The prostate surrounds the proximal urethra below the bladder, so prostate enlargement or inflammation quickly affects urination. Testicular and scrotal conditions range from surgical emergencies (torsion) to highly curable cancers.

Benign prostatic hyperplasia (BPH)

• Non-cancerous growth of the prostate's inner (transition) zone under androgen (dihydrotestosterone) stimulation; very common after age 50
• Causes lower urinary tract symptoms: weak stream, hesitancy, straining, intermittency, dribbling, incomplete emptying (obstructive) and frequency, urgency, nocturia (irritative)
• Complications: acute urinary retention, urinary tract infection, bladder stones, hydronephrosis, kidney injury

Prostatitis

• Acute bacterial: sudden fever, chills, perineal pain, dysuria, and a very tender prostate; usually gram-negative bacteria
• Chronic bacterial: recurrent UTIs with the same organism
• Chronic pelvic pain syndrome: pelvic pain without infection — the most common form

Prostate cancer

• Usually adenocarcinoma of the peripheral zone (palpable on rectal exam); often slow-growing
• Risk factors: increasing age, Black ancestry, family history, inherited mutations (e.g., BRCA2)
• Spreads to pelvic nodes and bone (osteoblastic lesions of spine and pelvis)
• Early disease is usually asymptomatic; urinary symptoms usually reflect coexisting BPH

Testicular disorders

• Testicular cancer: most common solid cancer in men aged 15–35; usually germ cell tumors (seminoma, nonseminoma). Risk: undescended testis (cryptorchidism), family or personal history. Very high cure rate
• Testicular torsion: the testis twists on the spermatic cord, cutting off blood supply — a surgical emergency; peak in adolescents
• Epididymitis: infection of the epididymis — under 35 usually sexually transmitted (Chlamydia trachomatis, Neisseria gonorrhoeae); older men usually enteric bacteria (e.g., E. coli)
• Hydrocele (fluid collection, transilluminates), varicocele (dilated veins, "bag of worms," can reduce fertility), spermatocele

Erectile dysfunction (ED) — often a marker of vascular disease (diabetes, hypertension, smoking, dyslipidemia); also neurologic, hormonal, psychological, and drug causes (antihypertensives, antidepressants).

Penile lesions — a painless, firm, clean-based ulcer (chancre) suggests primary syphilis; it heals without treatment in about 3–6 weeks, but the infection continues. Painful ulcers suggest herpes or chancroid.

BPH

• Symptom scoring (e.g., International Prostate Symptom Score)
• Digital rectal exam (DRE): smooth, firm, symmetric, enlarged prostate
• Distended bladder (suprapubic dullness), overflow incontinence

Prostate cancer — DRE may reveal a hard, nodular, irregular prostate; advanced disease: bone pain (back, hips), weight loss, leg weakness or urinary retention (spinal cord compression), hematuria.

Acute prostatitis — high fever, perineal and low back pain, dysuria, retention; tender, warm, boggy prostate (DRE should be gentle; vigorous massage is avoided).

Scrotal findings

ED — sexual history, cardiovascular risk factors, medications, mood.

BPH — medications

Avoid drugs that worsen retention: anticholinergics, antihistamines, decongestants (pseudoephedrine), opioids.

BPH — procedures

• Transurethral resection of the prostate (TURP) — standard surgery; others include laser enucleation or vaporization, prostatic urethral lift, open or robotic prostatectomy for very large glands
• After TURP: three-way catheter with continuous bladder irrigation (CBI), sometimes catheter traction for bleeding

Acute urinary retention — urgent bladder catheterization; complete drainage is standard (the old practice of clamping after a set volume is not evidence-based), then monitor for hematuria, hypotension, and post-obstructive diuresis; catheter-associated UTI risk; start an alpha blocker before a trial without catheter.

Prostatitis — antibiotics based on culture (e.g., fluoroquinolone or trimethoprim-sulfamethoxazole): acute for 2–4 weeks, chronic bacterial for 4–6 weeks. Fluoroquinolones carry boxed warnings (tendinopathy and tendon rupture, peripheral neuropathy, CNS effects) plus warnings for aortic aneurysm and blood glucose disturbances; NSAIDs, sitz baths, stool softeners, fluids. Chronic pelvic pain: multimodal therapy (alpha blockers, pelvic floor physical therapy).

Prostate cancer

• Low risk: active surveillance (serial PSA, MRI, repeat biopsy)
• Localized: radical prostatectomy or radiation (external beam, brachytherapy)
• Advanced: androgen deprivation therapy (ADT) — GnRH agonists (leuprolide; initial testosterone surge can cause tumor flare, so an antiandrogen is often given first), GnRH antagonists; adverse effects: hot flashes, loss of libido, ED, osteoporosis, weight gain, diabetes, cardiovascular risk. Newer androgen-pathway inhibitors, chemotherapy, radiopharmaceuticals
• Bone metastases: denosumab (subcutaneous) or zoledronic acid — check calcium before each dose, correct vitamin D, dental exam (osteonecrosis of the jaw); opioids and radiation for pain

Testicular cancer — radical inguinal orchiectomy (a scrotal biopsy is avoided because it can spread tumor), then surveillance, chemotherapy (e.g., cisplatin-based — nephrotoxicity, ototoxicity, nausea; bleomycin — pulmonary toxicity), or radiation. Offer sperm banking before treatment.

