00:01
Our topic here in this
table, incredibly important.
00:04
And it summarize some of the
conditions embryologically
and also we’ll go into our
adult penile pathologies.
00:12
We’ll begin by looking at hypospadia.
00:14
If you take a look at
simple picture here,
we have the ventral
portion of the penis
in which that you
find an opening.
00:19
And what does this mean to you?
Embryologically, it’s the
ventral surface of the penis
due to failure of the
urethral folds to fuse.
00:28
What happens?
Well, hypospadia’s
more common than epi,
and you’re worried
about with hypo,
infection type of issues
especially, well, if an
organism get’s into --
Take a look at the picture --
that access to the
ventral portion,
then it might then
get into urethra,
and then get into the
urinary bladder,
welcome to cystitis.
00:50
Everything’s a story.
00:52
For the most part,
95% of your boards
in medicine use concepts.
00:57
That’s what you should
focus on always.
01:00
And we have epispadia,
take a look at where
the opening here is
and this is on the dorsal
surface of the penis.
01:06
What does this mean to you?
This means that you have
extrophy of the bladder
which is a serious complication.
01:12
Just to make sure we’re clear,
We have due to malpositioning
of the genital tubercle,
is the embryologic
malformation with epispadia.
01:20
Whereas with hypospadia,
what was it?
Failure of urethral folds.
01:27
Well, if your patients in
the above two were young
because of congenital issues,
well, here we’re still
discussing penile pathology,
but yes, this is also
a young patient.
01:39
However, the problem
is with phimosis
is that the prepuce,
inability to retract the
prepuce over the glans.
01:48
Can you picture that, please?
I want you to picture the glans
and then let’s say
that you have a child
that did not have
circumcision yet, okay?
And so therefore, there is
the fold, the foreskin,
and literally what happens is
the fact that the foreskin
is trapping the structure
underneath it.
02:04
What’s the structure?
The penis.
02:07
So therefore literally
you’re suffocating
and you’re strangulating the
penis with the foreskin.
02:14
You can’t even
retract the prepuce
over the glans versus --
I’ll talk to you about another
condition upcoming called
paraphimosis in a second.
02:23
So what happens here?
Well, accumulation of smegma.
02:27
Smegma would be the
type of fluid that –
not the most hygienic
and there used to be a research
and there used to be theories out
there that maybe perhaps smegma,
accumulation of smegma
in uncircumcised males
then perhaps at some point lead
into squamous cell cancer.
02:44
Well, that’s too controversial.
02:46
They won’t ask you that.
02:47
But imagine if you
can’t properly
clean up the area and
then smegma and
then perhaps infection
known as balanitis.
02:57
As I said, there might be small
risk of squamous cell cancer.
03:01
Circumcision gives a decreased risk
of spread of -- well it is important.
03:04
Well, it is important.
03:06
Circumcision decreases spread -- now
this is statistically proven --
of both very important viruses
that are a part your STI or
sexually transmitted infections,
HPV and HIV.
03:18
At least know that much in
terms of what the process
or what circumcision will provide in
terms of protection for your male.
03:31
Continuing our discussion
of penile pathology,
this time with paraphimosis.
03:34
What does this mean to you?
Phimosis means, once again, you
weren’t able to properly retract
the foreskin over the prepuce.
03:43
Whereas now,
paraphimosis literally –
Now I want you to
picture the glans
and you’re right about
to get into the shaft.
03:50
And at that point literally,
it’s like you taking your hands
and choking me around me my neck
and you're choking literally
underneath the glans.
03:58
The retraction of tight
foreskin over the prepuce
can lead to strangulation and
infarction of the glans penis.
04:07
Please know this as being the
definition for paraphimosis.
04:11
If you’re confused,
go back to the previous
discussion that we just had
with phimosis.
04:19
Iatrogenic in children and
congestive type of ischemia
is what you’re thinking about
here with paraphimosis.
04:29
Next, we have what’s known
as Peyronie disease.
04:31
If it’s one word to
describe Peyronie disease,
it’s the fact that
there is fibrosis.
04:36
And there’s a couple
of other things here
that you’d find to be interesting
with Peyronie disease.
