Sexual dysfunction and disorders (Both male and female)

What is sexual dysfunction?

Sexual dysfunction refers to a problem occurring during any phase of the sexual response cycle that prevents the individual or couple from experiencing satisfaction from the sexual activity. The sexual response cycle traditionally includes excitement, plateau, orgasm, and resolution. Desire and arousal are both part of the excitement phase of the sexual response.

While research suggests that sexual dysfunction is common (43 percent of women and 31 percent of men report some degree of difficulty), it is a topic that many people are hesitant to discuss. Because treatment options are available, it is important to share your concerns with your partner and health care provider.

What are the types of sexual dysfunction?

Sexual dysfunction generally is classified into four categories:

  • Desire disorders —lack of sexual desire or interest in sex
  • Arousal disorders —inability to become physically aroused or excited during sexual activity
  • Orgasm disorders —delay or absence of orgasm (climax)
  • Pain disorders — pain during intercourse

Who is affected by sexual dysfunction?

Sexual dysfunction can affect any age, although it is more common in those over 40 because it is often related to a decline in health associated with aging.

What are the symptoms of sexual dysfunction?

In men:

  • Inability to achieve or maintain an erection suitable for intercourse (erectile dysfunction)
  • Absent or delayed ejaculation despite adequate sexual stimulation (retarded ejaculation)
  • Inability to control the timing of ejaculation (early or premature ejaculation)

In women:

  • Inability to achieve orgasm
  • Inadequate vaginal lubrication before and during intercourse
  • Inability to relax the vaginal muscles enough to allow intercourse

In men and women:

  • Lack of interest in or desire for sex
  • Inability to become aroused
  • Pain with intercourse

What causes sexual dysfunction?

  • Physical causes — Many physical and/or medical conditions can cause problems with sexual function. These conditions include diabetes, heart and vascular (blood vessel) disease, neurological disorders, hormonal imbalances, chronic diseases such as kidney or liver failure, and alcoholism and drug abuse. In addition, the side effects of some medications, including some antidepressant drugs, can affect sexual function.
  • Psychological causes — These include work-related stress and anxiety, concern about sexual performance, marital or relationship problems, depression, feelings of guilt, concerns about body image, and the effects of a past sexual trauma.

How is sexual dysfunction diagnosed?

In most cases, the individual recognizes that there is a problem interfering with his or her enjoyment (or the partner’s enjoyment) of a sexual relationship. The clinician likely will begin with a complete history of symptoms and a physical. He or she may order diagnostic tests to rule out any medical problems that may be contributing to the dysfunction, if needed. Typically, lab testing plays a very limited role in the diagnosis of sexual dysfunction.

An evaluation of the person’s attitudes about sex, as well as other possible contributing factors (fear, anxiety, past sexual trauma/abuse, relationship concerns, medications, alcohol or drug abuse, etc.) will help the clinician understand the underlying cause of the problem, and will help him or her make recommendations for appropriate treatment.

How is sexual dysfunction treated?

Most types of sexual dysfunction can be corrected by treating the underlying physical or psychological problems. Other treatment strategies include:

Medication — When a medication is the cause of the dysfunction, a change in the medication may help. Men and women with hormone deficiencies may benefit from hormone shots, pills, or creams. For men, drugs, including sildenafil , tadalafil , vardenafil , and avanafil may help improve sexual function by increasing blood flow to the penis.

Mechanical aids — Aids such as vacuum devices and penile implants may help men with erectile dysfunction (the inability to achieve or maintain an erection). A vacuum device (Eros) is also approved for use in women, but can be costly. Dilators may help women who experience narrowing of the vagina.

Sex therapy — Sex therapists can be very helpful to couples experiencing a sexual problem that cannot be addressed by their primary clinician. Therapists are often good marital counselors, as well. For the couple who wants to begin enjoying their sexual relationship, it is well worth the time and effort to work with a trained professional.

Behavioral treatments — These involve various techniques, including insights into harmful behaviors in the relationship, or techniques such as self-stimulation for treatment of problems with arousal and/or orgasm.

Psychotherapy — Therapy with a trained counselor can help a person address sexual trauma from the past, feelings of anxiety, fear, or guilt, and poor body image, all of which may have an impact on current sexual function.

