Genital Ulcers

Genital Ulcers are specifically mentioned on our syllabus. They are more likely to be non sexually tramsitted than sexually transmitted (surprisingly!).

Herpes
HSV1 is now the most common cause of genital herpes. HSV2 is more likely to result in recurrent episodes. The majority of infections are subclinical and symptomatic viral shedding, or symptomatic lesions can occur.

Get painful ulceration, dysuria, urethral or vaginal discharge. May get fever and myalgia. On examination, you get blistering and ulceration with painful lymphadenopathy.

Treat with a full sexual health screen, and oral aciclovir. Condoms won't reliably prevent transmission - abstain for a week after symptoms resolve.

Syphillis
Syphillis should be treated in specialist GUM clinics. It is more common in MSM. It normally presents with a painless ulcer, with a clean base. Secondary infection has multisystem involvement.


Bechets
A systemic vasculitis of unknown aetiology (not considered to be auto-immune), that typically starts in young adults. You get recurrent oral and genital ulceration, uveitis, skin changes, arthritis, neuro involvement and tendency to thrombosis. It is prevalent in Japan, the middle East, and some Mediterranean countries. Treatment depends on which organ is involved.
Genital ulcers are less common than oral ulcers.

Reactive
EBV, CMV and parathyphoid can cause post infective or reactive genital ulcers (lipschutz ulcers). They can be very painful, and associated with lymphadenopathy. They normally resolve within a few weeks. The ulcers normally have a yellowish centre, that may become black due to tissue necrosis, with a surrounding red rim. They may be associated with swelling.
Take viral and bacterial swabs. Look for underlying illness, and test for EBV. Treat according to the cause.

Crohn's
Cancer
Pemphigus
Pemphigoid
Steven-Johnson syndrome
Erythema multiforme

References 
http://www.dermnetnz.org/topics/non-sexually-acquired-genital-ulceration/
http://www.aafp.org/afp/2012/0201/p254.html
http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1167392705
http://pmj.bmj.com/content/76/900/629
http://learning.bmj.com/learning/module-intro/genital-ulceration-diagnosis-management.html?moduleId=10058483&searchTerm=%E2%80%9Culcers%E2%80%9D&page=1&locale=en_GB

Penile Problems

Most penile problems are better evaluated if you have a nerve block in place.

Dorsal Penile Nerve Block
The two dorsal nerves are at 10 and 2 o'clock positions at the root of the penis.
Ramifications of these nerves usually commence 1 cm distal to the penile root, and a nerve block should be just proximal to those.
The depth of the needle need not be more than 0.25 to 0.5 cm.
Aim to hit the pubic symphysis, and then go below.

Phimosis
Check for diabetic control
Palpate the glans - and if there is a lump, refer urgently to urology
Consider a steroid cream - like betnovate

Paraphimosis
Remove a catheter or any piercings first
Start with analgesia - a nerve block might be helpful!

Manual Reduction - put pressure or a compression bandage on the distal penis
Ice 
Sugar on glans and penis
Puncture oedematous band
After reduction, urology follow up as is likely to happen again!

Fracture of the Penis
Differential is rupture of the deep dorsal vein of the penis
- You don't hear a crack or popping sound
- Detumescence doesn't occur
- Needs to be surgically explored
- Can get urethral injury

Priapism
Most of the time, this is primary (idiopathic) 40%

Secondary causes:
  Haematological   (sickle cell, leukaemia, myeloma)
  Neurologic    (spinal cord injury - leave these alone, time heals)
  Traumatic   (genital, perineal) 10%
  Neoplastic   (bladder, prostate)
  Medication   (antipsychotic like chlorpromazine and haloperidol   antidepressants like fluxetine, anticoagulation, recreational drugs like cocaine, intracavernosal injections)

  - analgesia
  - hydration
  - exercise (run up and down the stairs)
  - cold bath, or maybe a warm bath
  - therapeutic masturbation can help
  - involve urology team for drainage. This needs written consent - there is a high risk of associated impotence. It involves consent, cleaning, inserting a needing into the side of the penis to a depth of 1cm, take blood gas, then aspirate up to 100ml thick dark blood.

References 
http://bestpractice.bmj.com/best-practice/monograph/765/treatment/step-by-step.html
https://wikem.org/wiki/Priapism 
http://www.foamem.com/2015/04/17/priapism/
http://pedemmorsels.com/phimosis/
http://learning.bmj.com/learning/module-intro/.html?moduleId=10057996&searchTerm=%E2%80%9Cphimosis%E2%80%9D&page=1&locale=en_GB