04:42
It’s chronic inflammation.
What does that mean to you?
Fibrosis.
04:46
It’s fibrosis taking place over
the penis, that’s correct.
04:49
So what does that mean to you?
This is going to
then be painful.
04:53
Painful, keep that in mind.
04:55
Chronic inflammation causing
increased thickness of the
tunica albuginea
and with that thickness
surrounding the corpus cavernosa.
05:04
With that increase in thickness
at some point in time,
it may then cause –
well, we’ll take look.
05:09
Differential diagnoses:
Rupture of corpus cavernosa
due to penile fracture.
05:14
So with that Peyronie disease,
with this type of fibrosis, well,
there’s another association to –
If my hand looked like this,
I can’t help it, okay?
Let’s say I’m a patient
that has this condition
in my hand and my penis
are both curved.
05:30
Why is my hand curved and
why is my penis curved?
Because in Peyronie disease
in the hand that I’m
the maneuver that I’m doing here
is something called Dupuytren
and these are all
fibromatosis or fibrosis
that’s taking place
of these organs.
05:47
And when there is chronic
inflammation of the penis,
you call this Peyronie.
05:50
If it’s chronic inflammation
of the hands and it contracts,
that’s called Dupuytren.
05:55
Okay. So you’ve heard
of Peyronie before,
but you probably have heard it
in the context of Dupuytren.
06:02
You have ischemic priapism,
what does this mean to you?
It means that you don’t have
proper blood supply to the penis,
and you should be thinking about
something like sickle cell disease.
06:15
And sickle cell disease,
think about that
African American boy,
and when he is playing,
then you have your RBCs,
which get sickled.
06:23
And when they get polymerized,
then they behave like a thrombus.
06:27
So when they’re behaving like a
thrombus in penile circulation,
we have a condition
called ischemic priapism.
06:34
In other words, what
does this mean to you?
This is opposite of
erectile dysfunction.
06:38
This means that you will --
or the child or the boy or the male
is experiencing painful erection,
you must know the definition
of greater than 4 hours.
06:49
Of course, we have
drugs that do that
such as Viagra and such,
totally different mechanism.
06:53
Our focus here
will be pathology.
06:56
Immediate treatment with,
well, you have to, have to now
decompress or decrease the
amount of blood we have,
corporal aspiration.
07:04
We have intracavernous
type of phenylephrine
and surgical decompression.
07:09
You almost want to think
of this as being like
increased intracranial pressure.
07:14
For example, if there’s a hematoma
sometimes, what do you want to do?
You put in a burr
hole in the skull,
you can relieve the pressure.
07:20
Kind of like what you’re
doing here as well.
07:22
Important penile pathologies
that you want to know for sure,
some would be children and
some would be adults.
07:28
Keep your patient in
mind every single time
you go through one
of these diseases.
07:36
Our topic here brings
us to what’s known as
penile type of
carcinoma in situ.
07:43
So CIS stands for
carcinoma in situ.
07:47
So what does this mean to you?
It means there is malignancy.
07:50
However,
it doesn’t mean at this
point that we’ve invaded.
07:54
Is that clear?
Same concept that we did
with cervix and vulva.
08:02
Remember the intraepithelial
neoplasias.
08:04
At some point, they then
went on to become in situ
and if they invade, then it’s
a totally different story.
08:11
Okay, so let’s talk
about penile in situ.
08:14
Bowen disease in penile shaft
presenting as leukoplakia.
08:20
I want us to stop
here for a second.
08:22
Bowen disease, you
want to memorize that.
08:25
Next, leukoplakia.
08:28
Well, many times, med students
take a topic or whatever
and they’re just kind of
like put it somewhere
and then they use
it as a buzzword.
08:38
Don’t do that.
08:39
What I’m saying is leukoplakia,
a lot of students and
residents think,
“Oh, it must be on the tongue.”
Well, no.
08:45
You could have it on the tongue,
but you must understand the
definition of leukoplakia.
08:51
What it means is that
the squamous cells
are undergoing hyperplasia.
08:57
When they do, it takes
on whitish color,
leuko-plakia.
09:02
What kind of cells do you
have on your tongue?
Squamous cells.