Education and communication — Education about sex and sexual behaviors and responses may help an individual overcome his or her anxieties about sexual function. Open dialogue with your partner about your needs and concerns also helps to overcome many barriers to a healthy sex life.

Can sexual dysfunction be cured?

The success of treatment for sexual dysfunction depends on the underlying cause of the problem. The outlook is good for dysfunction that is related to a condition that can be treated or reversed. Mild dysfunction that is related to stress, fear, or anxiety often can be successfully treated with counseling, education, and improved communication between partners.

Epididymitis (Testicle infection): Practice Essentials, Background, Anatomy, Risk Factors & Treatment First Line

DEFINITION

Epididymitis is an inflammatory reaction of the epididymis caused by an infectious agent or local trauma.

  • Acute epididymitis: Pain for <6 weeks
  • Chronic epididymitis: Pain for >3 months

PHYSICAL FINDINGS AND CLINICAL PRESENTATION

  • Tender swelling of the scrotum with erythema, usually unilateral testicular pain and tenderness
  • Dysuria and/or urethral discharge
  • Fever and signs of systemic illness (less common)
  • Pain and redness on scrotal examination
  • Hydrocele or even epididymo-orchitis, especially late
  • Chronic draining scrotal sinuses, with a beadlike enlargement of the vas deferens in tuberculous disease



CAUSE

  • In young sexually active men, the most common infectious agents isolated are Neisseria gonorrhoeae and Chlamydia trachomatis.
  • In men older than 35 years or with underlying urologic disease:
  1. Gram-negative aerobic rods are predominant.
  2. Similar organisms are found in men following invasive urologic procedures.
  3. Gram-positive cocci are rarely seen in these groups.
  4. Mycobacteria are also a cause of epididymitis.
  • Young prepubertal boys may present with epididymitis caused by coliform bacteria, almost always a complication of underlying urologic disease such as reflux.
  • In AIDS patients, cytomegalovirus (CMV) and Salmonella epididymitis have been described. CMV may have a negative urine culture. Toxoplasmosis should also be considered as a cause of epididymitis in AIDS patients.

RISK FACTORS

  • UTI, prostatitis
  • Indwelling urethral catheter
  • Urethral instrumentation or transurethral surgery
  • Urethral or meatal stricture
  • Transrectal prostate biopsy
  • Prostate brachytherapy (seeds) for prostate cancer
  • Anal intercourse
  • High-risk sexual activity
  • Strenuous physical activity
  • Prolonged sedentary periods
  • Bladder obstruction (benign prostatic hyperplasia, prostate cancer)
  • HIV-immunosuppressed patient
  • Severe Behcet disease

DIFFERENTIAL DIAGNOSIS

  • Orchitis
  • Testicular torsion, trauma, or tumor
  • Epididymal cyst
  • Hydrocele
  • Varicocele
  • Spermatocele
  • Testicular torsion should be considered in all cases.

WORKUP

  • Consideration of a full assessment of the urologic tract in patients with bacterial infection, especially if recurrent
  • Imaging with sonography
  • If discharge is present: cultures and Gram stain smear of urethral exudate
  • In homosexual men: gonococcal cultures of the throat and rectum possibly of value
  • If testicular torsion a consideration: radionuclear imaging
  • Examination of first-void uncentrifuged urine for leukocytes if the urethral Gram stain is negative. A culture and Gramstained smear of this urine specimen should be performed along with nucleic acid amplification studies (ligase chain reaction [LCR]) from urine samples for gonorrhea and Chlamydia spp.

LABORATORY TESTS

  • Urinalysis and urine culture if dysuria is present or urinary tract infection is suspected
  • VDRL chlamydia serology in sexually active men
  • Purified protein derivative (PPD) placed and chest x-ray if TB suspected
  • Rarely, biopsy to ensure the diagnosis of tuberculous epididymitis
  • HIV testing and counseling

TREATMENT

  • Ice packs and scrotal elevation for relief of pain
  • Analgesia with acetaminophen with or without codeine or nonsteroidal anti-infl ammatory drugs (NSAIDs).
  • Antibiotics to cover suspected pathogens
  • In sexually active men, doxycycline
  • Best treatment for older men with gram-negative bacteriuria: ofloxacin or levofloxacin
  • Pseudomonas covered by ciprofl oxacin
  • Surgical aspiration of local abscesses or even open surgical drainage
  • Repair of underlying structural defects is considered, especially if infections are severe or recur.
  • Surgical repair of refl ux in young boys should be undertaken promptly and at a young age when possible.
  • Sex partners of patient should be referred for evaluation and treatment.

