1 What are the main components of the male reproductive system?

The penis, the scrotum (with testicle, epididymis, and deferens), the seminal vesicles, and the prostate (Fig. 16-1).

Figure 16-1 Male pelvic anatomy.

(From Meszaros G: Crash Course Endocrine and Reproductive Systems. St. Louis, Mosby, 2006.)

2 What is the best technique for examining male genitalia?

The same as for examining the rectum: with the patient either standing up or lying down on one side. Still, it is probably easier to assess the testes (and search for hernias) with the patient standing up and the examiner seated in front of him.

3 What should I focus on during inspection of this region?

(1) Penis

4 Describe the anatomy of the penis.

The penis consists of a shaft, formed by three juxtaposed columns of spongy and vascular tissue: the corpora cavernosa. These can be temporarily filled with blood, thus providing a unique erectile capacity to the organ. The distal tip of the penis consists of a cone-shaped structure called the glans (“acorn” in Latin), which contains the vertical slit-like opening of the urethra (urethral meatus). The glans is separated from the shaft by a circular sulcus called the corona (“crown” in Latin), which in uncircumcised men is covered in a hood-like fashion by the prepuce or foreskin, a fold surgically removed during circumcision. All areas must be examined (see Fig. 16-2).

Figure 16-2 Structure of the penis.

(From Meszaros G: Crash Course Endocrine and Reproductive Systems. St. Louis, Mosby, 2006.)

5 What steps should I take to properly examine the penis?

The first, of course, is precautionary: put on a pair of gloves because some sexually transmitted diseases (including syphilis) can be acquired through simple skin abrasions. With gloves on, examine the penis by first palpating the shaft, and then by carefully looking for areas of induration or tenderness. Then, look for unusual curvatures (see Peyronie’s disease, question 47). Retract the prepuce to gain access to the glans, and inspect it for abnormalities. After completing the exam, return the foreskin to its original position since failure to do so may cause severe edema in unconscious patients. Finally, gently compress the glans between your thumb and forefinger to visualize the urethral meatus, and possibly express secretions. Note that this maneuver may be unyielding even in patients with a history of penile discharge. In this case, milk the shaft of the penis (from its base to the glans), since this may produce a few precious drops for analysis. Finally, examine the base of the penis for hair or skin abnormalities.

6 What is priapism?

A fancy term for a protracted erection, usually associated with pain. If we look back at the American presidency, we might conclude that priapism qualifies as a White House occupational hazard, were it not for the fact that this condition is usually not associated with sexual desire. The term “priapism” is actually rooted in Greek mythology, specifically in Priapus, one of the many illegitimate sons of Zeus, King of the Gods (which confirms our suspicion that power and sex may be linked, at least among American presidents and Greek deities). According to tradition, Hera (Zeus’ unfortunate wife) found out about this umpteenth illicit affair of her husband and decided to attend the child’s birth, to cast a mortal spell on the baby. Things, however, did not go as expected, since Priapus was born so well endowed that Hera, taken by surprise, completely missed her chance. Hence, the baby was rushed to safety, and a new medical term was born. Priapism eventually came to signify a condition characterized by chronic, protracted, and painful erections. Still, Priapus also prompted great respect for the penis, which became a symbol not only of fertility, but also of luck, since it had literally saved his owner’s life. From that time on, Romans developed a penchant for wearing little phalluses around their neck, usually made in coral (because of its apotropaic virtue [i.e., the ability to ward off the evil eye]), but occasionally also in gold. They also carved phalluses on buildings—as hopeful lucky charms. For example, the great Roman wall erected (no pun intended) in England by Emperor Hadrian during the 1st century AD was riddled with various penile carvings, still visible today and accurately catalogued in local museums by serious British archeologists. Stone phalluses were supposed to bring good luck to the wall’s defenders but unfortunately fell short of expectations: Hadrian’s wall was pierced by raiding Scots and Picts and eventually abandoned. The reverence for the penis, however, continued unabated throughout the Mediterranean basin. Indeed, in some parts of Italy and Greece (not to mention South Philadelphia) it is still possible to see golden pricklets hanging from people’s necks, a reminder of the long-lasting value of Greek mythology and penile lore.

7 What is the pathophysiology of priapism?

It is a persistent erection of the corpora cavernosa of the penis, due to disturbances in the mechanisms controlling penile detumescence.

8 Does priapism involve all erectile tissue?

No. Only the corpora cavernosa of the penis. The one surrounding the urethra and the corpus spongiosum of the glans remains instead flaccid.

9 What is the cause of priapism?

Often idiopathic. Yet, priapism also may reflect systemic or local abnormalities:

10 And what about drugs?

Many drugs can cause priapism. In addition to the various products that release nitric oxide into the corpora cavernosa (e.g., sildenafil [Viagra]) or the intracavernosal injection of medications for impotence, drugs that can induce priapism include:

11 What is phimosis?

From the Greek phimos (muzzle or snout), this is a narrowed opening of the prepuce, so that the foreskin cannot be retracted over the glans penis (Fig. 16-3). Usually congenital (from membranes binding the prepuce to the glans), phimosis also may result from acquired adhesions, often the sequela of poor hygiene, previous infections (chronic balanoposthitis), or a too-forceful retraction of a congenital phimosis. If untreated, it can degenerate into squamous intraepithelial cancer of the penis.

