Absence of upper wall of urethra. Frequency 1 in 30,000. Urethra opens onto the dorsum of the glans penis or penile shaft as an epithelial-lined groove.
Termination of urethra ventral and posterior to its normal opening. Frequency 1 in 160–1800. Orifice found anywhere from the glans to the perineum. Often associated with other local anomalies [under-developed foreskin, chordee (downward bending of penis), meatal stenosis].
Non-tender cord-like firm swelling in coronal sulcus. Probably related to sexual trauma (prolonged or frequent intercourse). May be associated with preputial oedema. Self-limiting (usually within days, up to 3 weeks); just requires reassurance.
Strangulation of the glans penis by retracted prepuce. Usually results from partially phimotic prepuce, which has been retracted and cannot be reduced. However, may follow trauma with swelling of the glans (e.g. from vigorous sexual activity) with a retracted normal calibre prepuce. Requires urgent intervention either by manual reduction (using anaesthetic cream and ice to reduce oedema) or by surgical intervention to prevent infection and gangrene.
Fibrous infiltration of the penile intracavernous septum. Leads to single plaque formation, causing curvature and angulation of the erect penis, pain and subsequent erectile dysfunction. Cause unknown, but associated with penile trauma, diabetes mellitus, and Dupuytren’s contracture. May spontaneously resolve. If not, medical treatments (intralesional or systemic) or surgical options may be considered.
Tight constriction of the prepuce, preventing retraction over the glans penis. Aetiology includes;
• Congenital: physiological in 1st year of life.
• Acute: underlying infection, e.g. syphilis (sub-preputial chancre), genital herpes, candidiasis.
• Chronic and progressive: response to repeated trauma (physical, chemical, repeated infections), skin disorders (e.g. lichen sclerosus), local malignancy.
Surgical referral for circumcision may be required.
Pathologically prolonged erection without libido. May be associated with blood disorders (e.g. sickle-cell disease, leukaemia), drugs used to manage erectile dysfunction, and rarely infection (e.g. gonorrhoea). ▶ Failure to achieve detumescence using ice packs requires urgent urological referral.
Commonly detected as incidental findings or raised by concerned patient, especially those aged >40 years. Usually <1 cm in diameter and filled with spermatozoa (spermatoceles) or serum (epididymal cysts); therefore, they transilluminate well. They arise from the epididymis (not testis) and generally reassurance can be given. If large or painful, they can be aspirated by needle, but surgical removal is not advised as there is a risk of sterility. Ultrasonography is recommended for intrascrotal lumps or swellings where malignancy is considered.
Open dorsal or ventral to urethra, and are usually rudimentary blind tracts, although they may terminate in bladder or posterior urethra. Accessory peri-urethral ducts are commonly found in ♂ opening into or around the meatus, and are blind tracts extending from 2 to 10 mm.
Dilatation and tortuosity of the veins of the scrotal pampiniform plexus (along the spermatic cord). 90% are left sided (due to difference in drainage routes of left versus right spermatic veins) 10–17% of young ♂affected, with spontaneous regression common. Swollen veins within the scrotum are bluish and feel like a ‘bag of worms’. Most commonly diagnosed because of infertility, but 67% of ♂ with varicoceles are fertile (infertility possibly results from impairing the mechanism that usually keeps scrotal temperature below body temperature, or because of impaired blood supply). Adolescents found to have a varicocele should have an annual assessment of ipsilateral testicular volume and be referred if there are concerns. Baseline investigations for an adult could include semen analysis, follicle-stimulating hormone (FSH) and serum testosterone. Abnormal sperm concentration or motility may identify those more likely to benefit from surgery. Generally, no treatment is required, although further assessment and surgical intervention should also be considered if any of the following occur: sudden onset and associated pain, varicocele does not drain when the patient is supine, solitary right-sided varicocele (to exclude a mass obstructing the downstream testicular vein)
Cysts arise following obstruction of the drainage duct, whereas abscesses are caused by local pathogens, most commonly Neisseria gonorrhoeae (up to 80% of abscesses) but also Chlamydia trachomatis, staphylococci, streptococci, and Gram –ve enteric bacteria. Found most commonly in ♀ aged 20–29 years with abscesses occurring about ×3 as commonly as cysts. Most small abscesses respond well to appropriate antibiotics, although needle aspiration may be required. Chronic or recurrent cysts may require duct catheterization or marsupialization. In ♀ >40 years, cyst edges should be examined histologically to exclude carcinoma. Recurrences may occur in up to 20%.
Often an incidental finding during routine examination but may present with post-coital or intermenstrual bleeding. Red fleshy cervical projections, ~1–2cm long, containing both squamous and columnar cell epithelium. Found more commonly in multiparous ♀ >20 years and may be associated with chronic local inflammation. 1.7% are malignant and 27% are associated with an endometrial polyp. Usually, removed by gently twisting the base, which should be sent for histology to exclude malignancy. Excision with basal electrocautery or laser vaporization may be required for larger lesions.
Most are associated with functioning ovaries and age-appropriate external genitalia, but also abnormalities of the renal and axial skeletal systems. Examples include vaginal agenesis, longitudinal or transverse vaginal septae, unicornuate uterus (1 hemi-uterus, ovary and fallopian tube), uterus didelphys (2 hemi-uteri, 2 cervices, 1 or 2 vaginas), bicornuate uterus (2 separate, but communicating endometrial cavities, 1 cervix and vagina) septate uterus (incomplete resorption of the fibromuscular uterine medial septum). Some may present in early adolescence (with cryptomenorrhoea, cyclical abdominal pain, and haematocolpos), but others may not present until a woman becomes sexually active, needs a vaginal speculum examination, or becomes pregnant.
Seen primarily in post-menopausal women. Caused by eversion of a portion of the distal urethra (most commonly the posterior edge). Treatment is conservative (warm baths) or with hormone replacement therapy (HRT). Differential diagnosis includes urethral prolapse (circumferentially everted mucosa) or urethral malignancy.