Facts about Ejaculation and Orgasm Disorders

What is Ejaculation?

Clinically significant disorders of ejaculation include failure of emission, retrograde ejaculation, premature ejaculation, delayed ejaculation, painful ejaculation, hematospermia, and anorgasmia.

Failure of emission occurs when semen is not propulsed into the urethra during orgasm, resulting in a dry ejaculate. Retrograde ejaculation is a backward flow of semen into the bladder.

Premature ejaculation exists when there is an inability to delay ejaculation such that ejaculation occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners.

Hematospermia is the appearance of blood in the ejaculate. Anorgasmia is the inability to achieve orgasm in a timely manner.

CLINICAL PRESENTATION

  • Failure of emission: no ejaculate is produced during orgasm. Physical findings may reveal nervous system dysfunction (e.g., spinal cord injury); may present with infertility (e.g., ejaculatory duct obstruction).
  • Retrograde ejaculation: little or no ejaculate is expelled out of the urethra at orgasm. Patients may report cloudy postcoital urine. Physical examination is usually normal; may present with infertility.
  • Premature ejaculation: ejaculation occurs sooner than desired, either before or shortly after penetration. Physical examination is normal. Sexual and psychological history may be revealing. Up to 30% of patients may report concomitant erectile dysfunction.
  • Painful ejaculation: perineal, scrotal, or testicular pain during or shortly after ejaculation. Physical examination may demonstrate pain on examination of external genitalia, or with digital rectal examination; may present with infertility.
  • Hematospermia: reddish-brown ejaculate, usually painless. Physical findings usually unremarkable; not associated with malignancy.
  • Anorgasmia: patient is not able to achieve orgasm despite appropriate stimulation.

ETIOLOGY

  • Retrograde ejaculation may be caused by anatomic abnormalities of the bladder neck, or nerve injury affecting the bladder neck sphincter.
  • Either retrograde ejaculation or failure of emission may result from functional abnormalities, such as spinal cord injury, diabetes mellitus, retroperitoneal surgery, transurethral prostate surgery, urethral strictures, alpha-blocker therapy, antipsychotics, multiple sclerosis, and peripheral neuropathy.
  • The etiology of premature ejaculation is complex and multifactorial, and includes genetic, behavioral, and psychologic contributions.
  • Causes of painful ejaculation may be infectious (e.g., epididymo-orchitis, urethritis, prostatitis), obstructive (e.g., vasectomy, prostatectomy, hernia repair), or psychologic.
  • Hematospermia may be idiopathic, secondary to prolonged abstinence, or due to infection or inflammation of the genitourinary tract.
  • Anorgasmia may be caused by spinal cord injury, psychologic factors, dysfunctional sexual techniques, or medications, particularly serotonin re-uptake inhibitors.

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Erectile dysfunction
  • Low seminal fluid volume attributable to hypogonadism or ejaculatory duct obstruction

C. Inflammatory disorders of the genitourinary tract

C. Hypoactive sexual desire

LABORATORY TESTS

  • In the setting of a dry or low-volume ejaculate, post-ejaculate urine should be evaluated for the presence of spermatozoa, in order to differentiate failure of emission from retrograde ejaculation.
  • Hematuria, in the setting of hematospermia or painful ejaculation, may signal an underlying inflammatory disorder or a malignancy and should prompt a complete evaluation.
  • A fasting blood glucose may be considered if diabetes is suspected as a cause of lack of emission or retrograde ejaculation.
  • Urinalysis, urine culture, and screening for sexually transmitted diseases, when indicated, can rule out an infectious etiology of painful ejaculation.

IMAGING STUDIES

Transrectal ultrasonography can rule out ejaculatory duct obstruction or absence of the seminal vesicles.

