Penis Diseases
A. Malformations of the urethral groove of the penis
1. Hypospadias
a. Abnormal opening on the ventral surface of the penis
b. Most common malformation of urethral groove
c. Risk factors
(1) Father or previous male sibling with defect
(2) Monozygotic twins
• Insufficient production of human chorionic gonadotropin by single placenta
d. Frequently associated with ventral curvature of penis
• Called chordee
e. Pathogenesis
(1) Due to faulty closure of the urethral folds
(2) Possibly related to abnormal androgen production
2. Epispadias
a. Abnormal opening on the dorsal surface of the penis
b. Due to a defect in the genital tubercle
B. Phimosis of the penis
1. Orifice of the prepuce is too small to retract over the head of the penis
2. Commonly associated with infections
C. Balanoposthitis of the penis
1. Infection of the glans and prepuce
a. It usually occurs in uncircumcised males with poor hygiene.
b. Accumulation of smegma leads to infection.
• Candida, pyogenic bacteria, and anaerobes
2. Inflammatory scarring may produce an acquired phimosis.
D. Miscellaneous disorders of the penis
1. Peyronie disease
a. Type of fibromatosis
b. Painful contractures of the penis
• Causes lateral curvature of the penis
c. May cause infertility
2. Priapism
a. Persistent and painful erection
b. Causes include sickle cell disease, penile trauma
E. Carcinoma in situ (CIS) of the penis
1. Bowen disease
a. Leukoplakia involving the shaft of the penis and scrotum
(1) Patients are usually >35 years old
(2) Association with human papillomavirus (HPV) type 16
b. Precursor for invasive SCC (~10% of cases)
c. Association with other types of visceral cancer
2. Erythroplasia of Queyrat
a. Erythroplakia located on the mucosal surface of the glans and prepuce
b. HPV type 16 association
c. Precursor for invasive SCC
3. Bowenoid papulosis
a. Multiple pigmented reddish brown papules on the external genitalia
b. Association with HPV type 16
c. Does not develop into invasive SCC
• Only CIS with no predisposition for invasion
F. SCC of the penis
1. Epidemiology
a. Circumcision protects against developing SCC of penis.
b. SCC is the most common cancer of the penis.
(1) Usually affects men 40 to 70 years old
(2) Most common sites
• Glans or mucosal surface of prepuce
c. Two-thirds of cases associated with HPV types 16 and 18
• Products from smoking tobacco may act as cocarcinogens with HPV.
d. Risk factors
(1) Lack of circumcision
• Greatest risk factor
(2) Bowen disease, erythroplasia of Queyrat
2. Metastasizes to inguinal and iliac nodes
Testis, Scrotal Sac, and Epididymis Diseases
A. Cryptorchidism of the testes
1. Normal descent of testes
a. Transabdominal phase
(1) Testes descend to lower abdomen or pelvic brim
(2) Müllerian inhibitory substance (MIS) is responsible for this phase.
b. Inguinoscrotal phase
(1) Descent through the inguinal canal into the scrotum
(2) Androgen- and human chorionic gonadotropin (hCG)-dependent
2. Cryptorchidism
a. Epidemiology
(1) Incomplete or improper descent of the testis into the scrotal sac
(2) Most common genitourinary (GU) disorder in male children
(3) Occurs in 30% of premature males and 5% of full-term males
(4) Associations
• Androgen insensitivity syndrome, Kallmann syndrome, cystic fibrosis
(5) Locations
(a) Inguinal canal is the most common site (80% of cases)
• Palpable mass; majority are unilateral (90% of cases)
(b) Intra-abdominal (5%–10% of cases)
(6) Many will spontaneously descend by 3 months of age
(a) Due to combination of androgens and hCG
(b) Spontaneous descent is uncommon after 3 months.
b. Complications if uncorrected
(1) Potential for infertility
(a) Arrest in germ cell maturation
(b) Testicular atrophy
(c) Similar changes occur in the normally descended contralateral testis.
(d) Greatest risk if intra-abdominal or long duration in the inguinal canal
(2) Increased risk for developing a seminoma
(a) Risk for cancer in the cryptorchid testis increases by fivefold to tenfold.
