PENIS

High pressure vein cane

Congenital

Hypospadias - the peehole is on the bottom of the shaft (ventral side). It’s due to failure of urethral fold closure. The urologist can surgically repair it using bits of the foreskin. 

Epispadias - the peehole is on the top of the shaft (dorsal side). Very rare. It’s due to abnormal positioning of the genital tubercle. Associated with bladder exstrophy (bladder wall pokes out of the abdomen)

Acquired

Priapism - an unintended erection lasting longer than four hours. The penile veins refuse to constrict.Caused by trazadone, sickle cell and sildenafil. Will progressively turn painful and ischemic. Phenylephrine will help with vasoconstriction, but if it doesn’t work then suck the blood out of the penis with a needle and syringe. 

Peyronie’s Disease - curved penis due to fibrosis plaques in the shaft. Caused by repetitive minor trauma (sex baby). 

Erectile Dysfunction- inability to achieve an erection. Caused by normal aging, anxiety and vasculopathy (diabetes). Tell them to lick a stamp and put it on their penis before bedtime. If the stamp fell off, that means they got an erection overnight, which is normal. That means the cause is related to stress and anxiety. If the stamp is still stuck on in the morning, they didn’t get an erection overnight which suggests neurovascular damage. Treat with sildenafil (Viagra), the magic blue pill that dilates the penile veins by blocking PDE-5. 

Neoplastic

Squamous Cell Carcinoma of the Penis - penile skin cancer. Risk factors include HPV and being uncircumcised (the hood is a breeding ground for smegma, which is stinky nasty inflamed weiner cheese). There are some high yield precursor lesions (in situ carcinomas)

     (a)       Bowen Disease - white plaque on the shaft

     (b)      Erythroplasia of Queyrat - red plaque on the glans

     (c)      Bowenoid Papulosis - red papules

TESTICLES

Family jewels

Cryptorchidism is when the ball(s) don’t drop out of the abdomen. It’s very common (1%). Most cases resolve on their own. But if they haven’t dropped down into the scrotum by the age of 2, you need to call a surgeon to move it for them (orchiopexy). This condition is only important for one reason - it harms the Sertoli cells. The only reason that balls dangle down is that Sertoli Cells prefer a temperature colder than 98.6˚F. So if they fail to descend, they’ll be stuck in the warm abdomen, cooking them alive. The heat causes the Sertoli cells to wither away (atrophy), while the Leydig cells are unaffected. No Sertoli cells means no sperm. Bilateral cases will be infertile, if they aren’t treated early. But here’s the real reason why Cryptorchidism is important -- cooking the Sertoli cells leads to chronic cellular damage, and THAT can lead to cancer. Specifically, they’re at risk for a seminoma, which is a cancer of the regenerating sperm stem cells. 

Orchitis is simply inflammation of the testicle. It’s almost always due to an infection. The infection can be an STI (Chlamydia trachomatis D-K or Neisseria gonorrhoeae), UTI (E. coli or Pseudomonas) or viral illness (Mumps). Untreated it can cause sterility.

Epididymitis is inflammation of the epididymis, the large tube posterior to the nut that stores sperm. It improves when you lift up the testicles (Prehn sign). It’s otherwise very similar to Orchitis (same infectious etiologies)

Testicular Torsion is a twisting of the spermatic cord. It’s usually due to a congenital absence of the bell-clapper, a tiny ligament that secures the nuts to the inside of the sack to prevent twisting. If you lack the bell-clapper, your nuts can spin like crazy. Once a boy reaches puberty, his testicles will grow and descend further under the influence of androgens. This increased mass often precipitates torsion, usually while moving a certain way during some normal activity (eg, chores, soccer, walking). Torsion causes sudden severe testicular pain, often accompanied by nausea or lower belly pain. Importantly, the testicle can twist and untwist, causing the pain to spontaneously go away. Many patients will note that their torsion was preceded by a few similar, but milder, episodes in the days and weeks leading up to the main event. So you should keep in mind that the pain can wax and wane over the course of a few days. Testicular torsion is an emergency! If you don’t untwist their testicle, either through manipulation with your hands or with surgery, they will permanently lose their testicle. This means that you should test every male with testicular pain for torsion. The gold standard test is a doppler ultrasound.  As the testicle spins, the cord shortens, and the testicle rises. It’s like spinning a tire swing! The low-pressure veins will become squished. This stops the flow of blood through the testicle, and causes blood to pool (hyperemesis) in the testicular tissue. This results in pretty dramatic unilateral testicular swelling. The high-pressure arteries are less affected by the torsion. Blood will continue to pour into the testicle, despite all the veins being obstructed. As the testicle eventually starts to starve (ischemia) and then die (necrosis), blood will continue to pour into the testicle, which is why this disorder famously causes hemorrhagic infarction (red infarction) on histology. The nerves that innervate the testicles will be squished. These nerves have an important task -- whenever something touches the scrotum or inner thighs, it tells the brain to elevate the balls away from the stimulus. This is called the Cremasteric Reflex. So in a patient with torsion, if you stroke the upper inner thigh, their balls WON’T elevate. Not a lot of other testicular diseases will impact the Cremasteric Reflex, making it a pretty specific test. 