09:07
What if there was trauma that
was introduced to the tongue
and now, the squamous
cells undergo hyperplasia
and it appears white.
09:15
Leukoplakia,
that, you’ve heard of.
09:17
And with a tongue depressor,
you can’t scrape that off.
09:21
You can’t scrape off squamous
cells like you would oral thrush.
09:25
That’s when most –
Med students have heard of this.
09:28
But if there’s
leukoplakia elsewhere
which just means squamous
cell hyperplasia
and there is a risk of going to
cancer,
here it’s on the penis.
09:38
Then you have Bowenoid.
09:40
Pick the name and dissect it.
09:42
The suffix –oid means
like, correct?
Epitheliod, leukomoid.
09:48
Here’s Bowenoid.
09:50
It’s called Bowenoid papulosis
and presents as reddish papules
and here, HPV16 in young men seems
to be the causative agent perhaps.
10:01
Reddish papule, Bowenoid.
10:04
Red – D.
10:06
Bowenoid – D.
10:08
Bowen would be
leukoplakia, whitish.
10:11
All part of a spectrum of
CIS, carcinoma in situ.
10:18
Then we have erythroplasia
of Querat of glans,
presents as erythroplakia.
10:24
Very much sounds exactly
the type of organization
that you did with the
tongue, doesn’t it?
You have the white,
that was leukoplakia.
10:31
and then you had the red, it
was called erythroplakia,
That was on the tongue and
if there’s hyperplasia.
10:35
Here, if it’s on the penis,
we have Bowen which is white.
10:39
And bowenoid, which is
more reddish papules.
10:42
Whereas if it’s what’s
something called erythroplasia
of Queyrat of the glans,
this then presents
as erythroplakia.
10:50
Three different presentations,
all the spectrum of CIS.
10:54
Students tend to confuse this
and get questions wrong because
you just didn’t take enough time
to reinforce the information.
11:01
Just take a couple of things
here, white, red and red.
11:04
Red papules and erythroplakia.
11:07
Now, we’re going into actual
squamous cell cancer of the penis.
11:11
More common in Africa, Asia,
South America, associated with
the higher strains of HPV
and we also have detected
alter in a particular
tumor suppressor
gene called p16.
11:25
And if you remember correctly, p16
will be a tumor suppressor gene.
11:29
It inhibits the kinase,
I-N-K, I-N-K, I-N-K.
11:33
If there’s a mutation in which
the INK then becomes mutated,
if you inhibit the inhibitor,
“Uh-oh, what have you done?”
You phosphorylated the
Rb, removed the BRCA,
E2F is allowed to run free
and my G12S phase is unimpeded,
my cells spend eternity
in cell cycle.
11:50
Welcome to cancer.
11:51
Okay.
11:52
So single 60s, these
are risk factors.
11:56
Single, amazingly.
11:57
So if a male is single,
I’m saying that --
interesting, isn’t it?
That he, by just default, single
has increased risk for
squamous cell cancer.
12:07
60s, the older you are
and you’re single.
12:10
And also later circumcision,
just know that and, as a theory,
that often tested on the boards.
12:18
Big time important.
12:19
So this is with the penis.
12:21
And let’s talk about
its spread, okay?
Now what I’m trying to get
at is there’s two spreads
that students get confused
with all the time.
12:30
Periaortic and para-aortic
versus something here
that we see with the penis.
12:36
What kind of cancer are
we dealing with here?
Penile cancer.
12:39
At some point, what other type
of cancer will we deal with
in which its spread
would be para-aortic?
Good.
12:46
Testicular.
12:48
Two different cancers,
two different anatomical
parts of the male.
12:53
Penile cancer, if it
wishes to spread,
would be lymphatic
to superficial,
to deep inguinal then to the
external iliac lymph node.
13:04
Memorize that, commit
that to memory.
13:06
I don’t care how you do it.
13:08
All I’m saying is do not
confuse this with the spread
that we will take a look
at with testicular cancers
in which it will then spread to the, lymphatically, para-aortic.
13:18
It’s easy to confuse the two.
13:19
They’re in the same vicinity,
but please make sure you keep that
separate for your boards and wards.