Diagnosis of Male sexual conditions
Male sexual conditions Diagnosis: Book Excerpts
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IMPOTENCE:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there a history of alcohol or drug ingestion? A host of antihypertensive drugs, including the beta-blockers, may cause impotence. In addition, tricyclic drugs, nicotine, and alcohol intoxication may cause impotence.
- Is there loss of secondary sex characteristics? These findings suggest Fröhlich's syndrome,
Klinefelter's syndrome, and other congenital disorders.
- Are there abnormalities on urologic examination? Various conditions such as Peyronie's disease, atrophied testes, prostatitis, and Leriche's syndrome may be found on urologic examination.
- Are there abnormalities on the neurologic examination? Neurologic examination may reveal diabetic neuropathy, spinal cord tumor, multiple sclerosis, and other neurologic disorders.
DIAGNOSTIC WORKUP
A thorough psychiatric and sexual history is necessary before undertaking expensive laboratory tests. It is wise to interview the spouse or sexual partner also because the symptom may be exaggerated by the patient. Do not hesitate to order a drug screen. Routine tests include a CBC and differential count, a urinalysis, a urine culture and colony count, a chemistry panel, VDRL test, thyroid profile, serum testosterone, and gonadotrophin assay. A referral to a urologist is probably wise at this point. He will work up the patient further with a nocturnal tumescent study, Doppler ultrasonography, and penile blood pressure studies. In addition, he may want to do a cystoscopy. It may be wise to perform a postage stamp test before referral for a formal tumescence study.
Nerve conduction velocity studies and EMGs may be needed to rule out diabetic neuropathy. MRI of the spine, cystometric studies, and SSEP studies will help to rule out multiple sclerosis and other spinal cord lesions. A sacral reflex latency time may be very helpful in diagnosing sacral nerve injury. A spinal tap may help rule out central nervous system lues. Angiography may be needed to exclude a Leriche's syndrome.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PRIAPISM:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there paraplegia or other neurologic signs? Neurologic findings would suggest spinal cord trauma, tumor or inflammation, multiple sclerosis, and several other disorders.
- Is there splenomegaly or lymphadenopathy? These findings would suggest leukemia and other blood dyscrasias.
- Is there African ancestry? This finding would suggest sickle cell anemia.
- Are there abnormalities on urologic examination? Urethral tumors, traumatic hematomas of the penis, thrombosis of the corpora cavernosa, and prostatism may cause priapism.
DIAGNOSTIC WORKUP
The basic workup includes a CBC, sedimentation rate, urinalysis, urine culture and colony count, sickle cell preparation, coagulation profile, chemistry panel, and serum protein electrophoresis. A urologist should also be consulted.
If there are neurologic signs, MRI of the brain or appropriate level of the spinal cord should probably be done. However, a neurologist should be consulted before ordering these expensive tests. A spinal tap will be helpful in diagnosing multiple sclerosis and central nervous system syphilis.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
SCROTAL SWELLING:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is it diffuse or focal? Diffuse scrotal swelling would suggest congestive heart failure, nephrosis, uremia, and cirrhosis, as well as focal disease such as filariasis or bilateral hydrocele. Focal scrotal swelling would suggest a hernia, hydrocele, torsion of the testicle, abscesses, epididymitis, orchitis, varicoceles, and testicular tumors.
- If it is diffuse, is there ascites or generalized edema? The presence of diffuse edema of the scrotum with ascites or generalized edema would suggest congestive heart failure, nephrosis, uremia, or cirrhosis.
- If it is focal, is it painful? The presence of painful scrotal swelling would suggest an incarcerated or strangulated inguinal hernia, torsion of the testicle, a hematoma, orchitis, epididymitis, furuncle, or periurethral abscess.
- Does it transilluminate? If the mass transilluminates, it is very likely a hydrocele of the testicle or a spermatocele.
- Is it reducible? If the mass is reducible, it is most likely an inguinal hernia or a varicocele.