Figure 16-3 A, Phimosis. B, Paraphimosis.

12 Is a phimosis always pathologic?

No. A congenital phimosis can be quite physiologic in children, in fact well into the teenage years. In a recent study from Japan (where circumcision is not routinely done), a congenital phimosis was seen in 88.5% of children aged 1–3 months, and 35% of those aged 3 years. In fact, only 39.7% of these children had foreskins fully retractable by 3 years of age. Other studies have shown persistence of congenital phimoses in 6% of boys aged 8–11, and 3% of those aged 12–13. Only 20% of 200 boys aged 5–13 years had fully retractable foreskins.

13 What is paraphimosis?

A condition related to, but actually different from, a phimosis. Once a phimotic prepuce is forcibly retracted over the glans, the edematous foreskin cannot be brought forward again, thus resulting in paraphimosis, a tight band of retracted foreskin behind the coronal sulcus (see Fig. 16-3). This is a very painful condition, which, if unrelieved, can cause urinary tract obstruction, venous engorgement, edema, and even necrosis of the foreskin and glans.

14 What are the causes of paraphimosis?

The same as those of phimosis: an uncircumcised or incorrectly circumcised penis. In fact, both conditions are often indication for circumcision to prevent vascular or infectious complications. In children, the narrowed preputial opening of a congenital phimosis often results in paraphimosis, especially if parents forcibly retract the foreskin while attempting to clean the glans. In adults, there is often a history of catheterization (without allowing the foreskin to return over the glans) or poor hygiene (with balanoposthitis eventually leading to phimosis and then to paraphimosis). Vigorous sexual activity can predispose to paraphimosis, too. Finally, body piercing with penile rings that prevent the reduction of a retracted foreskin can be a unique, but not too uncommon, cause.

15 What is balanoposthitis?

It is the inflammation of the glans (balanos is Greek for acorn) and prepuce (posthe is Greek for foreskin) due to a wide variety of organisms. This is often seen in uncircumcised males because of poor local hygiene, with accumulation of (and irritation by) smegma—a mix of desquamated epithelial cells, sweat, debris, and transudated oils (from the Greek term for “soap”). Examination of prepuce and the glans reveals a red, moist, and macular lesion, at times with areas of yellow-to-black discoloration. Irregular borders and lichenification suggest instead human papillomavirus or a chronic bacterial process, eventually leading to phimosis. Ulceration and deep erosion occur only with fungal infection in immunocompromised hosts.

16 What are the causes of balanoposthitis?

The most common is infection, either by bacteria (staphylococci and streptococci, but also anaerobes, Gardnerella sp., and S. pyogenes sp.) or yeasts (usually candidal). This is usually facilitated by poor hygiene and poorly retractile foreskin. Contact dermatitis also may cause it, and in one third of cases no specific etiologies are established. Associations with ulcerative colitis and Crohn’s disease also have been reported. Refractory or recurrent forms may benefit from circumcision. Still, do not confuse balanoposthitis with balanitis.

17 What is balanitis?

An inflammation of the glans, usually in uncircumcised men with poor personal hygiene. It is common, affecting 11% of American men in a urology clinic. Irritation from smegma causes edema and inflammation of the glans, with eventual adherence of the foreskin to the penis (i.e., phimosis). Local burning and a red rash also are common. The skin may appear to peel off, as if scalded. Predisposing conditions include diabetes, but also morbid obesity, edema (nephrosis, cirrhosis, and heart failure), and old age. Seborrheic and contact dermatitis can do it, too. Given its frequent infectious nature, it may be sexually transmitted.

18 What is Reiter’s syndrome? What are its manifestations?

Reiter’s is a reactive arthritis, usually triggered by an infection. This may be sexually transmitted (Chlamydia, genital mycoplasmas, and, to a lesser degree, gonococci) or enteric (Shigella, Salmonella, Yersinia, and Campylobacter spp.). Its clinical manifestations include acute arthritis/arthralgia, lower urogenital tract inflammation, mucocutaneous lesions, and conjunctivitis/iridocyclitis. One quarter of affected men have small, ulcerated plaques around the glans and foreskin. In fact, the most common mucocutaneous lesion involves the penis and is called circinate balanitis (circinata means round in Latin, and balanitis is the Greek term for inflammation of the glans). This is a painless inflammation of glans, sulcus, and corona, which starts as tiny blebs, eventually merging into a larger ring of inflammatory tissue that may completely circumscribe the glans. In addition, Reiter’s patients often have mucocutaneous lesions of the mouth, palms, and soles. Over the hands and feet, these tend to be scaly, sometimes pustular, and frequently resembling severe psoriasis (keratoderma blennorrhagica). Whether initial infection was sexually transmitted or enteric, there also may be urethritis with discharge. This is scanty, thin, and whitish—hence, quite different from the profuse, thicker, and more purulent discharge of gonorrhea. In fact, the discharge of Reiter’s resembles that of other nongonococcal urethritides (like chlamydia) insofar as it is usually clear. Acute Reiter’s also can present with systemic symptoms (fever, malaise, anorexia, and weight loss). Most cases resolve in 2–6 months with annual risk of recurrence of mucocutaneous manifestations around 15%, at intervals of months or years. The arthritis is usually persistent.

