Male Genitalia, Hernias, and Rectal Exam

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Chapter 16 Male Genitalia, Hernias, and Rectal Exam

A. Male Genitalia

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.

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.

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.

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

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