TREATMENT

NON-PHARMACOLOGIC THERAPY

  • Retrograde ejaculation and failure of emission do not require treatment unless fertility is desired.
  • In the setting of retrograde ejaculation, viable sperm can be recovered from the postejaculate urine and used for intrauterine insemination or in vitro fertilization.
  • Premature ejaculation can improve with psychotherapy and behavioral interventions (e.g., “coronal squeeze” or “start-and-stop” technique) and effective partner communication. These approaches may be more effective when combined with pharmacologic therapy.
  • Idiopathic hematospermia may be followed expectantly and is usually self-limited to 10 to 15 ejaculations.
  • Anorgasmia caused by serotonin reuptake inhibitors usually improves with withdrawal of the medication. Sexual therapy and counseling can improve anorgasmia caused by dysfunctional sexual techniques or psychologic issues. Vibratory or electrical stimulation of emission is helpful in selected cases.

ACUTE GENERAL Rx

  • Retrograde ejaculation: pharmacologic therapy is only effective in patients without an anatomic disturbance of the bladder neck. Sympathomimetic medications (phenylpropanolamine, ephedrine, pseudoephedrine) and imipramine may be useful in converting retrograde ejaculation to antegrade ejaculation.
  • Failure of emission: may be converted to retrograde ejaculation by oral sympathomimetic therapy, as listed above.
  • Premature ejaculation: selective serotonin reuptake inhibitors (SSRI) (sertraline, fluoxetine) and the tricyclic antidepressant clomipramine can successfully delay ejaculation when taken daily. Recent research has focused on dapoxetine, a short-acting SSRI, which has shown promise as an “on-demand” treatment for premature ejaculation. Topical anesthetics such as lidocaine cream and topical sprays have also been used, with variable success. The use of phosphodiesterase inhibitors (PDE5i) (sildenafil, vardenafil, tadalafil) with SSRIs may be beneficial in men with concomitant erectile dysfunction and premature ejaculation.
  • Antimicrobial treatment (if indicated), NSAIDs, and muscle relaxants may help decrease discomfort associated with painful ejaculation.
  • The use of the pharmacologic therapies listed above for the treatment of various disorders of ejaculation is strictly off label and does not carry FDA approval.

SURGICAL THERAPY

There is no role for surgery for the majority of ejaculatory disorders. Rarely, painful ejaculation due to obstructive causes may show improvement with surgical intervention (e.g., vasectomy reversal).

What is Vaginal Prolapse: Symptoms, Surgery & Treatment

INTRODUCTION

  • Description: Vaginal prolapse is loss of the normal support mechanism, resulting in descent of the vaginal wall down the vaginal canal. In the extreme, this may result in the vagina becoming everted beyond the vulva to a position outside the body. Vaginal prolapse is generally found only after hysterectomy and is a special form of enterocele.
  • Prevalence: Depends on the severity of the original defect, type of surgery originally performed and other risk factors (estimated to be between 0.1% to 18.2% of patients who have had a hysterectomy).
  • Predominant Age: Late reproductive and beyond.
  • Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

  • Causes: Loss of normal structural support because of trauma (childbirth), surgery, chronic intra-abdominal pressure elevation (such as obesity, chronic cough, or heavy lifting), or intrinsic weakness. A recurrence within 1 to 2 years of surgery is considered a failure of  technique.
  • Risk Factors: Birth trauma, chronic intra-abdominal pressure elevation (such as obesity, chronic cough, or heavy lifting), intrinsic tissue weakness, or atrophic changes resulting from estrogen loss.

CLINICAL CHARACTERISTICS

Signs and Symptoms

  • Pelvic pressure or heaviness, backache
  • Mass or protrusion at the vaginal entrance
  • New onset or paradoxical resolution of urinary incontinence

DIAGNOSTIC APPROACH

Differential Diagnosis

  • Cystocele
  • Urethrocele
  • Rectocele
  • Bartholin’s cyst
  • Vaginal cyst or tumor

Associated Conditions: Urinary incontinence, pelvic pain, dyspareunia, intermenstrual or postmenopausal bleeding. A cystourethrocele, rectocele, and/or enterocele is almost always present when complete prolapse has occurred.

Workup and Evaluation

Laboratory: No evaluation indicated.