19 Who was Reiter?

Hans C. Reiter (1881–1969) was a German physician and the son of a rich Leipzig industrialist. He described his famous syndrome in 1916, while serving with the Hungarian Army in the Balkans during World War I. There, he encountered a young lieutenant affected by diarrhea, urethritis, arthritis, and conjunctivitis. Reiter first thought that the patient might have had syphilis but eventually changed his diagnosis and recognized the new syndrome. The same constellation of findings was described 2 years later by Sir Benjamin Brodie in his textbook, Diseases of the Bones and Joints. Reiter also is famous for having identified the spirochete causing Weil’s disease while being stationed on the Western front. He later became a member of the Nazi party, was appointed minister of health for Mecklenburg, and even signed an oath of allegiance to Adolf Hitler—hence the recent calls to remove his name from medical textbooks.

20 What about gonococcal urethritis?

It is the hallmark of gonorrhea, characterized in men by urethritis with thick and profuse discharge, urethral itch, dysuria, and epididymal pain (although more than one half of all men and women with gonorrhea are asymptomatic). If untreated, gonorrhea can lead to major sequelae, such as epididymo-orchitis and possibly infertility.

21 What kind of skin lesions can be seen on the penis?

The most common are classified on the basis of appearance (Table 16-1):

1. Ulcerating: Skin craters filled with serum, pus, or crust. They represent a full-thickness loss of epidermis and can be single or multiple.

2. Non-ulcerating: Further divided into:

Papules: Small (<1   cm in diameter) lesions, raised above the skin surface

Plaques: Larger (>1   cm in diameter) lesions, flat-topped

Table 16-1 Penile Lesions

22 How do ulcerating lesions present?

As single or multiple. The single are more serious, since they reflect sexually transmitted diseases such as primary syphilis, chancroid, granuloma inguinale, and lymphogranuloma venereum. Penile cancer also can present as a painless, irregular, genital ulcer.

23 Describe the ulcerating lesion of primary syphilis

It is a single, round, nontender, and painless ulcer (often called a chancre) with bilateral lymphadenopathy.

24 Describe the ulcerating lesion of chancroid

It is a painful, single ulcer, at times multiple, with lymphadenopathy.

25 Describe the ulcerating lesion of granuloma inguinale

It is a single, painless ulcer without lymphadenopathy.

26 Describe the ulcerating lesion of lymphogranuloma venereum

It is a small, nontender ulcer with unilateral tender lymphadenopathy.

27 Which other dermatoses can be transmitted through sexual contact?

Definitely scabies and pediculosis. In both cases, itching is the prevalent symptom, and redness the predominant finding. Note that whereas scabies burrow under the skin to lay eggs, lice bite into the skin to draw blood. Hence, lice present with red and scaly areas of skin or hair where insects and eggs may be visible. Scabies, on the other hand, present with little bumps, blisters, and crusting in areas of pruritus.

28 What about multiple ulcerating lesions?

These are more common than single ulcers and may have less serious causes. Based on duration, they can be acute (<2-week course) or chronic (>2-week course).

29 What are the most important acute multiple ulcerating lesions?

30 Describe the multiple ulcerating lesions of secondary syphilis

Secondary syphilis is characterized by a papulosquamous rash involving not only the penis but also the palms and soles. Multiple, irregular, shallow, painless, and gray ulcers (often described as “serpiginous” since they move like a snail track along the penis) are usually present. There also may be a flu-like illness and a blotchy, red body rash.

31 What are aphthous ulcers?

Small, shallow, painful ulcers that most commonly appear in the mouth but also can affect the penis. Typically, they have a gray center surrounded by a bright red halo, occur in crops, and resolve without treatment. They can easily be confused with herpes simplex ulcers, so laboratory tests are necessary to reliably distinguish the two. They are not infectious, and their cause is unknown.

32 Describe the multiple ulcerating lesions of herpes simplex

They appear as small, multiple vesicular skin lesions that are painful, in clusters, and not associated with adenopathy. Note that chancroid lesions also can be multiple.

33 Are genital herpetic lesions due to HSV-1 or HSV-2?

Usually to herpes simplex virus type 2, the leading cause of infectious genital ulceration in the United States (HSV-1 is instead the most common cause of oral infections). Although one out of five American adults is seropositive for this virus, more than one half remain asymptomatic and yet capable of shedding and transmitting the virus. Lesions present as small, clustered vesicles on an erythematous base, rapidly progressing into pustules and painful ulcers, and eventually forming a crust. Since lesions follow the distribution of a sensory nerve, they tend to recur at (or near) the same site. Fever, malaise, and acute toxicity also may occur—especially in primary infections.