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This article provides a summary of common male urological complaints. It focuses on conditions of the penis and scrotum, as conditions of the prostate and the urinary tract are covered in other articles in this series.
Phimosis is a condition that occurs when the prepuce (foreskin) cannot be fully retracted (pulled back) over the glans (the head of the penis). It is the result of a narrowing or tightness of the preputial opening (the opening of the foreskin) that prevents retraction and stops the glans from being exposed. It is often physiological (normal) in younger children and self resolves, but if it lasts into late teenage and adult years then it often becomes pathological (caused by disease). Phimosis is uncommon in adults but, when present, is usually pathological rather than physiological. It can also be associated with penile cancer, particularly if malignant change develops in areas concealed by a tight foreskin.
There are many contributing factors to the development of phimosis, such as balanitis xerotica obliterans (BXO, the name used for lichen sclerosus when it affects the penis), a condition that causes scarring of the foreskin. BXO often results in narrowing of the foreskin with a whitening of the glans (scar tissue). It can also cause urethral strictures (narrowings of the urethra) and narrowing of the urethral meatus (the opening at the tip of the penis).
Complications of phimosis include poor penile hygiene and increased rates of sexually transmitted infections as it is more difficult to clean under the foreskin. Pain on intercourse due to splitting of the foreskin is also common in younger men, and urinary retention is more common in older men.
Management is usually topical steroid creams initially, with circumcision (removal of the foreskin) as a more definitive (lasting) treatment.
Image - Phimotic penis
Public Domain Source by Just somedude123 [Public domain]
Paraphimosis is a condition that occurs when the retracted foreskin becomes stuck and starts to constrict the glans of the penis, reducing any lymphatic or venous drainage from the tissues. It results in a painful, swollen, and oedematous glans that will worsen over time until the tissue becomes infected, ulcerated, and even necrotic.
It can occur after intercourse. It can also occur after catheterisation (post-catheterisation) if the foreskin is not pulled forward again afterwards, or if a penile cancer mass stops the foreskin from being returned to its place.
Paraphimosis is managed initially through a manual reduction (returning the foreskin to its normal position over the glans by hand) by applying counter pressure between the thumbs and fingers following compression of the oedematous glans with a saline soaked swab. More established cases may require anaesthesia in the form of a penile block (a local anaesthetic injection around the base of the penis) and drainage to reduce the swelling. Very neglected cases could require a dorsal incision for relief and circumcision for prevention of any recurrence.
Diagram - A swollen glans due to paraphimosis
Creative commons source by Drvgaikwad [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Penile cancer is a relatively rare cancer with more than 800 new cases a year in the UK (source). Even though it is rare, it is important to recognise red flag signs (warning signs that need urgent assessment) of penile cancer. These include a growth, lump or sore on the penis that has not healed within 4 weeks, bleeding from the penis or under the foreskin, difficulty pulling back the foreskin (phimosis), or other changes in the appearance of the penis, such as a rash or a change in skin colour. NICE advises considering a suspected cancer pathway referral (an urgent referral for possible cancer) for a penile mass or ulcer once a sexually transmitted infection has been excluded, and for unexplained or persistent symptoms affecting the foreskin or glans.
Factors that increase the risk of penile cancer include phimosis, Human papillomavirus (HPV) infection, increasing age (it is more common in men aged 50 or over), a weakened immune system and smoking. About 6 in 10 penile cancers are caused by HPV, and HPV types 16 & 18 are the most common types found.
More than 95% of penile cancers are squamous cell carcinomas (cancers of the flat, skin-like cells that cover the penis). They can develop anywhere on the penis, but the most common sites are the glans (the head of the penis) and the foreskin (source).
These cancers are investigated using a biopsy (a small sample of tissue examined under a microscope) and imaging. An MRI scan shows where the cancer is and how big it is, and a CT scan of the abdomen and pelvis looks for any metastases to lymph nodes or other organs. The groin lymph nodes may also be checked with an ultrasound scan and a fine needle sample, or with a sentinel lymph node biopsy (testing the first lymph node that the cancer is likely to spread to). Treatment depends on the size of the cancer and whether it has spread. Surgery is the most common treatment. Operations include circumcision and partial or full amputation of the penis (penectomy), and more superficial lesions (abnormal areas of tissue) can be excised (cut out) with reconstruction afterwards. Very early cancers may be treated with laser treatment or creams. Radiotherapy (treatment with high-energy radiation) and chemotherapy (treatment with anti-cancer drugs) can also be used.
Circumcision is a surgical procedure involving the removal of the foreskin. It has been and still is common practice in many religions, such as Islam and Judaism, to circumcise the infant. It is seen as being cleaner, or as part of belonging to that faith (source).