DIAGNOSTIC WORKUP
Routine laboratory tests include a CBC, sedimentation rate, urinalysis, urine culture, and urethral smear. If prostatic disease is suspected, a PSA should be ordered. If intestinal obstruction is suspected, a flat plate of the abdomen and lateral decubiti should be ordered. A radionuclide testicular scan with technetium-99m is useful in differentiating between testicular torsion and epididymitis. Scrotal ultrasound may be done to evaluate any kind of testicular or scrotal mass. However, it is much less costly to refer the patient to a urologist.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Priapism:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Low-flow, or “ischemic”-type: Corpora cavernosa are rigid; corpora spongiosum and glands are spared; there is decreased venous outflow, sludging, and stasis; painful
–Intracorporeal injection for impotence (most common cause in adults): Papaverine, prostaglandin E1, phentolamine, phenoxybenzamine
–Sickle cell disease (most common cause in
children)
–Leukemia
–Penile infiltration with solid tumors
(bladder cancer, prostate cancer)
–Prescription drugs: Trazodone,
chlorpromazine, sildenafil
–Illicit drugs: Marijuana, crack cocaine
–Idiopathic
–Other (e.g., total parenteral nutrition,
dialysis, vasculitis)
-
High-flow: Caused by increased arterial blood flow due to arterial-cavernosal shunt; whole penis is rigid; not usually painful
–Groin or straddle injury
–Cocaine
-
Less common etiologies
–Post-spinal cord trauma or injury to the medulla (clinically similar to high-flow priapism)
–Polycythemia
–Thalassemia
–Fabry's disease
–May occur in clitoris as well as penis
Workup and Diagnosis
- History should focus on time of onset (usually hours to days), medications (e.g., antidepressants; antipsychotics; sildenafil), past medical history (e.g., sickle cell disease, anticoagulation therapy, diabetes mellitus, leukemia, genitourinary malignancies, schizophrenia, depression), prior erectile dysfunction for which treatment has been sought, and activity with onset of erection (e.g., following oral or injection treatment for impotence, with sexual activity, trauma, illicit drug use)
- Physical examination including abdomen, back, genitalia (palpate penis for areas of tenderness or induration), digital rectal examination and neurologic exam
–Penis: Is there pain? What segments of the penis are involved? Are there signs of trauma, injection or neoplasm?
–Testicles/scrotum: Are there masses or evidence of trauma?
–Prostate: Palpate for signs of neoplasm
-
Initial laboratory studies include CBC, urinalysis and urine screen for toxic substances
-
Consider also BUN/creatinine, electrolytes, peripheral smear, ESR, and PSA
-
Immediate urologic consultation is imperative to prevent continuing injury and long-term sequelae
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Source: In a Page: Signs and Symptoms, 2004
Scrotal Swelling:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
- Hydrocele
–Fluid surrounding the testicle
–Typically seen in infancy
–Results from remnant of testicular descent from the abdomen through the inguinal canal into the scrotum
–May be communicating or noncommunicating; communicating hydroceles have retained patency of the tract of descent, and noncommunicating hydroceles do not
–Communicating hydroceles may be reducible and are likely to fluctuate in size depending on the amount of fluid within the scrotal sac; crying or any increase in intra-abdominal pressure results in an increase in size
–Usually is noncommunicating; i.e., not reducible, and does not change in size with crying
–Testes may be difficult to palpate because surrounded by the hydrocele
- Hernia
–Protrusion of a loop of bowel into the scrotum
–Direct hernias represent a channel directly through the musculature of the pelvic floor; indirect hernias have proceeded through the inguinal canal
–Usually painless unless incarcerated
–Usually reducible and changes in size with changes in intra-abdominal pressure
–Testes usually palpable below the hernia
-
Varicocele
–A collection of dilated veins in the scrotum
–Usually painless, but patients may complain
of heaviness
-
Edema
–Generalized edema often is accompanied by scrotal edema
-
Tumor
–Presents as painless nodule on testes
–May be accompanied by sexual precocity or
gynecomastia secondary to hormone production by the tumor
-
Leukemia
–Patients may present with unilateral scrotal swelling (common site for relapse)
Workup and Diagnosis
-
History
–Onset, duration of symptoms
–Unilateral or bilateral
–Associated systemic symptoms
-
Physical exam
–General state of health, including growth parameters
and weight loss
–Unilateral or bilateral lesions
–Reducibility of scrotal mass or enlargement
–Palpation of testes: Tenseness, nodules
–Hydroceles can sometimes be transilluminated
–Patent defects can usually be palpated when there is a
