Common Urological Problems in Adolescent Males Discussed

Young men are less likely to see a doctor than their female counterparts, and the reasons behind this are varied. However, it is important that when they attend, their problem is recognised, diagnosed and given appropriate advice and treatment.

This article provides a background on five common urologic conditions, focusing on elective/non-emergency presentations. We have not attempted to address emergency presentations, such as testicular torsion or paraphimosis, as they are treated comprehensively elsewhere.

The natural history of the foreskin is well documented, with 90% becoming fully retractable by the age of three and, beyond that, data suggest that only 1-2% will need intervention (only 0.6% have a absolute indication), although in an English survey, medical circumcision rates were found to be 3.8%.2,3

Lichen sclerosis and atrophicus remains the only absolute indication for medical circumcision, and this is rarely seen before five years of age, but can be seen in adolescents. However, there is a group of adolescents who find the retraction of the foreskin very uncomfortable, especially if their penis is erect. When examined, they may have a short frenulum (this can be shortened by scarring) or a tight preputial band that catches on the crown of the glans.

The vast majority of adolescent foreskin cases referred to a specialist clinic are normal or require minor (non-surgical) intervention, and there are no published data for this group. As a result, it is important to develop a strategy for how to treat these patients.

For example, it is sensible to explain the natural history of the foreskin, while examination quickly reveals whether the foreskin is retracted regularly and whether cleaning is taking place underneath. This is the first tip that should be given: withdraw every time you urinate and during every bath/shower. The patient may also want to try a steroid cream, and application instructions are important. The patient should use it twice a day, every day for six weeks and apply the cream specifically to the affected area (i.e., the tight band).

If all else fails, a "Heineke Mikulicz-type" approach can be performed on both the frenulum and the foreskin to allow for more comfortable retraction of the foreskin. In particular, experience has taught us that consenting to frenuloplasty or prepuceplasty without the other occasionally leads to a situation where you wish you could do both, but cannot, as the patient has only consented to A procedure.

The advice remains that circumcision is rarely necessary outside the presence of lichen sclerosis, and that regular retraction and steroids are often helpful, but frenuloplasty and/or prepuceplasty may be necessary in some cases.

It is important to remember that not all varicoceles are the same and treatment decisions can be difficult as surgery carries a complication rate (e.g. hydrocele) of up to 28%.

Adolescent males who notice and present with a varicocele are an unselected group who have noticed a new "lump" in the scrotum. Varicoceles have an incidence of 15 to 20% in adolescent men.

These men have an 80% chance of having normal fertility and there is no demonstrable difference in outcome whether they have a varicocele repaired in adolescence or later in life.

Other surrogate parameters, such as differential testicular growth, have been used as a predictor of late function, but none have translated into an improvement in paternity rate. There are data supporting the view that testicular asymmetry in adolescent males should be considered with caution and is not an indication to treat in a single measurement.

However, in their meta-analysis Silay et al. suggest that improvement in pain attributed to varicocele after repair may be observed in up to 100% of patients, although data are limited. It appears to be the case that correction of a varicocele where the left testicle is ≥20% (or ≥2 ml) smaller than the right side will lead to an improvement in semen parameters and catch-up testicular growth, but there is no data that reliably supports a functional benefit.

In the author’s opinion, it is necessary to evaluate adolescents who present a varicocele, measure testicular volume and follow up for 12 to 18 months. If the patient is over 16 years of age, she should be offered semen analysis to assess fertility potential, although it is important to remember that semen analysis has considerable variability at this age and may improve over time.

Varicoceles can be found. in 30-40% of adult men who have fertility problems; Although these appear to be selected patients, the data support improvement in semen parameters and paternity after varicocele repair within this group.

Cases of testicles not located in the scrotum are a clinical challenge. The data in infants (5% incidence) and the recommendation for surgery (ideally) before 12 months are well documented.

In adolescents there is little data or guidelines. If the testicles are palpable in the groin, then the patient should be informed of their increased risk of testicular cancer , which is approximately 1.7%. There is a 74% increased risk of cancer in the contralateral testicles, with an approximately six-fold increased risk in the ipsilateral testicle.

If the undescended testis is unilateral, this will have almost no effect on fertility, but bilateral cryptorchidism can cause a marked change in characteristics seen on testicular biopsy and semen parameters.

Except in very specific (and rare) circumstances, the testicle should not be left in the groin.

It should be mobilized and, if possible, relocated to the scrotum. It is essential that patients be warned that if the testicle cannot be safely mobilized into its blood supply, then it will be removed.