Imaging: No imaging indicated.

Special Tests: Urodynamics testing may be considered if there is altered voiding or continence.

Diagnostic Procedures: History and physical examination.

Pathologic Findings

Tissue change common because of mechanical trauma and desiccation.

MANAGEMENT AND THERAPY

Nonpharmacologic

  • General Measures: Weight reduction, modification of activity (lifting); address factors such as chronic cough.
  • Specific Measures: Pessary therapy, surgical repair (culdoplasty, plication of the uterosacral ligaments, sacrospinousm ligament fixation, mesh-based support, or colpocleisis). When surgical repair is undertaken, attention must also focus on correction of any anterior or posterior vaginal wall support problems.
  • Diet: No specifi c dietary changes indicated.
  • Activity: No restriction, although heavy lifting or strenuous activities may predispose to the development or recurrence of prolapse.
  • Patient Education: Reassurance; American College of  Obstetricians and Gynecologists Patient Education Pamphlet AP012 (Pelvic Support Problems), AP081 (Urinary Incontinence).

Drug(s) of Choice

Estrogen replacement therapy (for postmenopausal patients) improves tissue tone and healing and is often prescribed before surgical repair or as an adjunct to pessary therapy.

Contraindications: Estrogen therapy should not be used if undiagnosed vaginal bleeding is present.

FOLLOW-UP

  • Patient Monitoring: Normal health maintenance. If a pessary is used, frequent follow-up (both initially and long term) is required.
  • Prevention/Avoidance: Maintenance of normal weight, avoidance of known (modifiable) risk factors.
  • Possible Complications: Thickening or ulceration of the vaginal tissues, urinary incontinence, kinking of the ureters, and obstipation. Complications of surgical repair include intraoperative hemorrhage, nerve damage (sciatic), damage to the rectum, damage to the ureters, postoperative infection, and complications of  anesthesia.
  • Expected Outcome: Vaginal prolapse tends to worsen with time. If uncorrected, complete prolapse is associated with vaginal skin changes, ulceration, and bleeding.

Transurethral Resection of the Prostate Syndrome

Definition

Systemic absorption of fluids used for bladder distention during a transurethral resection of a prostate mass (TURP). Occurs in approximately 2% of patients undergoing this procedure.

Presentation

  • Hyponatremia
  • Central nervous system manifestations:
  • Mental status changes
  • Diplopia
  • Nausea and vomiting
  • Cardiovascular symptoms:
  • Hypertension
  • Bradycardia
  • Myocardial ischemia and dysrhythmia

Pathophysiology

Nonionic irrigating solution (mannitol, glycine, or sorbitol) enters the circulation through open venous sinuses. Excessive absorption of irrigating solution leads to hyponatremia, circulatory overload, or neurotoxicity (if glycine-containing solution is used).

DIFFERENTIAL DIAGNOSIS

  • Congestive heart failure
  • Hyponatremia

Immediate Management

  • Discontinue administration of irrigation fluid.
  • Send blood for serum electrolyte levels (Na+).
  • Administer furosemide (20 mg IV); adjust dose for preoperative creatinine.
  • The TURP syndrome is usually time-limited (generally resolves within 6 hours after surgery).
  • Terminate the procedure as soon as practical.

Diagnostic Studies

  • Complete blood count
  • Basic metabolic panel

Subsequent Management

  • Continue monitoring into the postoperative period until symptoms abate. The patient may be monitored in the postanesthesia care unit or the intensive care unit.
  • Consider administration of hypertonic (3%) saline in patients with severe hyponatremia (<120 mEq/L, or those with neurologic symptoms).

Risk Factors

  • Prolonged operative time (approximately 1 liter of fluid is absorbed per 40 minutes operating time)
  • High irrigating pressure (determined by the height of the bag above the patient)
  • Large prostate, extensive resection
  • Glycine-containing solution (may cause transient blindness)

Prevention

  • Consider use of regional anesthesia (permits early detection of CNS changes).
  • The patient should be kept horizontal, because using the Trendelenburg position reduces the intravesical pressure required to initiate absorption, thus increasing the risk of irrigation fluid absorption.
  • Avoid glycine-containing solutions if able.
  • The height of the irrigating fluid bag should be approximately 60 cm above the patient

Peyronie’s Disease

Peyronie’s disease is an abnormal curvature and shortening of the penis during an erection. This is caused by scarring of the tunica albuginea of the corpora cavernosa.