hernia, particularly if the patient performs a Valsalva maneuver (“turn your head and cough”)
–Varicocele is usually left sided and feels like “a bag of worms”
-
Labs
–CBC and differential, LDH, ESR if malignancy is suspected
-
Radiology
–Ultrasound may be helpful confirming hernia, hydrocele, or varicocele
–PET scans are used to detect malignant metastasis or relapse
-
Studies
–A testicular nodule usually must be biopsied to rule out malignancy
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Source: In A Page: Pediatric Signs and Symptoms, 2007
IMPOTENCE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful examination of the external genitalia, the prostate, and secondary sex characteristics is essential. The laboratory workup may include a glucose tolerance test, blood testosterone and cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and a chromosomal analysis. A nocturnal penile tumescence study is performed to rule out organic causes. If the physical examination is normal, it may be wise to administer psychometric tests or to refer the patient to a psychiatrist before doing an extensive endocrine and neurologic workup. A sympathetic physician may be able to find the supratentorial cause and cure it with a few long discussions with the patient. A female physician may have more success in this area than a male.
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Source: Differential Diagnosis in Primary Care, 2007
PRIAPISM:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of priapism usually depends on the association of other symptoms and signs (e.g., boggy prostate), but a blood smear or bone marrow examination may be necessary to exclude leukemia. A careful history of the patient’s sexual activities to rule out too-frequent masturbation or sexual excesses may be indicated.
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Source: Differential Diagnosis in Primary Care, 2007
Impotence:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Priapism:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient’s condition permits, ask him when the priapism began. Is it continuous or intermittent? Has he had a prolonged erection before? If so, what did he do to relieve it? How long did he remain detumescent? Does he have pain or tenderness when he urinates? Has he noticed changes in sexual function?
Explore the patient’s medical history. If he reports sickle cell anemia, find out about factors that could precipitate a crisis, such as dehydration and infection. Ask if he has recently suffered genital trauma, and obtain a thorough drug history. Ask if he has had drugs injected or objects inserted into his penis.
Examine the patient’s penis, noting its color and temperature. Check for loss of sensation and signs of infection, such as redness or drainage. Finally, take his vital signs, particularly noting a fever.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Scrotal swelling:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting a fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient supine and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Genital lesions in the male:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin by asking the patient when he first noticed the lesion. Did it erupt after he began taking a new drug or after a trip out of the country? Has he had similar lesions before? If so, did he get medical treatment for them? Find out if he has been treating the lesion himself. If so, how? Does the lesion itch? If so, is the itching constant or does it bother him only at night? Note whether the lesion is painful. Ask for a description of any drainage from the lesions. Next, take a complete sexual history, noting the frequency of relations, number of sexual partners, and pattern of condom use.
Before you examine the patient, observe his clothing. Do his pants fit properly? Tight pants or underwear, especially those made of nonabsorbent fabrics, can promote the growth of bacteria and fungi. Examine the entire skin surface, noting the location, size, color, and pattern of the lesions. Do genital lesions resemble lesions on other parts of the body? Palpate for nodules, masses, and tenderness. Also, look for bleeding, edema, or signs of infection, such as purulent drainage or erythema. Finally, take the patient’s vital signs.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Introduction: Sexual Disorders:
Sexual history
(Professional Guide to Diseases (Eighth Edition))
Careful assessment helps identify the cause of a sexual problem as psychological or physical. A sexual history provides the basis for prevention, diagnosis, and treatment.
❑ Ensure privacy, as for physical assessment. Allow sufficient time so that the patient doesn’t feel rushed.
❑ Approach a sexual history objectively. Remember, sexual health is relative; avoid making assumptions or judgments about the patient’s sexual activities.