Testicular torsion — immediate surgical detorsion and fixation (orchiopexy); testicular salvage is highest within 6 hours of pain onset. Imaging should not delay surgery when suspicion is high.

Epididymitis — under 35 or STI risk: ceftriaxone plus doxycycline; insertive anal sex: ceftriaxone plus levofloxacin (covers gonorrhea and enteric organisms); enteric organisms only (e.g., after urinary instrumentation or prostate biopsy, older men without STI risk): levofloxacin; scrotal elevation, ice, NSAIDs, rest; treat partners.

Erectile dysfunction

• PDE5 inhibitors (sildenafil, tadalafil): absolutely contraindicated with nitrates (severe hypotension); caution with alpha blockers; headache, flushing, visual changes; seek care for an erection lasting more than 4 hours (priapism) or sudden vision or hearing loss
• Alprostadil (prostaglandin E1) by intracavernosal injection or intraurethral pellet: priapism, penile pain, fibrosis; rotate injection sites
• Vacuum devices, penile prosthesis; address cardiovascular risk

Listed in priority order.

1. Emergencies first
   • Suspected testicular torsion: keep NPO, notify the surgeon immediately, give analgesia, prepare for surgery
   • After urinary drainage of a large volume: monitor blood pressure, pulse, hematuria, and urine output hourly for post-obstructive diuresis (replace fluids as ordered)
   • Spinal cord compression or hypercalcemia in metastatic prostate cancer: report at once
2. After TURP
   • Continuous bladder irrigation: titrate the rate so drainage is light pink; output minus irrigant = true urine output
   • Bright-red urine with clots, falling blood pressure = hemorrhage — increase irrigation per protocol and notify
   • Bladder spasms: check catheter patency first (clots); give antispasmodics as ordered; do not let the client strain
   • Watch for TUR syndrome (dilutional hyponatremia from irrigating fluid): confusion, nausea, bradycardia, hypertension, seizures — check sodium. The risk is mainly with hypotonic irrigant (monopolar TURP) and much lower with bipolar TURP using saline
3. Catheter care — secure, keep the bag below bladder level, monitor for infection; remove as soon as indicated
4. Pain management — scrotal support and ice for epididymitis and after scrotal surgery
5. After radical prostatectomy — Foley care (often 1–2 weeks), leg bag teaching, pelvic floor (Kegel) exercises for incontinence; ED counseling
6. Psychosocial support — fertility, sexuality, and body image; privacy and non-judgmental communication

• Alpha blockers: rise slowly; take doxazosin or terazosin at bedtime and tamsulosin about 30 minutes after the same meal daily; report dizziness or fainting; tell eye surgeons you take them
• Finasteride/dutasteride: pregnant partners must not handle broken tablets; benefit takes months; PSA will fall
• BPH self-care: void when the urge occurs, double void, limit fluids in the evening, limit caffeine and alcohol, avoid over-the-counter cold and allergy medicines that contain decongestants or antihistamines
• After TURP: drink 2–3 L/day unless restricted; avoid straining, heavy lifting, and prolonged sitting for several weeks; stool softeners; blood-tinged urine can occur around 10–14 days when the scab separates — report heavy bleeding or clots; retrograde ejaculation (dry orgasm) is common
• PSA screening decision (see Country Notes): a shared decision about benefits (small reduction in deaths) and harms (false positives, overdiagnosis, incontinence, ED)
• Testicular self-awareness: know what is normal; examine after a warm shower, rolling each testis gently between thumb and fingers and comparing the two sides; report any painless lump, heaviness, or change promptly
• STI prevention: condoms, partner treatment, abstain until treatment is complete; primary syphilis is treated with penicillin even though the chancre heals on its own
• Circumcision care (newborns): petroleum-coated gauze or ointment on the glans at diaper changes, change diapers often to keep the site clean, yellow crust after day 1–2 is normal healing; report bleeding more than a few drops, no urination within 12 hours, or signs of infection

• BPH: smooth, firm, symmetric enlarged prostate; obstructive and irritative symptoms
• Prostate cancer: hard, nodular prostate; PSA and MRI then biopsy; bone metastases
• Alpha blockers: orthostatic hypotension, do not shrink the gland; 5-ARIs shrink the gland, lower PSA, teratogenic to handle
• Avoid decongestants and antihistamines with BPH
• CBI after TURP: light-pink drainage; subtract irrigant from output; check patency for spasms
• TUR syndrome = hyponatremia
• Testicular torsion: sudden pain, high-riding testis, no cremasteric reflex — surgery within 6 hours
• Testicular cancer: painless mass, age 15–35; AFP, beta-hCG, LDH; inguinal orchiectomy; sperm banking
• PDE5 inhibitors never with nitrates; priapism over 4 hours is an emergency
• Alprostadil: intracavernosal vasodilator for ED
• Denosumab: check calcium first
• Painless indurated chancre = primary syphilis; heals in 3–6 weeks but needs treatment