Medical indications for circumcision in children include recurrent balanitis (resulting from infections of the foreskin) or persistent urinary tract infections. In adults, recurrent balanitis, phimosis, severe or recurrent paraphimosis, BXO, or penile cancer can all require circumcision as part of treatment.
Acute scrotal pain is caused by a few conditions aside from direct trauma. This is an emergency presentation, with the most serious cause being testicular torsion.
The testicle rotates on its cord (the spermatic cord, which carries the blood vessels to and from the testicle) and so cuts off the blood supply. At first the veins are blocked (venous obstruction), so the testicle swells. The artery is then compressed too (arterial compression). The presentation occurs usually in young males as a sudden onset of severe, constant unilateral scrotal pain with associated nausea and abdominal pain. If it is not treated quickly enough, irreversible ischaemia and necrosis of the testicle can follow. Surgical repair should ideally be done within 6 hours to save the testicle. Severe testicular atrophy (shrinkage) can develop after as little as 4 hours if the cord is twisted by more than 360 degrees.
Treatment is immediate surgical intervention to untwist the cord (detorsion) and fix both testicles in place (bilateral orchidopexy) to prevent any further rotation. Testicular torsion is primarily a clinical diagnosis, and urgent surgical exploration should not be delayed for imaging when torsion is suspected, as very quick action is needed to save testicular function.
If the testicle is already necrotic upon exploration, then it will need removal and prosthetics can be used in reconstruction to give a more natural feel. Anatomical variants such as the “bell clapper” deformity (an abnormal attachment of the testicle to the tunica vaginalis, the thin sac around it, which lets the testicle swing and rotate) can increase the likelihood of torsion occurring.
Inflammation of the testicle and the adjacent epididymis (the coiled tube behind the testicle), known as epididymo-orchitis, can also be a cause of acute scrotal pain. The inflammation is usually a result of an infection, be it urinary tract or sexually transmitted in origin. Chlamydia trachomatis or Neisseria gonorrhoeae are common causative organisms (the bacteria responsible) in younger men, with Escherichia coli in older men. Sometimes there will be a recent history of either catheterisation or urethral instrumentation (passing instruments into the urethra), acting as a source of the urinary tract infection. Mumps is also a recognised cause of this type of inflammation, usually in men who have been through puberty. It usually causes inflammation of the parotid glands (the salivary glands in front of the ears). Pancreatitis (inflammation of the pancreas) is an occasional complication.
On examination the scrotum will be swollen and erythematous (red), with the affected testis and epididymis being enlarged and tender on palpation. Any fluctuant areas (soft areas that feel fluid-filled) could represent an abscess and the scrotum should be investigated using ultrasound. Blood tests such as full blood count, urea and electrolytes, and cultures should be taken if the patient is thought to be septic. A mid-stream urine sample should also be sent for microscopy, culture and sensitivities (which antibiotics will kill the bacteria). If a sexually transmitted infection is possible, a first-pass urine sample or a urethral swab should also be tested by nucleic acid amplification tests (NAAT, which detect the genetic material of organisms such as chlamydia and gonorrhoea). Treatment involves antibiotics chosen according to the likely cause (local protocols vary). For a likely sexually transmitted infection, NICE CKS suggests a single injection of the antibiotic ceftriaxone, plus doxycycline tablets (another antibiotic) for 10 to 14 days. For a likely gut organism such as E. coli, it suggests ofloxacin or levofloxacin (antibiotics from the quinolone group). Any abscesses that have formed need surgical drainage. In very severe circumstances the testicle may need to be removed.
Torsion of the Hydatid of Morgagni
In young children, an embryological remnant (a leftover structure from development before birth) known as the hydatid of Morgagni can rotate and cut off its own blood supply. This can be identified clinically as it is only the top of the testicle that is tender and a blue spot (the “blue dot sign”) in the same location can be seen when light is shone through the scrotum (illumination). The torsion can be managed conservatively (without surgery), or the hydatid can be surgically removed depending on the severity of the symptoms.
Fournier’s gangrene is a very severe and rapidly progressing infection of the genitals, the perineum (the area between the genitals and the anus) and the area around the anus. It is usually caused by a mixture of bacteria (polymicrobial), including anaerobic organisms (bacteria that grow without oxygen). It is a type of necrotising fasciitis (an infection that kills the tissue layers beneath the skin) that commonly occurs in diabetic patients. Rare cases have been linked to SGLT2 inhibitors, a type of diabetes medicine. This infection has a high mortality rate, often reported at around 20-30%. It requires immediate emergency surgical debridement (cutting away dead tissue) and broad-spectrum antibiotics (antibiotics that act against many types of bacteria).
