1. Testicular Disorders and
Erectile Dysfunction
Patrick Carter MPAS, PA-C
Clinical Medicine I
March 4, 2011

2. Objectives
 For each of the following diseases describe the
etiology, epidemiology, pathophysiology, risk
factors, signs and symptoms, diagnostic work-up, and
treatment:
 Testicular torsion
 Hypogonadism
 Hypospadias
 Epispadias
 Cryptorchidism
 Hydroceles
 Varicoceles
 Erectile dysfunction

3. Testicular Torsion

4. Testicular Torsion
 General considerations
 Ischemic Urologic Emergency
 Typical sudden onset of pain
 May have intermittent
torsion & pain
 Color flow Doppler

5. Testicular Torsion
 Epidemiology
 Bimodal Peak
 Neonatal Period
 Age 12-18 years
 Left side more common
 Usually preceding physical
exertion or trauma but may be
spontaneous

6. Testicular Torsion
 Signs and symptoms
 Sudden, severe pain
 Swollen & Tender testis
 Testes in affected side lies
higher in scrotum &
Transverse position
 Absent cremasteric reflex
 Nausea & vomiting
 NO FEVER

7. Testicular Torsion

8. Pediatric Testicular Torsion

9. Testicular Torsion
 Treatment
 Immediate urologic consultation
 Prepare patient for the OR
 Doppler ultrasound if it will not delay surgery
 Detorsion may be attempted if the patient is seen
within a few hours of onset
 ―Open book‖ method
 Pain relief should be immediate
 Do not delay operative intervention, since testicular
infarction will occur within 6 to 12 h after torsion

10. Testicular Torsion
 Prognosis
 Less than 6 hours – salvage rate is excellent
 Beyond 6 hours – salvage rate becomes worse
 After 48 hours – salvage rate is zero

11. Testicular Torsion
 Clinical Pearls
 Patients may report similar, less severe episodes
that spontaneously resolved in the recent past
 Half of all torsions occur during sleep
 Abdominal or inguinal pain is sometimes present
without pain to the scrotum

12. Hypogonadism

14. Hypogonadism
 Etiology
 Insufficient testosterone secretion by testes
(MOST COMMON)
 Decreased gonadotropin secretion by pituitary
 EtOH, Cushing’s, chronic illnesses
 Clinical features
 Decreased libido, ED, fatigue, depression

15. Hypogonadism
 Signs
 Diminished sexual hair growth
 Decreased testicular mass
 Loss of muscle mass
 Diagnostic studies
 Morning serum testosterone level
 LH and FSH
 LH and FSH is high in patients with testicular
dysfunction and low in patients with pituitary
disorders

16. Hypogonadism
 Management
 Evaluation for prostate cancer
 Testosterone replacement
 Oral
 IM
 Transdermal

17. Hypospadias

18. Hypospadias
Classifications
A. Glandular (opening proximal to
glans)
B. Coronal (opening at coronal sulcus)
C. Penile Shaft
D. Penoscrotal
F. Perineal

19. Hypospadias
 Testing
 Patients with ―Penoscrotal‖ and ―Perineal‖
openings should be considered to have potential
intersex problems and should be karotyping to
establish genetic sex
 Treatment
 Surgical repair preferred before school age
 Over 150 procedures

20. Epispadias

21. Epispadias
Urethra is displaced
dorsally

22. Epispadias
 Classification
 Glandular – opens on dorsal aspect of glans
 Penile – borad and gaping on dorsum of penile shaft
 Penopubic – junction with groove extending through
glans
 Females will have bifid clitoris & separation
of labia. Most are incontinent
 Penile & Penopubic will usually have urinary
incontinence
 Surgery is required to correct incontinence

23. Cryptorchidism

24. CRYPTORCHIDISM
DEFINITION:
A condition in which one or both testes fail to descend
into the scrotum.
FACTS & FIGURES
• Most common congenital condition involving the
testes
• 3% of all full-term males at birth
• 20% of all premature males at birth
• Less than 1% of males by 3 months of age

26. CRYPTORCHIDISM
CLINICAL:
No testis detected with palpation of scrotum.
CONCERNS:
• Impaired fertility
• Risk of testicular cancer 35-50% higher than in
men who have descended testes
DX:
• CT scan
• Ultrasound

27. CRYPTORCHIDISM
TREATMENT:
Administration of HCG (given IM biweekly),
which may initiate descent.
Referral to urologist by 6 months, surgery by age
1 or 2 at the latest
Orchiopexy DOES NOT reduce risk of cancer, but
does facilitate examination and early detection

28. CRYPTORCHIDISM

29. Hydrocele

30. HYDROCELE
DEFINITION: A collection
of fluid within the tunica
vaginalis
Most common cause of
Scrotal Swelling!
•Common in infancy
•Associated with 10% of
testicular tumors

31. HYDROCELE
CLINICAL:
•Painless swelling
•Readily transilluminated
•Feels like “weight in testes”
CAN OCCUR WITH:
•Epididymitis
•Trauma
•Hernia
•Tumor

32. HYDROCELE
REMEMBER:
• No scrotal erythema
• No pain
• Transilluminates
• Any Age
• No Infertility
• No Dysuria
• No Systemic Symptoms

33. Varicocele

34. VARICOCELE
DEFINITION:
Dilation of veins within
the Spermatic cord
(Pampiniform plexus)

35. VARICOCELE
CLINICAL:
Soft, irregular painless
mass posterior and
anterior to testes.
Swelling can collapse
with lying down, can
refill with standing
upright.