❑ After listening to the patient, determine his level of sexual understanding and phrase your questions in language that he can understand. Avoid technical terms.
❑ Begin with the least threatening questions. Usually, a menstrual or urologic history helps lead into a sexual history.
❑ Inquire about what the patient accepts as normal sexual behavior. Ask about sexual needs and priorities and whether the patient can discuss them with a sex partner.
❑ Assess risk behavior concerning selection of sex partners and specific sexual practices.
❑ Ask about possible homosexual activity, which can influence the risk and treatment of some STDs.
❑ Ask the female patient if she has adequate lubrication during intercourse and if she has ever experienced orgasm or pain with sexual contact. Ask the male patient if he has ever had difficulties with erection or ejaculation.
❑ Ask about current or past contraceptive practices.
❑ Try to use the history therapeutically by encouraging the patient to express anxiety. Such fears may be alleviated simply by providing factual information and answering questions.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Impotence:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination in a systematic way, moving from less sensitive to more sensitive matters. Begin with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What’s the age and health status of his sexual partner? Find out about past marriages, if any, and ask him why he thinks they ended. If you can do so discreetly, ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have type 2 diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient’s impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about intake of alcohol, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What’s its current status? Make your questions specific, but remember that many patients have difficulty discussing sexual problems, and many don’t understand the physiology involved.
The following sample questions may yield helpful data: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Ask the patient to rate the quality of a typical erection on a scale of 0 to 10, with 0 being completely flaccid and 10 being completely erect. Using the same scale, also ask him to rate his ability to ejaculate during sexual activity, with 0 being never and 10 being always.
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient’s sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient’s vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Priapism:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient’s condition permits, ask him when the priapism began. Is it continuous or intermittent? Has he had a prolonged erection before? If so, what did he do to relieve it? How long did he remain detumescent? Does he have pain or tenderness when he urinates? Has he noticed any changes in sexual function?
Explore the patient’s medical history. If he reports sickle cell anemia, find out about any factors that could precipitate a crisis, such as dehydration and infection.Ask if he has recently suffered genital trauma, and obtain a thorough drug history. Ask if he has had any drugs injected or objects inserted into his penis.
Examine the patient’s penis, noting its color and temperature. Check for loss of sensation and signs of infection, such as redness or drainage. Finally, take his vital signs, particularly noting fever.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Scrotal swelling:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient isn’t in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or a lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Genital lesions in the male:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient when he first noticed the lesion. Did it erupt after he began taking a new drug or after a trip out of the country? Has he had similar lesions before? If so, did he get medical treatment for them? Find out if he has been treating the lesion himself. If so, how? Does the lesion itch? If so, is the itching constant or does it bother him only at night? Note whether the lesion is painful. Ask for a description of any drainage from the lesion. Next, take a complete sexual history, noting the frequency of relations, the number of sexual partners, and the pattern of condom use.
Before you examine the patient, observe his clothing. Do his pants fit properly? Tight pants or underwear, especially those made of nonabsorbent fabrics, can promote the growth of bacteria and fungi. Examine the entire skin surface, noting the location, size, color, and pattern of the lesions. Do genital lesions resemble lesions on other parts of the body? Palpate for nodules, masses, and tenderness. Also, look for bleeding, edema, or signs of infection, such as purulent drainage or erythema. Finally, take the patient’s vital signs.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Impotence:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Basic history. Although written questionnaires may elicit sexual dysfunction, most patients prefer to communicate such issues in the privacy of verbal communication with their primary care provider. For the initial inquiry, simply ask: “Are you sexually active?” For sexual dysfunction evaluation, gender orientation is not relevant to diagnosis or therapy, so that whether the patient is homosexual, heterosexual, or bisexual has no distinct bearing on the diagnostic or therapeutic direction. For persons who are not sexually active, next determine whether this is a matter of choice or an obstacle that prevents sexual activity (e.g., lack of partner, ED, physical disorder).
