Diseases of the penis, scrotum and epididymis

1. Diseases of the Penis

A) Malformations

• Aphallia — absence of penis; failure of embryologic development of genital tubercle.
• Diphallia — duplication of penis.
• Hypospadias — urethra opens on ventral surface (near glans, or on shaft / scrotum); failure of urethral fold fusion.
• Epispadias — urethra opens on dorsal surface.
• Both associated with ↑ UTIs.

B) Inflammatory Lesions

• Balanitis — inflammation of glans penis (poor hygiene).
• Posthitis — inflammation of prepuce (foreskin).
• Balanoposthitis — inflammation of both glans + foreskin.
  • Result of poor hygiene in uncircumcised males → smegma (desquamated cells + sweat + debris).
  • Causes: C. albicans, anaerobes, pyogenic bacteria.
  • Penis: red, swollen, tender with purulent discharge.

Phimosis

• Foreskin cannot be retracted over glans.
• Congenital or acquired (scarring from balanoposthitis).

Paraphimosis

• In uncircumcised patients; foreskin retracted → cannot be reduced → trapped between coronal sulcus + glans corona.
• → Compromised circulation, pain, swelling, congestion.
• Prevention: circumcision.

Peyronie disease

• Penile fibromatosis.
• Fibrous thickening of dermis + fascia between corpora cavernosa + tunica albuginea.
• → Abnormal curvature toward lesion side during erection.
• Restricts erection/intercourse.
• Associations: β-blockers, thiazides, HTN, diabetes.

Priapism

• Prolonged penile erection without sexual stimuli > 4 hr.
• Causes:
  • Vascular: sickle cell disease, leukemia.
  • Neurological: spinal cord lesions.
  • Medications: ED treatments, antidepressants, blood thinners.
• Urological emergency → fibrosis + impotence if untreated.

C) Neoplasms

Benign

• Condyloma acuminatum (genital wart):
  • HPV-related lesion; anogenital area.
  • Sites: glans, foreskin, coronal sulcus, inner surface of foreskin.
  • HPV 6 + 11 (low-risk).

Penile intraepithelial neoplasia

• Bowen disease = squamous cell carcinoma in situ.
  • Older uncircumcised males.
  • Gross: solitary plaque-like lesion on shaft.
  • Histology: malignant cells in epidermis without stromal invasion.
  • Can progress to invasive SCC.

Malignant

• Invasive squamous cell carcinoma of penis:
  • 45–60 yr.
  • Gross: gray, crusted papular lesion on glans.
  • Histology: typical keratinizing SCC.
  • Infiltrates underlying CT → indurated ulcerated lesion with irregular margins.
  • Slow, locally infiltrative.
  • Metastasis to inguinal LN; distant mets uncommon.
  • Cure: partial / total amputation.
• Verrucous carcinoma: papillary variant of SCC; low malignant potential.
• Risk factors: HPV (16, 18), lack of circumcision, smoking, phimosis.

2. Diseases of the Scrotum

A) Inflammatory lesions

• Scabies, fungal infections, syphilis, systemic dermatoses (psoriasis).

Fournier’s gangrene

• Life-threatening necrotizing fasciitis of genitalia + perineum.
• Risk: trauma, burns, anorectal disease, diabetes, leukemia.
• Surgical emergency.

B) Swelling of scrotum (independent of testis)

Condition	Content
Hydrocele	Serous fluid in tunica vaginalis; #1 cause of scrotal enlargement; idiopathic or reactive
Hematocele	Blood in tunica vaginalis (trauma)
Chylocele	Lymphatic fluid in tunica vaginalis
Pyocele	Pus in tunica vaginalis
Elephantiasis	Extreme scrotal enlargement from *lymphatic obstruction by Wuchereria bancrofti • (filariasis)

C) Neoplasms

• Squamous cell carcinoma (most common); well-differentiated, slow-growing; mets to inguinal LN.
• Malignant mesothelioma — tunica vaginalis.

3. Diseases of the Funiculus Spermaticus (Spermatic Cord)

A) Malformations

• Congenital agenesis of spermatic cord / atresia of ductus deferens → sterility.

B) Inflammation

• Vasitis / deferentitis — inflammation of ductus deferens.
• Funiculitis — inflammation of spermatic cord.
• Usually progression from testis / epididymis inflammation.

C) Vascular Disturbances

Spermatic cord torsion

• Sudden twisting of cord → testicles rotate → cut off own blood supply by strangulation of testicular veins.
• Neonatal torsion — shortly after birth; no congenital defect.
• Adult torsion — adolescence; bilateral congenital anomaly = “bell-clapper” deformity.
• May result in hemorrhagic infarction.
• Tx: orchiopexy (surgical emergency).

Varicocele

• Dilated, tortuous veins of pampiniform plexus of spermatic cord.
• Causes: venous obstruction (portal HTN, neoplasm), valve insufficiency.
• More common on left (left testicular vein drains into left renal vein → nutcracker effect).
• Sx: “bag of worms” scrotal mass, infertility.

D) Neoplasm-like lesion

• Spermatocele — dilation of efferent ductules / rete testis / head of epididymis.
  • Painless cystic bulging; all ages (mostly 20–50 yr).
  • Usually idiopathic.
• Neoplasms: lipoma, embryonal rhabdomyosarcoma (rare).

💡 High-yield: Hypospadias (ventral, failed urethral fold fusion) vs epispadias (dorsal); both ↑ UTI. Balanoposthitis = poor hygiene + smegma in uncircumcised. Phimosis (can’t retract) vs paraphimosis (can’t reduce → vascular emergency). Peyronie disease = penile fibromatosis → curvature. Priapism > 4 hr = emergency (sickle cell, leukemia, ED meds). Condyloma acuminatum = HPV 6/11. Bowen disease = SCC in situ → invasive SCC (HPV 16/18, uncircumcised, mets to inguinal LN). Fournier’s gangrene = necrotizing fasciitis (diabetes). Hydrocele = #1 scrotal enlargement. Spermatic cord torsion = bell-clapper deformity → hemorrhagic infarct (orchiopexy emergency). Varicocele = left side, “bag of worms”, ↑ infertility. Wuchereria bancrofti = scrotal elephantiasis.