_ Peyronie’s disease occurs in approximately 1% of men.

_ It is commonly seen between the ages of 45 and 60 yr.

CAUSE

_ Specific cause is unknown. It is believed that scar tissue forms on either the dorsal or ventral midline surface of the penile shaft. The scar restricts expansion at the involved site, causing the penis to bend or curve in one direction.

_ The precipitating factor appears to be trauma from repetitive microvascular injury caused by vigorous sexual intercourse, accidents, or prior surgeries (e.g., transurethral or radical prostatectomy, cystoscopy).

CLINICAL 

_ Painful erections

_ Tenderness over the scar tissue area

_ Erectile dysfunction

_ Curvature of the erected penis interfering with penetration

_ Dupuytren’s contracture is a commonly associated finding in patients with Peyronie’s disease

WORKUP

History and physical examination alone will usually establish the diagnosis of Peyronie’s disease.

LABORATORY 

There are no specific blood tests to diagnose Peyronie’s disease.

MANAGEMENT

_ A conservative approach of reassurance and observation is taken at first because the disease process may be self-limiting.

_ Acute treatment

  • Vitamin E 400 mg bid.
  • Paraaminobenzoic acid 12 g/day.
  • Colchicine 0.6 mg bid for 2 to 3 wk.
  • Fexofenadine 60 mg bid for 3 mo.
  • Steroid injection into the scar tissue.
  • Collagenase injection into the scar tissue.
  • Radiation to the scar tissue area.
  • Extracorporeal shockwave therapy (ESWT)

P3nis Pain & Its Management? Watch A Video

Part of being an adult male is knowing that the more attention paid to penis health, the less likely a guy is to have penile issues to contend with. However, that’s not to say that a guy will never have any issue if he keeps an eye on his penis health.

What are sleep-related painful erections?

When most men hear the phrase “sleep-related painful erections,” they just assume it means something like waking up in the morning with a little penis pain from having slept with too much weight on a morning erection. In fact, this is a different condition altogether.

Fortunately, sleep-related painful erections are considered rare, affecting an estimated one percent of adult men. However, it is also thought that the condition is under-reported and may be more common than thought. The jury is still out on the exact incidence.

When a man has sleep-related painful erections, he achieves one or more erections during the course of the night. Erections that occur during non-REM sleep appear to be normal, causing no problems or pain. But frequently the erections that a man has during periods of REM (rapid eye movement) sleep produce great penis pain – to the extent that they awaken a man from his sleep and often prevent him from easily returning to dreamland.

Very painful

It’s important to emphasize once again that the penis pain of this condition is of a different kind and level than the throbbing a man might occasionally experience from sleeping the wrong way on an erect penis. This pain can be so bad that a man may not return to sleep for an extended period of time. As a result, men with sleep-related painful erections have fatigue and irritability, and it may contribute to mental issues related to lack of sleep.

Most cases of this condition do not appear in a man until he is age 40 or older. Most men who experience it report that it then becomes increasingly common as they get older. Diagnosis of the condition is difficult, as it is sometimes assumed to be related to priapism. However, treatment for priapism is not thought to have a positive effect on this problem. It is usually diagnosed through study in a sleep laboratory setting.

Treatment

Since the cause of the disorder is currently unknown, treatment is difficult. Doctors tend to focus on treating the symptoms. Most often, patients are prescribed antidepressants, which seem to have had good results in several cases. In some instances, beta blockers have also been seen to produce excellent results.

As indicated, sleep-related painful erections are thought to be rare. If a man has symptoms consistent with the disorder, he should bring them to the attention of his physician or urologist.

Benign Prostatic Hyperplasia (BPH) & Management Methods

Benign prostatic hyperplasia (BPH) is the benign growth of the prostate, generally originating in the periureteral and transition zones, with subsequent obstructive and irritative voiding symptoms.

_ Synonyms

  • Benign prostate hyperplasia
  • BPH
  • Prostatic hypertrophy

_ 80% of men have evidence of BPH by age 80 yr.