For persons who are sexually active, a series of follow-up questions will uncover most relevant psychosexual pathology. Begin with: “How would you rate your sex life on a scale of 1 to 10?” If the response is 10, sexual dysfunction is decidedly unlikely. However, most individuals respond, “Oh, about a 7.” Follow with, “What would have to be different to change your sex life from a 7 to a 10?” This forced-choice inquiry often produces responses which directly indicate problematic underlying issues: “Well, if I could just get a good erection.” “If my erection could last more than 30 seconds.” “If my partner didn’t always pick a fight with me and then expect to have sex.”
For impotent men, their response is usually direct and simple, indicating an inability to get or maintain an erection. Follow-up questions should determine the duration and nature of onset. Absence of morning erections should be sought, as this typifies organic impotence. Men who are much more likely to have psychogenic ED are those who report sudden, complete loss of sexual function, or “circumstantial” impotence, for example, (a) good function with one partner, but not another; (b) good erections with masturbation but not with interactive sex; (c) good morning erections, but not at times of interactive sex; or (d) overt anxiety or relationship conflict. Because organic ED generally leads to psychological consequences, many patients suffer a combination of psychogenic and organic impotence.
B. Inquiry about libido is a crucial diagnostic point for testosterone deficiency. Testosterone is necessary for libido, but not erections. Men who present with good libido have only a remote possibility of having testosterone deficiency.
C. A medication history should be taken for all men complaining of impotence, recalling that most medication-induced impotence is evident by the temporal relationship between onset of impotence and medication initiation. On the other hand, agents such as thiazides can produce impotence after months of use. Similarly, some antidepressants can produce sexual dysfunction either early or after weeks of therapy. The relationship of medications to impotence can often be clarified by a drug holiday.
Physical examination
Although physical examination is usually not enlightening, general agreement is seen that the genitals should be examined for evidence of overt testicular atrophy, and the penis for Peyronie’s disease. In the latter, inflammatory plaques in the corpora cavernosa produce an area of limited expansile capacity, with subsequent penile deviation on erection which can prevent intromission. A rectal examination to document rectal sensation as well as tone can be complemented by the bulbocavernosus reflex. This reflex is elicited by briskly squeezing the glans penis in one hand while a single digit from the other is in the rectum. A normal examination, indicating an intact reflex arc, is manifest as a rectal contraction in response to the glans squeeze. Prostate examination is pertinent at this point, in the event testosterone therapy is required.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Priapism:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Specific information. Is there a history of penile or perineal trauma? How much pain does the patient experience? Does the patient take any medications that may predispose to priapism (2)? Is there any history of malignancy? Is there any history of sickle cell disease? How long has the priapism been present?
1. A history of penile or perineal trauma almost always precedes arterial priapism and is the most important historical information distinguishing between the two types of priapism.
2. Moderate to severe persistent pain, which is characteristic of veno-occlusive priapism, results from tissue ischemia. Pain is more frequently mild or transient with arterial priapism.
3. Studies have suggested that up to 41% of patients who present with priapism (veno-occlusive) have taken some type of psychotropic medication, usually neuroleptics or trazodone (2). Prazosin use has also been associated with priapism.
4. Priapism has been reported commonly (4% to 40%) after intracavernous injection with prostaglandin for the treatment of erectile dysfunction (ED) (Chapter 10.3). Subsequently, therapeutically induced prolonged erection has become the primary cause of priapism (3).
5. Any history of malignancy, especially genitourinary or pelvic carcinoma in patients who present with priapism, should result in a workup for penile metastasis. In a recent review, 20% to 53% of patients with penile metastases presented initially with priapism (4).
6. The most common cause of priapism in children is sickle cell disease.
B. Red flag. Priapism lasting longer than 4 hours, regardless of cause, is a true urologic emergency and immediate evaluation and treatment are necessary (3).
