to irritation, trauma or contact dermatitis. Recurrent balanitis is seen in diabetics from C. albicans. Patients typically complain of pain, discharge, and itching. The glans may appear erythematous and tender to palpation. Systemic symptoms may be present but are unusual. Management of fungal balanitis includes topical antifungal agents such as clotrimazole, adequate hygiene and glycemic control. In patients with no history of diabetes who present with fungal balanitis, diabetes should be considered and a finger stick should be obtained.

Phimosis is the inability to retract foreskin over the glans penis. It is a complication seen in uncircumcised men. About 50% of boys typically are able to retract their foreskin by 1 year of age and 80% by age 3. Topical estrogen therapy has been reported as successful, but no randomized trials support its use. However, low-potency topical corticosteroid therapy combined with daily prepuce retraction appears effective for phimosis. If retraction of foreskin is unsuccessful, the patient will require circumcision.

Testicular torsion usually occurs over an arc of 540 to 720 degrees. Manual detorsion generally requires one to three turns in the medial to lateral direction (“opening a book”) to restore blood flow and relieve pain, and is successful in up to 70% of patients. It is best carried out with the patient supine in a frog leg position.