(b) Risk also applies to the normally descended testicle.
(3) Increased risk for the undescended testis to undergo torsion (see later)
c. Treatment
(1) Orchiopexy may be done as early as 6 months; it should be performed by 2 years
of age.
(2) Hormonal therapy with hCG produces variable results.
(3) Administration of gonadotropin-releasing hormone (GnRH) before orchiopexy
may improve fertility in adult.
B. Orchitis
1. Mumps
a. Infertility is uncommon.
b. Most cases are unilateral.
c. Orchitis is more likely to occur in an older child or adult.
2. Congenital or acquired syphilis
3. HIV
4. Extension of acute epididymitis
C. Epididymitis
1. Causes
a. Common pathogens in persons <35 years old
(1) N. gonorrhoeae
(2) C. trachomatis
b. Common pathogens in persons >35 years old
(1) E. coli
(2) Pseudomonas aeruginosa
c. Tuberculosis
(1) Begins in the epididymis
• Spreads to the seminal vesicles, prostate, and testicles
(2) Caseating granulomatous inflammation
d. AIDS
• Association with cytomegalovirus, Toxoplasma, Salmonella
2. Clinical findings in acute epididymitis
a. Usually unilateral scrotal pain with radiation into spermatic cord or flank
b. Scrotal swelling, epididymal tenderness
c. Urethral discharge
• If it is sexually transmitted
d. Prehn sign
• Elevation of the scrotum decreases pain.
3. Treatment
a. If <35 years old, ceftriaxone + doxycycline (STD treatment)
b. If >35 years old, ciprofloxacin extended release
D. Varicocele
1. Epidemiology
a. Occurs in 15% to 20% of all males
(1) Usually occurs between 15 and 25 years of age
(2) Rarely occurs after 40 years old
b. Occurs in 40% of infertile males
c. Most common cause of left-sided scrotal enlargement in adults
d. Left spermatic vein drains into the left renal vein
(1) Increased resistance to blood flow
(2) Blockage of left renal vein can also produce a varicocele.
• Examples—renal cell carcinoma invading renal vein; superior mesenteric artery
compressing the left renal vein
e. Right spermatic vein drains into the vena cava
(1) Blockage of right spermatic vein produces right-sided varicocele.
(2) Examples—retroperitoneal fibrosis; thrombosis of the inferior vena cava
2. Pathogenesis
• Incompetent valves in the left spermatic vein from increased pressure
3. Clinical findings
a. Aching pain in scrotum
b. Dragging sensation in testicle
c. Visible “bag of worms”
d. Infertility (controversial)
• Heat decreases spermatogenesis.
4. Diagnose by ultrasound
5. Treatment
a. Varicocelectomy
b. Embolization by an intervention radiologist
E. Torsion of the testicle
1. Epidemiology
a. Majority occur between 12 and 18 years old.
b. Predisposing factors
(1) Violent movement or physical trauma
• Most common causes
(2) Cryptorchid testis
(3) Atrophy of testis
c. Twisting of spermatic cord cuts off the venous/arterial blood supply.
• Danger for hemorrhagic infarction of the testicle
2. Clinical findings
a. Sudden onset of testicular pain
b. Absent cremasteric reflex (key diagnostic finding)
• Stroking the inner thigh with a tongue blade normally causes the scrotum to retract.
c. Testicle is drawn up into the inguinal canal
3. Diagnose with ultrasound
4. Treatment
a. One-third spontaneously remit.
b. Surgery is imperative within 12 hours for those that do not remit.
F. Hydrocele
1. Most common cause of scrotal enlargement in children
a. The tunica vaginalis fails to close.
b. Fluid accumulates in serous space between the layers of the tunica vaginalis.
c. It is invariably associated with an indirect inguinal hernia.
2. Diagnosis
• Ultrasound distinguishes fluid versus a testicular mass causing scrotal enlargement.
3. Other fluid accumulations
a. Hematocele contains blood.
b. Spermatocele contains sperm.