_ 10% to 30% of men with BPH have occult prostate cancer.

CAUSE

_ Multifactorial; a functioning testicle is necessary for development of BPH (as evidenced by the absence in males who were castrated before puberty).

CLINICAL

_ Digital rectal examination (DRE) reveals enlargement of the prostate.

_ Focal enlargement may be indicative of malignancy.

_ There is poor correlation between size of prostate and symptoms (BPH may be asymptomatic if it does not encroach on the urethral lumen).

_ Most patients with BPH report difficulty in initiating urination (hesitancy), decrease in caliber and force of stream, incomplete emptying of bladder often resulting in double voiding (need to urinate again a few minutes after voiding), postvoid “dribbling,” and nocturia.

LABORATORY TESTS

_ Prostate-specific antigen (PSA)

_ Urinalysis, urine culture, and sensitivity to rule out infection (if suspected).

_ Blood urea nitrogen and creatinine to rule out postrenal insufficiency.

IMAGING STUDIES

_ Transrectal ultrasound

_ Uroflowmetry

_ Urethral cystoscopy

MANAGEMENT

_ Asymptomatic patients with prostate enlargement caused by BPH generally do not require treatment.

_ TURP is the most commonly used surgical procedure for BPH.

_ Laser therapy for BPH is a less invasive alternative to TURP

_ Transurethral needle ablation with radiofrequency to remove periurethral prostate tissue is being increasingly used in patients with prostate volume >60 mL and moderate symptoms.

_ Balloon dilation of the prostatic urethra is less effective than surgery for relieving symptoms but is associated with fewer complications.

Balanitis

Inflammation of the glans penis is termed balanitis. Inflammation of the preputial skin is referred to as balanoposthitis. Clinically, these conditions usually coexist, with the surface of the glans and prepuce both swollen, hyperemic, tender, and itchy. A yellow exudate and superficial ulcers or denudation of the glans surface are characteristic of balanoposthitis. In chronic balanitis, the glans epithelium becomes thickened and assumes a whitish appearance (leukoplakia).

CAUSES

  • Causes include infectious agents, skin disorders, or miscellaneous
  • Infectious diseases: Candida species (40%), Neisseria gonorrhoeae, HPV, herpes simplex, Gardnerella vaginalis, Treponema pallidum (syphilis), HIV, Trichomonas, Staphylococcus aureus, anaerobic bacteria.
  • Skin disorders: circinate balanitis of Reiter’s syndrome, lichen sclerosis
  • Miscellaneous: poor hygiene, causing erosion of tissue with erythema and promoting growth of Candida albicans (Fig. E1B-5), trauma (zippers, urinary catheters), allergic reactions to condoms or medications.

SIGNS & SYMPTOMS

  • Itching and tenderness
  • Pain, dysuria, and local edema and erythema
  • Rarely, ulceration and lymph node enlargement
  • Severe ulcerations leading to superimposed bacterial infections
  • Inability to void: unusual, but a more distressing and serious complication

LABORATORY TESTS

  • VDRL, HIV, NAATs for chlamydia and gonorrhea
  • FBS, HBA1C to rule out diabetes
  • Wet mount for Trichomonas
  • KOH prep for yeast

MANAGEMENT

NONPHARMACOLOGIC THERAPY

  • Maintenance of meticulous hygiene
  • Retraction and bathing of prepuce several times a day
  • Warm sitz baths to ease edema and erythema
  • Consideration of circumcision, especially when symptoms are severe or recurrent
  • With Foley catheters, strict catheter care strongly advised

PHARMACOLOGIC THERAPY

  • Metronidazole 2 g PO as a single dose or fluconazole 150 mg PO × 1 or itraconazole 200 mg PO bid × 1 day
  • Clotrimazole 1% cream applied topically twice daily to affected areas
  • Bacitracin or Neosporin ointment applied topically 4 times daily
  • With more severe bacterial superinfection: cephalexin 500 mg PO qid
  • Topical corticosteroids added 4 times daily if dermatitis severe
  • Patients with suspected urinary tract infections: trimethoprim-sulfa DS twice daily or ciprofloxacin 500 mg PO bid after obtaining appropriate cultures