REPRODUCTIVE
HEALTH ISSUES FOR
ADOLESCENT MALES
Topics to be covered
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Normal male pubertal development
Sexuality and sexual activity
Male reproductive health evaluation
History
„ Physical exam
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Sexually transmitted infections
Testicular problems
Physical Changes During Puberty
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Development of secondary sexual
characteristics: genitalia, pubic hair (assessed
by Tanner stages)
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Final phase of linear growth (“growth
spurt”/peak height velocity)
Increase in weight
Changes in body shape and composition
(males: wider shoulder girdle, more muscle mass)
Growth and development of most organs,
including brain, heart, musculo-skeletal
system
Axillary hair; facial hair and voice changes
TANNER STAGES
Sequence of pubertal changes in males
Key Events in Male Pubertal
Development
EVENT
TYPICAL
AGE (yr)
NL AGE RANGE (yr) TANNER
STAGE
Testicular
enlargement
11.4
10-14
2
Pubic hair starts
12
10.7-12.7
2
Significant increase
in penile length
13
11.7-14.5
3
Spermarche
13.5
11.5-15.5
3
Peak height velocity 14
11.5-16
3-4
Axillary hair, early
facial hair
13-16
4-5
13-17
5
14.5
Adult size testes and 15
PH distribution
Gynecomastia
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Common finding in boys
Usually results from a relative imbalance of estrogen activity to
androgen activity: peak estradiol levels may be reached before
peak testosterone levels (thus, not due to excessive level of estrogen)
Peak prevalence: 64% at 14 yrs, with onset at SMR 2 for 50%
Bilateral in 77-95% of cases
Can be painful
Can be severe (> 4 cm of breast tissue)
Typically resolves by late adolescence
Gynecomastia
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(continued)
DDX: pubertal gynecomastia, drug exposure [including:
estrogen,
anabolic steroids, HCG, digoxin, spironolactone, cimetidine, alkylating agents],
excess adipose tissue*, Klinefelter syndrome, hyperthyroidism,
renal failure, cirrhosis, breast tumor
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Management: reassurance –- most will resolve in 6-12 mos;
surgical referral if severe, persistent and psychological sequelae
* = “adipomastia” , not breast tissue
Sexuality
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Involves a complex interaction between biologic
sex, sexual attraction toward others, sexual
behavior, societal expectations
Sexual identity (gay, lesbian, bisexual,
heterosexual, unsure) may be “fluid” during
adolescence; thus better to ask about attractions
and behaviors, rather than “are you
gay/straight/etc.?”
Sexual activity in male teens:
Epidemiology (YRBSS 2011)
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9% of males have had vaginal intercourse at least once
< 13 years old
49% of males have had vaginal intercourse at least once
by 12th grade
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Only 1/3 of these had sex within the past 3 months
(“currently sexually active”)
18% of HS males had > 4 lifetime partners
67% used a condom with last vaginal intercourse
Condoms: Efficacy
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Preventing pregnancy
Absolutely correct and consistent use: 97%
„ Typical use: 85%
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Preventing STIs
Consistent use significantly decreases transmission
of: HIV, gonorrhea, Chlamydia, ureaplasma
„ If the infected area is covered by a condom,
protective against: HSV, HPV, syphilis
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Teens and Condoms
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Most likely to be used with first sexual
intercourse rather than with subsequent
intercourse
At last sexual intercourse: used about 2/3 of the
time
More likely to be used by younger teens than
older teens
More likely to be used with “casual” partner as
compared to “usual” partner
Condoms: What can go wrong?
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Inconsistent use
Non-use
Incorrect use
Breakage (~ 2-3% of condoms break during
intercourse or during withdrawal)
Abstinence Counseling
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Abstaining from sexual intercourse is a healthy choice
for teens
Remaining abstinent until older (or until married) is
strongly supported by parents and by many teens;
however, in reality, abstinence is not maintained by the
majority of teens
Evidence shows that abstinence-only sex education
programs are NOT effective at delaying sexual
intercourse
Evidence shows that promoting abstinence, as part of a
comprehensive reproductive health program, IS
effective at delaying intercourse
Sexual Dysfunction in Teen
Males
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Not an uncommon problem; when taking a
sexual history, important to ask about this
Types:
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Erectile dysfunction (impotence)
„ Etiologies include:
depression, anxiety, “environmental”,
medical conditions [diabetes, sickle cell, other chronic
diseases, STI, neurologic disorder, medications, marijuana,
alcohol]
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Premature ejaculation
„ Etiology:
usually anxiety-related
Taking a Reproductive Health
History
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Pubertal changes—growing normally? any
concerns?
Sexual desires—any romantic relationships?
attracted to females, males or both? If males, do
you think of yourself as gay? bisexual? unsure?
Sexual experiences—ever? what type? ever
forced? If not SA, thinking about/planning it?
Pregnancy/STI prevention methods?
Any GU symptoms?