36. VARICOCELE
CLINICAL:
May feel like a “weight in
the testes” or “bag of
worms”
FACTS & FIGURES:
> 15 years old
More common on left side
(95%)

37. VARICOCELE
REMEMBER:
• No scrotal erythema
• No pain (usually)
• DOES NOT transilluminate
• Most common after puberty
• No dysuria
• No systemic symptoms
• In older men = think
bladder/renal tumor
• CAN CAUSE INFERTILITY

38. Erectile Dysfunction

39. Erectile Dysfunction
 Essentials of Diagnosis
 Most causes are organic and not
psychogenic
 Increasing incidence with older age
 Variety of treatment available, with
multiple oral agents

40. Erectile Dysfunction
 General Considerations
 Inability to maintain an erect penis with sufficient
rigidity to allow sexual intercourse
 Loss of erections occurs from arterial, venous,
neurogenic, or psychogenic causes
 Associated with concurrent medical problems
(hypertension, diabetes mellitus), or radical pelvic
or retroperitoneal surgery
 Look for concomitant cardiovascular disease

41. Erectile Dysfunction
 General Considerations
 Antihypertensive medications
 Centrally acting sympatholytics (methyldopa,
clonidine, reserpine) can cause loss of erection
 Beta Blockers & Thiazide Diuretics are common
 Androgen deficiency causes both loss of
libido and erections and lack of emission by
decreasing prostatic and seminal vesicle
secretions

42. Erectile Dysfunction
 General Considerations
 Psychogenic causes
 Anxiety related
 Due to a new partner
 Unreasonable expectations about
performance
 Emotional disorders

43. Erectile Dysfunction
 Causes of Organic ED
 Vascular
 Endocrine
 Neurologic
 Medications
 Alcoholism
 Postsurgical changes

44. Erectile Dysfunction
 Clinical findings
 History
 Erectile dysfunction should be distinguished
from problems with ejaculation, libido, and
orgasm
 Degree of the dysfunction—chronic, occasional,
or situational
 Timing of dysfunction
 Determine whether the patient ever has any
normal erections, such as in early morning or
during sleep

45. Erectile Dysfunction
 Clinical findings
 History
 Inquire about hyperlipidemia, hypertension,
neurologic disease, diabetes mellitus, renal
failure, adrenal and thyroid disorders, and
depression
 Trauma to the pelvis, pelvic surgery, or peripheral
vascular surgery
 Use of drugs, alcohol, tobacco, and recreational
drugs

46. Erectile Dysfunction
 Clinical findings
 Physical examination
 Secondary sexual characteristics
 Neurologic motor and sensory examination
 Peripheral vascular examination
 Examination of genitalia, testicles, and
prostate
 Evaluate for penile scarring, plaque formation
(Peyronie's disease)

47. Peyronie’s Disease
 Dense fibrous plaque that forms on the tunica
albuginea – causing a curvature of the erect
penis
 Etiology of the plaque is unknown
 May be scar tissue resulting from microscopic
tears of the tunica albuginea during intercourse
 Flaccid penis is usually normal on exam and
the curvature is only noted in the erect penis

48. Peyronie’s Disease

49. Peyronie's Disease

50. Erectile Dysfunction
 Laboratory Tests
 Complete blood count
 Urinalysis
 Lipid profile
 Serum glucose, testosterone, LH/FSH, and
prolactin
 Serum testosterone and gonadotropin levels may
help localize the site of disease (CNS vs Testes)

51. Erectile Dysfunction
 Imaging studies
 Cavernosometry (measurement of
flow required to maintain erection)
 Cavernosography (contrast study of
the penis to determine site and extent
of venous leak)
 Nocturnal penile tumescence testing

52. Erectile Dysfunction
 Medications
 Hormone replacement for androgen deficiency
 Alprostadil urethral suppository pellets
 PDE-5 inhibitors taken 1 hour prior to anticipated
sexual activity
 Viagra (sildenafil) 50 mg, Levitra (vardenafil) 5 mg,
or Cialis (tadalafil) 10 mg
 Contraindicated in patients receiving nitrates
 Some patients who do not respond to one PDE-5
inhibitor will respond to another

53. Erectile Dysfunction
 Treatment Procedures
 Direct injection of vasoactive substances
into the penis
 Prostaglandin E, papaverine, or a combination

54. Erectile Dysfunction
 Surgery
 Penile prosthesis: rigid, malleable, hinged,
or inflatable
 Surgery for disorders of the arterial system
 Vascular reconstruction
 Endarterectomy and balloon dilation for
proximal arterial occlusion
 Arterial bypass procedures for distal occlusion

55. Erectile Dysfunction
 Therapeutic
Procedures
 Vacuum
constriction device
 Behaviorally
oriented sex
therapy for men
with no organic
dysfunction

56. Questions?