Physical examination
should include a thorough genitourinary examination to look for trauma or malignancy. The corpora cavernosa, but not the corpora spongiosum, is involved with priapism and, therefore, the glans will remain flaccid while the shaft is erect and tender. Also palpate for inguinal lymphadenopathy [genitourinary (GU) malignancy], and examine the abdomen (abdominal or GU malignancy and trauma).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Scrotal Pain/Swelling:
Differential Overview
(Field Guide to Bedside Diagnosis)
Pain Predominant
❑ Epididymitis
❑ Testicular torsion
❑ Prostatitis
❑ Referred pain
❑ Trauma
❑ Orchitis
❑ Torsion of the appendix testis
❑ Inguinal hernia/incarcerated
Swelling Predominant
❑ Varicocele
❑ Inguinal hernia
❑ Hydrocele
❑ Spermatocele
❑ Sebaceous cyst
❑ Testicular cancer
Diagnostic Approach
Testicular torsion, a medical emergency, should be the primary consideration in a patient with an acutely painful scrotum; however, epididymitis is a more common cause than torsion by 10:1. Reduction in pain by manual elevation of the testicle (Phren sign) helps to distinguish epididymitis from testicular torsion. A cremasteric reflex is absent in testicular torsion but present in torsion of the appendix testis.
Testicular cancer must be definitively ruled out whenever a firm induration or mass is found to be contiguous with the testicle.
Referred pain can be differentiated from scrotal pathology by a normal testicular examination.
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Source: Field Guide to Bedside Diagnosis, 2007
Scrotal swelling:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
If the patient isn’t in distress, obtain his medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is he sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does the patient have a history of prostate surgery or prolonged catheterization? Is the swelling affected by changing his body position or level of activity?
Physical examination
Take the patient’s vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in supine and standing positions. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles’position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can’t be transilluminated.)
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Scrotal swelling:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient isn’t in distress, proceed with the medical history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
CULTURAL CUE:Patients of certain cultural backgrounds, such as Mexican-Americans, may need to establish a trusting relationship before discussing matters of a personal nature.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Genital lesions in the male:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by asking the patient when he first noticed the lesion. Did it erupt after he began taking a new drug or after a trip out of the country? Has he had similar lesions before? If so, did he get medical treatment for them? Find out if he has been treating the lesion himself. If so, how? Does the lesion itch? If so, is the itching constant or does it bother him only at night? Note whether the lesion is painful. Ask for a description of any drainage from the lesions. Next, take a complete sexual history, noting the frequency of relations, number of sexual partners, and pattern of condom use.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Impotence:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of impotence or of a condition that may be causing it, let him describe his problem without interruption. Then begin your examination with a psychosocial history. Is the patient married, single, or widowed? How long has he been married or had a sexual relationship? What's the age and health status of his sexual partner? Is he feeling stress or pressure from his partner to conceive a child? Find out about past marriages, if any, and ask him about his sexual experiences with former spouses. Ask about sexual activity outside marriage or his primary sexual relationship. Also ask about his job history, his typical daily activities, and his living situation. How well does he get along with others in his household?
Focus your medical history on the causes of erectile dysfunction. Does the patient have diabetes mellitus, hypertension, or heart disease? If so, ask about its onset and treatment. Also ask about neurologic diseases such as multiple sclerosis. Obtain a surgical history, emphasizing neurologic, vascular, and urologic surgery. If trauma may be causing the patient's impotence, find out the date of the injury as well as its severity, associated effects, and treatment. Ask about alcohol intake, drug use or abuse, smoking, diet, and exercise. Obtain a urologic history, including voiding problems and past injury.
Next, ask the patient when his impotence began. How did it progress? What's its current status? Make your questions specific, but remember that he may have difficulty discussing sexual problems or may not understand the physiology involved.
Other questions that can help yield helpful data include: When was the first time you remember not being able to initiate or maintain an erection? How often do you wake in the morning or at night with an erection? Do you have wet dreams? Has your sexual drive changed? How often do you try to have intercourse with your partner? How often would you like to? Can you ejaculate with or without an erection? Do you experience orgasm with ejaculation?