HYDROCELES are collections of serous fluid in the ballsack. So how does peritoneal fluid get all the way down into the testicles? Because of embryology (oh boy)! The testicles are created smack dab in the middle of the abdomen. In utero, the balls slowly migrate downwards. They don’t stop when they reach the bottom of the peritoneal membrane. Instead, they continue moving forward (through the inguinal canal), dragging the peritoneum behind them. This creates a long tunnel of peritoneal membrane connecting the belly to the ballsack. This tunnel is supposed to close shut, isolating the testicles from the peritoneum. Once it closes, the island of peritoneal membrane in the scrotum is renamed the tunica vaginalis. If you transilluminate a hydrocele, light will clearly shine through it! This helpful trick can differentiate it from varicoceles and masses. There are two possible mechanisms in kids.

1. The “tunnel” remains open. Fluid can freely communicate between the scrotum and the abdomen

2. The “tunnel” closes at an inopportune time, while the scrotum is full of fluid. 

TESTICULAR CANCER

Testicular cancer will present with a testicular mass. Since it’s solid, you can’t shine a light through it (no transillumination). TC usually occurs in men aged 15 to 40. Unlike almost every other cancer, testicular tumors are NOT biopsied. That’s because (a) almost all testicular masses are cancerous and (b) testicular tissue is loose, so needle biopsies carry a risk of disseminating the cancer cells. Risk factors include Klinefelters and cryptorchidism.

Germ Cell Tumors 

Seminoma - this is a cancer of stem cells. It’s equivalent to an ovarian dysgerminoma. Look for large clear “fried egg” cells. The tumor is smooth. It has an exceptionally good prognosis -- surgery is usually curative, plus it melts away with radiation / chemo. Labwork often shows an elevated Placental Alk Phos (PALP). 

Embryonal Carcinoma - this is a cancer of early primitive embryo-like cells. Normal embryonal cells are programmed to shuffle around (aggressive), grow quickly (necrosis) and create blood vessels (hemorrhagic). It’s more likely to be painful. 

Teratoma - this is a special type of germ cell tumor in which you see actual tissue development (not just germ cells). Teratomas classically contain all 3 embryological layers (ecto, meso and endoderm). In most teratomas, you see mature tissues – like hair, sebaceous glands, skin, and teeth. Usually there are multiple different tissues from different germ cell layers (so you can see bone, cartilage, thyroid tissue, neural tissue – anything, really). Some teratomas are composed of immature stem cell tissues; still others are highly specialized, consisting entirely of one tissue, like thyroid tissue (this is called “struma ovarii” and it causes hyperthyroidism). In females, mature teratomas are usually benign, but in males the mature teratoma is usually cancerous. Mature teratomas are Malignant in Males. 

Yolk Sac Tumor - this is a cancer of the Yolk Sac. It’s extremely aggressive. Alpha Fetoprotein (AFP) is usually high. Most common tumor in kids (Youth). Histology shows Schiller-Duval Bodies, which are rings of cells surrounding a clump of blood, often described as “glomeruloid.” Yellow and mucinous on gross inspection, I’m told. 

Choriocarcinoma - this is a cancer of placenta. There will be disorganized trophoblasts without any villi. Since the placenta is responsible for fusing with mom’s blood vessels, this tumor is quite adept at spreading hematogenously, often to the brain or lungs. In fact, it spreads so fast that the metastases are often far bigger than the primary tumor! The trophoblasts make b-hCG, which can cause some paraneoplastic problems, because b-hCG is so similar to FSH / LH (gynecomastia) and TSH (hyperthyroidism). 

Sex Cord Stromal Tumors

Leydig Cell Tumors - this is a benign neoplasm of Leydig Cells. Like regular Leydig Cells, this tumor can produce hormones like testosterone (early puberty) and estrogen (gynecomastia). Histology shows pink little rods called Reinke Crystals. 

Sertoli Cell Tumors - this is a benign neoplasm of Sertoli Cells. Lots of tubules. Clinically silent. 

PROSTATE

The urine-semen switcher

Benign Prostatic Hyperplasia (BPH) is enlargement of the periurethral zone of the prostate (the center), which compresses the tube running through the center (the urethra), and results in difficulty peeing (weak stream, dribbling, difficulty initiating, retention). The Prostate Specific Antigen (PSA) test is often elevated, but this isn’t consistent. You can immediately dilate the urethra with an alpha 1 blocker -- selective blockers (tamsulosin) are preferred over nonselective blockers (terazosin) because they cause less orthostatic hypotension. Since prostate growth is driven by dihydrotestosterone (DHT), you can slowly shrink the prostate with a 5a-reductase inhibitor (finasteride). BPH has no metastatic potential, hooray!

Prostate Adenocarcinoma refers to prostate cancer. It’s the most common cancer in men and the third biggest killer. The biggest risk factors are being old and black. While BPH affects the prostate’s center, cancer goes right for the posterior aspect (palpable lumpiness on digital rectal exam) while sparing the center (few urinary symptoms). You start screening for prostate cancer with routine PSAs and rectal exams beginning at age 50. PSAs are a bit controversial nowadays. Confirm the diagnosis with a biopsy. The Gleason Grading System is based on the architecture (not nuclear atypia). Prostate cancer loves to spread to the lumbar spine and create dense bony tumors (osteoblastic mets). Treat prostate cancer with a prostatectomy, continuous GnRH Analogs (Leuprolide) or 5a-reductase inhibitors (Finasteride).