4. Treatment is surgery.
A. Malformations of the urethral groove of the penis
1. Hypospadias
a. Abnormal opening on the ventral surface of the penis
b. Most common malformation of urethral groove
c. Risk factors
(1) Father or previous male sibling with defect
(2) Monozygotic twins
• Insufficient production of human chorionic gonadotropin by single placenta
d. Frequently associated with ventral curvature of penis
• Called chordee
e. Pathogenesis
(1) Due to faulty closure of the urethral folds
(2) Possibly related to abnormal androgen production
2. Epispadias
a. Abnormal opening on the dorsal surface of the penis
b. Due to a defect in the genital tubercle
B. Phimosis of the penis
1. Orifice of the prepuce is too small to retract over the head of the penis
2. Commonly associated with infections
C. Balanoposthitis of the penis
1. Infection of the glans and prepuce
a. It usually occurs in uncircumcised males with poor hygiene.
b. Accumulation of smegma leads to infection.
• Candida, pyogenic bacteria, and anaerobes
2. Inflammatory scarring may produce an acquired phimosis.
D. Miscellaneous disorders of the penis
1. Peyronie disease
a. Type of fibromatosis
b. Painful contractures of the penis
• Causes lateral curvature of the penis
c. May cause infertility
2. Priapism
a. Persistent and painful erection
b. Causes include sickle cell disease, penile trauma
E. Carcinoma in situ (CIS) of the penis
1. Bowen disease
a. Leukoplakia involving the shaft of the penis and scrotum
(1) Patients are usually >35 years old
(2) Association with human papillomavirus (HPV) type 16
b. Precursor for invasive SCC (~10% of cases)
c. Association with other types of visceral cancer
2. Erythroplasia of Queyrat
a. Erythroplakia located on the mucosal surface of the glans and prepuce
b. HPV type 16 association
c. Precursor for invasive SCC
3. Bowenoid papulosis
a. Multiple pigmented reddish brown papules on the external genitalia
b. Association with HPV type 16
c. Does not develop into invasive SCC
• Only CIS with no predisposition for invasion
F. SCC of the penis
1. Epidemiology
a. Circumcision protects against developing SCC of penis.
b. SCC is the most common cancer of the penis.
(1) Usually affects men 40 to 70 years old
(2) Most common sites
• Glans or mucosal surface of prepuce
c. Two-thirds of cases associated with HPV types 16 and 18
• Products from smoking tobacco may act as cocarcinogens with HPV.
d. Risk factors
(1) Lack of circumcision
• Greatest risk factor
(2) Bowen disease, erythroplasia of Queyrat
2. Metastasizes to inguinal and iliac nodes
Testis, Scrotal Sac, and Epididymis Diseases
A. Cryptorchidism of the testes
1. Normal descent of testes
a. Transabdominal phase
(1) Testes descend to lower abdomen or pelvic brim
(2) Müllerian inhibitory substance (MIS) is responsible for this phase.
b. Inguinoscrotal phase
(1) Descent through the inguinal canal into the scrotum
(2) Androgen- and human chorionic gonadotropin (hCG)-dependent
2. Cryptorchidism
a. Epidemiology
(1) Incomplete or improper descent of the testis into the scrotal sac
(2) Most common genitourinary (GU) disorder in male children
(3) Occurs in 30% of premature males and 5% of full-term males
(4) Associations
• Androgen insensitivity syndrome, Kallmann syndrome, cystic fibrosis
(5) Locations
(a) Inguinal canal is the most common site (80% of cases)
• Palpable mass; majority are unilateral (90% of cases)
(b) Intra-abdominal (5%–10% of cases)
(6) Many will spontaneously descend by 3 months of age
(a) Due to combination of androgens and hCG
(b) Spontaneous descent is uncommon after 3 months.
b. Complications if uncorrected
(1) Potential for infertility
(a) Arrest in germ cell maturation
(b) Testicular atrophy
(c) Similar changes occur in the normally descended contralateral testis.
(d) Greatest risk if intra-abdominal or long duration in the inguinal canal
(2) Increased risk for developing a seminoma
(a) Risk for cancer in the cryptorchid testis increases by fivefold to tenfold.
