Материал: Oxford American Handbook of Urology ( PDFDrive )
182 CHAPTER 5 Infections and inflammatory conditions
Inflammatory and other disorders of the penis
See Table 5.6 for dermatologic descriptors. Most penile ulcers and vesicobullous lesions are associated with a sexually transmitted disease.
Premalignant lesions associated with penile cancer are discussed in Chapter 6.
Balanitis
This is a condition seen most commonly in uncircumcised men with poor hygiene. Balanitis is the inflammation of the glans penis. When the foreskin and prepuce are involved it is termed balanoposthitis. The most common complication of balanitis is phimosis.
Daily hygiene is most critical in treatment, with careful cleaning after retraction of the foreskin. Clotrimazole can be used in adults with probable candidal balanitis. Betamethasone 0.05% applied bid is useful, with some reports of success with topical 1% pimecrolimus cream.
Circumcision may sometimes be necessary.
Paraphimosis
This is a true urological emergency where in an uncircumcised male the foreskin is pulled behind the glans and cannot be brought back to the normal position. If not immediately reduced, swelling ensues and the tight band of tissue can compromise lymphatic and vascular flow to the distal, resulting in pain, edema, and possible tissue loss.
Manual reduction is preferred using ice packs, elastic compression, and topical anesthetic such as 2% lidocaine gel. Operative dorsal slit may be required in refractory cases.
Phimosis
Phimosis is when the foreskin cannot be retracted behind the glans. A physiological phimosis is present at birth due to adhesions between the foreskin and glans. As the penis develops, epithelial debris (smegma) accumulates under the foreskin, causing gradual separation.
Ninety percent of foreskins are retractile at age 3; few persist into adulthood (<1% phimosis at age 17). Recurrent balanitis in uncircumcised males can cause new phimosis.
Treatment
Older children with phimosis, suffering recurrent infection (balanitis), can be treated with a 6-week course of topical 0.1% dexamethasone cream, which acts to soften the phimosis and allow foreskin retraction (avoid circumcision where possible).
Adults may require a dorsal slit or circumcision for recurrent balanitis, voiding obstruction, or difficulties with sexual intercourse.
Complications
These include recurrent balanitis; balanoposthitis (severe balanitis where inflammatory secretions and pus are trapped in the foreskin by the phimotic band); paraphimosis; chronic inflammation; and squamous cell carcinoma of the penis.
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INFLAMMATORY AND OTHER DISORDERS OF THE PENIS |
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Table 5.6 |
Dermatologic descriptions of skin lesions useful in |
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examination of the penis |
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Blister, bulla |
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Vesicle >1 cm |
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Crust |
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Lesion covered with drying exudate (serum, blood, pus) |
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Erosions |
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Loss of epidermis |
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Erythema |
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Redness of skin (usually blanches on pressure) |
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Macule |
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Flat, discrete lesion; different color to surrounding skin; |
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<1 cm diameter |
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Maculopapular |
Raised spots different in color to surrounding skin |
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Nodule |
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Solid dermal or hypodermal lesion >0.5 cm |
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Papule |
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Raised palpable lesion <0.5 cm |
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Patch |
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Macule >1 cm diameter |
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Plaque |
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Coalesced papules (larger, raised, flat areas) |
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Pustule |
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Circumscribed pus-filled lesion |
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Scale |
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Flake of hard skin |
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Ulcer |
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Break in epithelium (+superficial dermis) |
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Vesicle |
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Small, fluid-filled lesion <1 cm |
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Chapter 6 |
185 |
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Urological neoplasia
Pathology and molecular biology 188
Prostate cancer: epidemiology and etiology 190
Prostate cancer: incidence, prevalence, and mortality 192
Prostate cancer pathology: premalignant lesions 193
Prostatic-specific antigen (PSA) and prostate cancer screening 194
Counseling before prostate cancer screening 195
Prostate cancer: clinical presentation 196
PSA and prostate cancer 198 PSA derivatives: free-to-total ratio,
density, and velocity 200 Prostate cancer: transrectal
ultrasonography and biopsies 202
Prostate cancer staging 206 Prostate cancer grading 212 Risk stratification in management
of prostate cancer 214 General principles of management
of localized prostate cancer 215 Management of localized prostate
cancer: watchful waiting and active surveillance 216
Management of localized prostate cancer: radical prostatectomy 218
Postoperative course after radical prostatectomy 222
Prostate cancer control with radical prostatectomy 224
Management of localized prostate cancer: radical external beam radiotherapy (EBRT) 226
Management of localized prostate cancer: brachytherapy (BT) 228
Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU 230
Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0) 232
Management of advanced prostate cancer: hormone therapy I 233 Management of advanced prostate cancer: hormone therapy II 234 Management of advanced prostate cancer: hormone therapy III 238 Management of advanced prostate
cancer: androgen-independent/ castration-resistant disease 240 Palliative management of prostate
cancer 242
Prostate cancer: prevention; complementary and alternative therapies 244
Bladder cancer: epidemiology and etiology 246
Bladder cancer: pathology and staging 248
Bladder cancer: presentation 252 Bladder cancer: diagnosis and
staging 254
Management of superficial UC: transurethral resection of bladder tumor (TURBT) 256
Management of superficial UC: adjuvant intravesical
chemotherapy and BCG 258 Muscle-invasive bladder cancer:
surgical management of localized (pT2/3a) disease 260
Muscle-invasive bladder cancer: radical and palliative radiotherapy 263
Muscle-invasive bladder cancer: management of locally advanced and metastatic disease 264
186 CHAPTER 6 Urological neoplasia
Bladder cancer: urinary diversion after cystectomy 266
Transitional cell carcinoma (UC) of the renal pelvis and ureter 270
Radiological assessment of renal masses 274
Benign renal masses 276 Renal cell carcinoma:
epidemiology and etiology 278 Renal cell carcinoma: pathology,
staging, and prognosis 280 Renal cell carcinoma: presentation
and investigations 284 Renal cell carcinoma: active
surveillance 286
Renal cell carcinoma: surgical treatment I 288
Renal cell carcinoma: surgical treatment II 290
Renal cell carcinoma: management of metastatic disease 292
Testicular cancer: epidemiology and etiology 294
Testicular cancer: clinical presentation 296
Testicular cancer: serum markers 299
Testicular cancer: pathology and staging 300
Testicular cancer: prognostic staging system for metastatic germ cell cancer 303
Testicular cancer: management of nonseminomatous germ
cell tumors (NSGCT) 304 Testicular cancer: management
of seminoma, IGCN, and lymphoma 308
Penile neoplasia: benign, viralrelated, and premalignant lesions 310
Penile cancer: epidemiology, risk factors, and pathology 314
Squamous cell carcinoma of the penis: clinical management 318
Carcinoma of the scrotum 320 Tumors of the testicular
adnexa 321 Urethral cancer 322
Retroperitoneal fibrosis 326 Wilms tumor and
neuroblastoma 328