Image - Necrosis of the scrotal skin from Fournier’s gangrene
Public Domain Source by Intermedichbo [Public domain]
Other Causes of Acute Scrotal Pain
A strangulated inguinal hernia (a hernia in the groin that has become trapped, cutting off its blood supply) can present with acute pain in the scrotum. The examiner would not be able to get above the mass (feel the top edge of the swelling) on examination. This is an emergency and requires urgent surgical correction by the general surgeons.
Very rarely there can be referred pain (pain felt away from its source) to the testicles from a ureteric stone. There will be no tenderness in the testicle on examination and there may be blood on a urine dipstick.
When assessing a scrotal lump there are a few key questions that need asking.
- Is the lump painful?
- How quickly has it appeared?
- Is it possible to palpate above (feel the top of) the lump in the scrotum? Any mass that the examiner cannot get above is presumed to be a descended inguinal hernia (a hernia that has come down into the scrotum) and should be referred to general surgeons.
- Is the lump found in the body of the testicle or separate to it?
- Does the lump fluctuate (feel fluid-filled)?
- Does the lump transilluminate (let light shine through when a torch is held behind it)?
A hydrocele occurs when there is an imbalance of fluid reabsorption and production within the tunica vaginalis (the thin sac around the testicle), resulting in a collection of fluid. Hydroceles can have a slow or sudden onset.
On examination there is unilateral swelling in the scrotum and the testis cannot be palpated separately. The mass fluctuates and transilluminates (lets light shine through), and the examiner is able to get above the testicle. It is generally not painful, and usually only operated on when it causes symptoms or for cosmetic purposes. A hydrocele can also be secondary to an underlying cause, such as a testicular tumour, torsion, epididymo-orchitis or trauma. An urgent ultrasound scan of the scrotum is arranged if the man is aged 18 to 40 or the testis cannot be felt.
Image - A unilateral scrotal swelling caused by a hydrocele
Creative commons source by EvguenieSokolov [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
A varicocele is formed when there are varicosities (swollen, twisted veins) in the pampiniform plexus, a network of veins that drain blood away from the testicle. They are described as feeling like a 'bag of worms'. Most varicoceles are painless, and fewer than 3% of men with a varicocele have pain or a dragging sensation. The veins are more swollen on standing and usually less swollen when the man lies down. On examination, they are felt separate to the testis and are non-tender to touch.
About 90% of varicoceles occur on the left. The left gonadal vein (the vein that drains the testicle) drains into the left renal vein vertically, at a right angle, and is also longer than the right one. The pressure in this column of blood is higher, which can dilate the veins of the pampiniform plexus. The right gonadal vein drains into the inferior vena cava at an oblique (slanting) angle, which gives it some protection. It is important to note that a sudden onset or right-sided varicocele can rarely be associated with a renal tumour, so an ultrasound scan of the abdomen is recommended to look for one. Varicoceles are associated with sub-fertility (reduced fertility). About 1 in 5 men with a varicocele has fertility problems, and up to 44% of men with primary infertility have one. A raised scrotal temperature is one proposed cause, along with low oxygen levels (hypoxia) and reflux of toxic metabolites. Many varicoceles need no treatment beyond advice and reassurance. Men with a larger symptomatic varicocele (grade II or III), or with abnormal semen parameters (sperm test results), are referred to a urologist (a specialist surgeon of the urinary tract and male genital organs) for possible surgery, and in adolescents the main reason for surgery is failure of testicular growth. If required, the vessels can also be blocked off by a radiologist (radiologically embolised).
An epididymal cyst is a cyst that forms in the epididymis. It is a painless lump that transilluminates, but is felt separate to the testis. These can be surgically removed if required.
Image - Epididymal cysts that are separate to the testicle
Creative commons source by E.dronism [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Testicular cancer makes up around 1% of cancers diagnosed in men in the UK every year (source). The usual initial presentation of a testicular tumour is that of a painless lump on the testicle of a young man. On examination the mass will have an irregular border, be firm and fixed in place on the testicle and will not transilluminate. The abdomen should be examined looking for any hepatomegaly (an enlarged liver) or para-aortic node masses (lumps in the lymph nodes beside the aorta). NICE advises considering a suspected cancer pathway referral (an urgent referral for possible cancer, also known as a two-week wait pathway referral) for a non-painful enlargement, or a change in shape or texture, of the testis. It also advises considering an urgent direct access ultrasound scan (one the GP can request) for unexplained or persistent testicular symptoms.
Image - A tumour originating in the body of the testicle
Creative commons source by Scientific Animations [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]
Testicular cancer makes up only about 1% of adult cancers, but it is the most common solid tumour in younger men aged 15 to 34. A GP will only see a handful in their lifetime. There is a strong association between undescended testicles and testicular cancer. Other proposed risk factors include prenatal hormonal influences, although the evidence for exogenous oestrogen exposure (oestrogen from outside the body) is less clear. More than 95% of men survive testicular cancer for 5 years or more, and for 10 years or more. The survival rate is good even with metastasis, because germ cell tumours (tumours that start in the sperm-forming cells) are very sensitive to cisplatin-based chemotherapy (treatment with a platinum-containing anti-cancer drug). It is therefore considered to be a curable cancer (source).