Next, perform a brief physical examination. Inspect and palpate the genitalia and prostate for structural abnormalities. Assess the patient's sensory function, concentrating on the perineal area. Next, test motor strength and deep tendon reflexes in all extremities, and note other neurologic deficits. Take the patient's vital signs and palpate his pulses for quality. Note any signs of peripheral vascular disease, such as cyanosis and cool extremities. Auscultate for abdominal aortic, femoral, carotid, or iliac bruits, and palpate for thyroid gland enlargement.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Priapism:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when the priapism began. Is it continuous or intermittent? Has he had a prolonged erection before? If so, what did he do to relieve it? How long did he remain detumescent? Does he have pain or tenderness when he urinates? Has he noticed changes in sexual function?
Explore the patient's medical history. If he reports sickle cell anemia, find out about factors that could precipitate a crisis, such as dehydration and infection. Ask if he has recently suffered genital trauma, and obtain a thorough drug history. Ask if he has had drugs injected or objects inserted into his penis. Obtain a complete drug history. Note use of medications for erectile dysfunction (ED) (phosphodiesterase inhibitors).
Examine the patient's penis, noting its color and temperature. Check for loss of sensation and signs of infection, such as redness or drainage. Finally, take his vital signs, particularly noting a fever.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Scrotal swelling:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient isn't in distress, proceed with the history. Ask about injury to the scrotum, urethral discharge, cloudy urine, increased urinary frequency, and dysuria. Is the patient sexually active? When was his last sexual contact? Does he have a history of sexually transmitted disease? Find out about recent illnesses, particularly mumps. Does he have a history of prostate surgery or prolonged catheterization? Does changing his body position or level of activity affect the swelling?
Take the patient's vital signs, especially noting fever, and palpate his abdomen for tenderness. Then examine the entire genital area. Assess the scrotum with the patient in a supine position and standing. Note its size and color. Is the swelling unilateral or bilateral? Do you see signs of trauma or bruising? Are there rashes or lesions present? Gently palpate the scrotum for a cyst or lump. Note especially tenderness or increased firmness. Check the testicles'position in the scrotum. Finally, transilluminate the scrotum to distinguish a fluid-filled cyst from a solid mass. (A solid mass can't be transilluminated.)
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Genital lesions, male:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by asking the patient when he first noticed the lesion. Did it erupt after he began taking a new drug or after a trip out of the country? Has he had similar lesions before? If so, did he get medical treatment for them? Find out if he has been treating the lesion himself. If so, how? Does the lesion itch? If so, is the itching constant or does it bother him only at night? Note whether the lesion is painful. Ask for a description of any drainage from the lesion. Next, take a complete sexual history, noting the frequency of relations, number of sexual partners, and pattern of condom use.
Before you examine the patient, observe his clothing. Do his pants fit properly? Tight pants or underwear, especially those made of nonabsorbent fabrics, can promote the growth of bacteria and fungi. Examine the entire skin surface, noting the location, size, color, and pattern of the lesions. Do genital lesions resemble lesions on other parts of the body? Palpate for nodules, masses, and tenderness. Also, look for bleeding, edema, or signs of infection, such as purulent drainage or erythema. Finally, take the patient's vital signs.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
IMPOTENCE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
A careful examination of the external genitalia, the prostate, and
secondary sex characteristics is essential. The laboratory workup may
include a glucose tolerance test, blood testosterone, free testosterone and
cortisol levels, thyroid function studies, a spinal tap, a skull x-ray, and
a chromosomal analysis. A nocturnal penile tumescence study is performed to
rule out organic causes. If the physical examination is normal, it may be
wise to administer psychometric tests or to refer the patient to a
psychiatrist before doing an extensive endocrine and neurologic workup. A
sympathetic physician may be able to find the supratentorial cause and cure
it with a few long discussions with the patient. A female physician may have
more success in this area than a male.
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Source: Differential Diagnosis in Primary Care, 2007
PRIAPISM:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The diagnosis of priapism usually depends on the association of other
symptoms and signs (e.g., boggy prostate), but a blood smear or bone marrow
examination may be necessary to exclude leukemia. A careful history of the
patient’s sexual activities to rule out too-frequent masturbation or sexual
excesses may be indicated.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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