What you might miss if you don’t do
a thorough genital exam
(also good time to ask if concerns & discuss normal findings)
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Abnormal development—delayed or
dysynchronous puberty
Penile problems—hypospadias, phimosis,
discharge
Hernia
Testicular problems—varicocele, mass,
hydrocele, undescended or hypoplastic
Skin lesions—warts, molluscum
Peri-anal exam—fissures, tags, hemorrhoids
Sexually Transmitted Infections:
Urethritis
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Etiologies
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Clinical presentation
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Chlamydia (most common cause < 25 yo)
Gonorrhea
Other: Ureaplasma, Mycoplasma, Trich, HSV
Symptoms: none; dysuria; purulent discharge
Exam: normal; purulent urethral discharge
Diagnostic tests – urethral swab or urine
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Nucleic acid amplification tests
For gonorrhea: culture, gram stain [rarely done now]
Urethritis
Urethritis: Treatment Options
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Gonorrhea*
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Chlamydia
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Ceftriaxone 250 mg IM X 1
AND azithromycin 1 gm X 1 or doxycycline 100 mg BID X 7 d
Azithromycin 1 mg po X 1
Doxycycline 100 mg po BID x 7 days
Ureaplasma; Mycoplasma – as for Chlamydia
Trichomonas
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Metronidazole 2 gm po X 1
*changed 8/12
Epididymitis
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Etiology: Chlamydia or gonorrhea (rarely urinary
pathogens in young men)
Clinical
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Diagnostic tests
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Mild/moderate testicular pain and swelling; usually gradual in
onset
Occasionally dysuria precedes other symptoms; rare: fever,
systemic signs
Test for Chlamydia and gonorrhea
Urine culture (always if pt has not been sexually active)
If cannot R/O torsion: Doppler US or nuclear scan
Treatment: treat underlying infection
Epididymitis
Other STIs: HPV
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Usually types 6 and 11 [low oncogenic potential but HPV is
the main cause of penile and anal cancers]
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Condyloma accuminata: external warts
Subclinical disease
Diagnosis: physical exam; HPV testing not indicated in
males
Treatments
Prevention
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Condoms
Future: vaccine
Genital HSV
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Primary (often with systemic symptoms) vs. recurrent infection
Clinical
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Diagnostic tests
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Itchy/tingly papules in a group Æ vesicles on an erythematous base Æ
painful ulcers on an erythematous base
May have: inguinal adenopathy, dysuria, clear urethral discharge
PCR
Culture (if intact vesicles)
Serology [limited utility]
Treatment of acute infection
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Valcyclovir 1 mg po BID X 7-10 d
Acyclovir 400 mg po TID X 7-10 d
Famcyclovir 250 po mg TID X 7-10 d
Other infections transmitted through
sexual contact
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Molluscum contagiosum (groin, thighs)
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Scabies (genital area, others)
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Pubic lice
(pubic hair)
Testicular Problems: Varicocele
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Etiology: dilation and tortuosity of the veins of the pampiniform
plexus (=varicose veins)
Clinical
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Found in 10-15% of males; becomes evident in adolescence
85-90% occur on the left side; 10% bilateral
“bag of worms” in the scrotal sac felt by patient or examiner; occasional
achiness/discomfort, especially after activity
Implications: decreased fertility in some
Treatment
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Surgery if decreased sperm count or ipsilateral testicle much smaller
[controversial]; may not reverse fertility concern
Varicocele
Testicular Problems: Hydrocele
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Fluid collection within the tunica vaginalis due to
incomplete closure of the processus vaginalis
Clinical
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Usually found in infancy; rarely lasts to adolescence
Painful if tense
Can palpate testicle separate from swollen scrotum
May be associated with a hernia
Diagnostic tests: transilluminate
Treatment: ? Elective surgery
Hydrocele
Testicular Problems: Torsion
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Clinical
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Diagnostic tests: If diagnosis is in doubt: color Doppler US or nuclear scan
[see no/decreased flow]
Treatment: urgent surgery
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Peak age: 12-18 years old
Acute onset of pain; often with nausea, vomiting; no urinary symptoms; ½ have
prior history of less severe pain
PE: swollen, tender testicle that is higher than the contralateral one
Surgery within 6 hours: 100% recovery of testicle
Surgery in > 12 hours: 20% recovery of testicle
TORSION OF THE APPENDIX OF THE TESTIS
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Early on, pain localized to superior pole of testicle; later diffuse pain and swelling
See “blue dot” through scrotal skin
Surgery needed only if extreme pain
Non-testicular Torsion
Testicular Cancer
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Epidemiology
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Most common solid tumor in young men (15-35 yo)
Most are germ cell: pre-pubertal – teratoma
post-pubertal -- seminoma
10-40X increased risk if history of cryptorchidism
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Clinical
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Painless, hard nodule on the testicle
„ May have sense of fullness
„ Recent genital trauma may call attention to the problem
„ Systemic symptoms (if metastatic)
Diagnostic tests: ultrasound; serum markers (ß-HCG, AFP); biopsy
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Treatment: orchiectomy ± chemotherapy
Prognosis: > 95% cure rate if Stage I seminoma
Testicular self-exam – USPSTF states “no evidence that teaching young men
how to examine themselves for testicular cancer would improve health
outcomes…”