There are two classifications of testicular germ cell tumours (tumours that start in the sperm-forming cells): seminomas or non-seminomatous germ cell tumours (including the subdivisions of teratoma, choriocarcinoma and yolk sac tumours).
Urology will perform an urgent ultrasound of the scrotum to confirm the diagnosis. They will also check the bloods for testicular tumour markers (substances in the blood that tumours can release). These include alpha-fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase (AFP, β-hCG and LDH). When these markers are raised, there is a high likelihood of testicular cancer, but a normal tumour marker does not exclude testicular cancer.
Testicular tumours are surgically removed through the groin by pulling the spermatic cord up through the inguinal canal (the passage through the lower abdominal wall in the groin) rather than through the scrotum. This is done to avoid any seeding (spread of tumour cells) of the scrotum. The scrotum drains to a separate set of lymph nodes, so any further lymphatic spread is then confined to the para-aortic lymph nodes. What happens after surgery depends on the stage and type of cancer. Some men need no further treatment but have regular check-ups (surveillance). Others have chemotherapy (anti-cancer drugs) or radiotherapy (high-energy radiation treatment). Doctors discuss storing sperm (sperm banking) before treatment starts, because some treatments can affect fertility.
Lower Urinary Tract Symptoms (LUTS)
LUTS describe symptoms during storage of urine, voiding (emptying the bladder), or after micturition (passing urine).
Hesitancy - the man will find it takes a while to get going when voiding
Poor Flow - this is most commonly due to bladder outlet obstruction (for example from prostatic enlargement), meaning the bladder has to work against increased resistance. Less commonly, reduced detrusor contractility (weak contraction of the bladder wall muscle) can contribute.
Post-micturition dribbling is involuntary leakage after passing urine has finished. It is a post-micturition symptom, distinct from a slow stream or terminal dribbling (dribbling at the end of passing urine) during voiding. Source: International Continence Society (ICS) symptom classification.
Frequency - men will find that they need to go more often than they used to but only void small amounts.
Urgency - when the man feels the need to urinate then he will be unable to hold it in for long.
Nocturia - when the man wakes one or more times during the night to pass urine.
Lower urinary tract symptoms were previously believed to relate only to prostatic enlargement, but we now know that there are many different causes for both voiding and storage-related symptoms.
Physical causes can result from urethral pathology. Examples are extreme phimosis, urethral strictures (narrowings of the urethra, which often cause a weak stream) and stenosis (narrowing) of the urethral meatus (the opening at the tip of the penis). They can also result from prostatic causes (prostate cancer or benign prostatic hyperplasia, a non-cancerous enlargement of the prostate).
Upper motor neurone disorders (disorders of the nerve pathways from the brain and spinal cord) can lead to a lack of coordination between the bladder and the urinary sphincter, so that the sphincter does not relax when the bladder is contracting.
The bladder can have reduced contractility (an underactive bladder, where the bladder wall muscle contracts weakly). Causes include nerve damage (neurogenic), such as diabetic autonomic neuropathy, failure of the muscle itself (myogenic) and medical treatment (iatrogenic, caused by medical care), and sometimes no cause is found (idiopathic).
Anything that irritates the bladder wall can cause storage symptoms. This could be due to an infection, a bladder stone or even bladder cancer.
An overactive bladder (a bladder muscle that squeezes at the wrong times, causing sudden urges to pass urine) is a common reason for the storage symptoms. In men, bladder outlet obstruction, for example from benign prostatic hyperplasia or a urethral stricture, can also cause them. Overactive bladder can be idiopathic (no known cause), but can have neuropathic (nerve-related) causes relating to conditions such as Parkinson’s, multiple sclerosis or even post-stroke.
The bladder can lose compliance (cannot stretch as much) if it is scarred, leading to a reduced functional capacity and earlier need to void. Causes can include pelvic radiotherapy (radiation treatment to the pelvis) or schistosomiasis infection (a parasitic worm infection).
The kidneys could also be polyuric, i.e. producing too much urine so the bladder fills up more quickly. This could be due to diabetes or excessive fluid intake.
The severity of male lower urinary tract symptoms is assessed using the International Prostate Symptom Score (IPSS). This score is based upon how often the various voiding and storage symptoms occur and also the quality of life that the patient has with these symptoms. A patient who tolerates the symptoms well will need less management. Please see our prostate pathology article for full details about the assessment and investigation of the enlarged prostate.
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
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