If a testicle is impalpable in an adolescent/adult, then it is important to obtain as much history and documentation as possible. It is not uncommon to find (but not safe to assume) that a testicle has been removed, but it is important not to ignore an unrecognized intra-abdominal testicle. Imaging before seeing a specialist is rarely helpful. However, once a patient is in clinic, there is more discretion related to the need for imaging in a teenager than in a younger child (where it is totally unnecessary). Many young adults in this situation have had complex surgeries in the past, which increases the risk of a laparoscopy.

Therefore, it would be prudent to obtain an MRI to try to visualize the testicle and its location, and then a decision can be made about intervention. This decision may well involve a discussion about MDT and offering options to a patient, and these can be difficult decisions for both the doctor and the patient.

Teenage men often come to doctors with a scrotal lump or swelling – this is important and everyone should be seen and examined. Appropriate medical response is an important part of encouraging young men to engage in testicular self-examination as a means of ensuring early diagnosis of testicular cancer.

In a primary care setting, it is entirely appropriate to refer patients to see a urologist if there is any doubt about the diagnosis. If a lump is thought to be testicular cancer, then the effort involved in diagnosis, treatment or reassurance is well spent. This may depend on the availability and quality of community ultrasound.

Epididymal cysts are common and can be single, multiple, unilateral or bilateral. Apart from the appearance of a lump, they usually do not cause other symptoms and, if they do, they should be left alone. Hydroceles can be considered in the same way; Its presence does not make surgery necessary. A small hydrocele that does not cause pain, affect activity, or impact aesthetics does not need intervention.

The difference between an epididymal cyst and a hydrocele (from the point of view of examination) is that with a cyst the body of the testicle can usually be distinguished as separate from the cyst and the testicular pathology examined. A hydrocele will usually surround the body of a testicle and it can be difficult to make sure the testicle feels normal. In any case, an ultrasound is reasonable and reassuring.

In adolescent males, a de novo hydrocele is usually similar to a hydrocele in an adult (i.e., there is usually no obvious vaginal process). With this in mind, it is important to take a careful history of when symptoms began and whether the hydrocele varies in size. Neither condition (in its own right) has any impact on fertility.

Surgery is only indicated if a cyst or hydrocele causes significant pain, the size limits activity, or there is suspicion of other pathology (i.e., malignancy).

A discussion of surgical technique is beyond the scope of this article. The reason for reluctance to surgery is the fact that both conditions are benign, and complications can occur in up to 30% of patients undergoing surgery that, although often relatively minor, would not occur at all without surgery. operating on an epididymal cyst is causing damage to the epididymis, resulting obstruction and an effect on fertility, which may occur in 1 in 50-250 cases.

All of these risks can be avoided with conservative treatment and, although this may not be appropriate for everyone, it means careful consideration and patient advice is needed before undertaking surgery.

It is common for young men to think about whether their penis is normal and whether it will affect their ability to have sex. The vast majority of these concerns will be resolved through self-inquiry or discussions within a family as a young person becomes an adult.

Most teenage boys referred to a teen clinic with penis problems need to be seen, examined, and reassured that they are normal . There are important points to consider, and misinformation is available for our patients who need reassurance with facts. The source of information is important: media like pornography is commonly viewed and believed by many men (not just teenagers), and there is emerging evidence that viewing pornography can have a detrimental effect on erectile function. Therefore, it is important that we use peer-reviewed data to provide reassurance or appropriate treatment.

Micropenis is defined in adult men by a stretched penis length of 7.5 cm or less. However, there is good data that 60% of men with a defined micropenis can still engage in healthy sexual relationships, although it is recognized that 38% may have psychological problems. Therefore, the need for careful support and advice is important, but operations purely to enhance penis size have a poor track record of effectiveness and patient satisfaction.

For those patients with anatomical abnormalities defined as hypospadias  many will have undergone surgery in childhood. They may have concerns about urinary and/or sexual function. There is data to show that, for many, urinary and/or sexual function may be good, but there may be dissatisfaction with the appearance of the penis in up to 30%, urinary symptoms (e.g. urine spraying) in 40-50. %, erectile dysfunction up to 24% and ejaculatory dysfunction up to 37%.

Many patients who have had hypospadias surgery do not need follow-up, so we do not know the precise complication rate, but there is now data to suggest that with long-term follow-up, beyond puberty, complication rates may appear. such as fistulas and strictures. be up to 25%.

For those patients who have unoperated hypospadias in adolescence or adulthood, they need careful examination and advice about the value (or not) of surgery, and those with distal (mild) hypospadias may not need surgery at all. absolute. Patients who have had previous surgery and develop problems later in life should be referred to a specialized center for evaluation and treatment.