(b) Risk also applies to the normally descended testicle.
(3) Increased risk for the undescended testis to undergo torsion (see later)
c. Treatment
(1) Orchiopexy may be done as early as 6 months; it should be performed by 2 years
of age.
(2) Hormonal therapy with hCG produces variable results.
(3) Administration of gonadotropin-releasing hormone (GnRH) before orchiopexy
may improve fertility in adult.
B. Orchitis
1. Mumps
a. Infertility is uncommon.
b. Most cases are unilateral.
c. Orchitis is more likely to occur in an older child or adult.
2. Congenital or acquired syphilis
3. HIV
4. Extension of acute epididymitis
C. Epididymitis
1. Causes
a. Common pathogens in persons <35 years old
(1) N. gonorrhoeae
(2) C. trachomatis
b. Common pathogens in persons >35 years old
(1) E. coli
(2) Pseudomonas aeruginosa
c. Tuberculosis
(1) Begins in the epididymis
• Spreads to the seminal vesicles, prostate, and testicles
(2) Caseating granulomatous inflammation
d. AIDS
• Association with cytomegalovirus, Toxoplasma, Salmonella
2. Clinical findings in acute epididymitis
a. Usually unilateral scrotal pain with radiation into spermatic cord or flank
b. Scrotal swelling, epididymal tenderness
c. Urethral discharge
• If it is sexually transmitted
d. Prehn sign
• Elevation of the scrotum decreases pain.
3. Treatment
a. If <35 years old, ceftriaxone + doxycycline (STD treatment)
b. If >35 years old, ciprofloxacin extended release
D. Varicocele
1. Epidemiology
a. Occurs in 15% to 20% of all males
(1) Usually occurs between 15 and 25 years of age
(2) Rarely occurs after 40 years old
b. Occurs in 40% of infertile males
c. Most common cause of left-sided scrotal enlargement in adults
d. Left spermatic vein drains into the left renal vein
(1) Increased resistance to blood flow
(2) Blockage of left renal vein can also produce a varicocele.
• Examples—renal cell carcinoma invading renal vein; superior mesenteric artery
compressing the left renal vein
e. Right spermatic vein drains into the vena cava
(1) Blockage of right spermatic vein produces right-sided varicocele.
(2) Examples—retroperitoneal fibrosis; thrombosis of the inferior vena cava
2. Pathogenesis
• Incompetent valves in the left spermatic vein from increased pressure
3. Clinical findings
a. Aching pain in scrotum
b. Dragging sensation in testicle
c. Visible “bag of worms”
d. Infertility (controversial)
• Heat decreases spermatogenesis.
4. Diagnose by ultrasound
5. Treatment
a. Varicocelectomy
b. Embolization by an intervention radiologist
E. Torsion of the testicle
1. Epidemiology
a. Majority occur between 12 and 18 years old.
b. Predisposing factors
(1) Violent movement or physical trauma
• Most common causes
(2) Cryptorchid testis
(3) Atrophy of testis
c. Twisting of spermatic cord cuts off the venous/arterial blood supply.
• Danger for hemorrhagic infarction of the testicle
2. Clinical findings
a. Sudden onset of testicular pain
b. Absent cremasteric reflex (key diagnostic finding)
• Stroking the inner thigh with a tongue blade normally causes the scrotum to retract.
c. Testicle is drawn up into the inguinal canal
3. Diagnose with ultrasound
4. Treatment
a. One-third spontaneously remit.
b. Surgery is imperative within 12 hours for those that do not remit.
F. Hydrocele
1. Most common cause of scrotal enlargement in children
a. The tunica vaginalis fails to close.
b. Fluid accumulates in serous space between the layers of the tunica vaginalis.
c. It is invariably associated with an indirect inguinal hernia.
2. Diagnosis
• Ultrasound distinguishes fluid versus a testicular mass causing scrotal enlargement.
3. Other fluid accumulations
a. Hematocele contains blood.
b. Spermatocele contains sperm.
4. Treatment is surgery.
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