1. Men's health

Question 1

What is phimosis? How is it caused?

Answer 1

Inability to fully retract skin - prepuce or foreskin - covering glans of penis.

Can be:

• physiological: tight foreskin during childhood that can persist during adolescence but normally resolves by 5-7 yrs
• pathological: due to scarring, infection or inflammation

Question 2

How would you manage phimosis? Why is this important?

Answer 2

Management = circumcision

Possible complications:

1. poor hygiene, increased STD risk
2. pain on intercourse, bleeding/splitting
3. balanitis (inflamed glans), posthitis (inflamed foreskin/prepuce), balanitis xerotica obliterans (BXO)
4. paraphimosis
5. urinary retention
6. penile cancer

Question 3

What is paraphimosis? How is it caused?

Answer 3

Painful constriction of glans penis by retracted prepuce proximal to the corona.

Can be caused by:

• phimosis
• catheterisation (pull foreskin back and forget to replace it)
• penile cancer

Question 4

How would you manage paraphimosis?

Answer 4

Reduction, usually achieved manually after anaesthetic penile block, but occasionally requires dorsal slit.

Question 5

What type of malignancy is involved in penile cancer?

Answer 5

squamous cell carcinoma

Question 6

Name 2 risk factors for penile cancer.

Answer 6

1. phimosis with poor hygiene and smegma accumulation (carcinogenic)
2. HPV 16 and 18

Question 7

Name 5 possible causes for acute scrotal pain.

Answer 7

1. testicular torsion
2. trauma
3. infection, e.g. epididymitis, orchitis, epididymo-orchitis (STDs, STIs, mumps)
4. torsion of Hyatid of Morgagni
5. ureteric calculi

Question 8

P presents with gradual onset unilateral scrotal pain. Testis is enlarged and tender, scrotum is reddened. Diagnosis?

Answer 8

Epididymo-orchitis (requires antibiotics, e.g. for STI, UTI)

Question 9

What is Fournier’s gangrene?

Answer 9

Necrotic area of scrotal skin - spread of black tissue - due to infection. High mortality rate (50%) Requires debridement and antibiotics.

Question 10

P presents with sudden onset unilateral pain, with testis tender and lying high in scrotum. Has nausea and vomiting. Diagnosis?

Answer 10

Testicular torsion (requires emergency scrotal exploration <6hrs)

Question 11

P presents with scrotal swelling that is not palpable separate from testis but transilluminates. Diagnosis?

Answer 11

hydrocoele - imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis (requires reassurance or surgical removal if large/symptomatic)

Question 12

P presents with painless scrotal swelling that is separate from testis (and can ‘get above’) and transilluminates. Diagnosis?

Answer 12

epididymal cyst (requires reassurance or excision if large)

Question 13

P presents with scrotal swelling that is not tender but aches at end of day and resembles a’bag or worms’. Diagnosis?

Answer 13

varicocoele (requires radiological embolisation if symptomatic, infertility or if present in adolescent and is restricting testicular growth)

Question 14

P presents with painless scrotal lump that is hard and associated with body of testis. Diagnosis? How would this be confirmed?

Answer 14

Testicular tumour

• USS scrotum
• check testis tumour markers (aFP, hCG, LDH)

Question 15

What are the 3 types of urinary retention? How will they affect the kidney?

Answer 15

1. ACUTE
   - pain (relieved by catheter drainage)
   - residual volume <1000ml
   - no kidney insult
2. CHRONIC
   - painless/less painful (may just notice abdominal swelling)
   - residual volume >300ml
   - may have kidney insult
3. ACUTE-ON-CHRONIC
   - pain
   - residual volume >1000ml
   - usually have kidney insult

Question 16

Name different causes for voiding symptoms.

Answer 16

1. Bladder outflow obstruction
   - urethral phimosis or stricture
   - prostate enlargement benign/malignant
   - neurological (UMN lesion): lack of coordination between bladder and urinary sphincter
   - increased sympathetic smooth muscle tone (prostate bladder neck) - a1 Rs
2. Reduced contractility
   - physical, e.g. scarring (after TB, schistosomiasis, pelvic radiotherapy), over-distension
   - neurological: anticholinergic drugs (e.g. psychiatric), LMN lesion

Question 17

Describe 2 types of drug that can be used to relieve urinary retention.

Answer 17

1. alpha blockers (e.g. Tamsulosin)
   - relax smooth muscle within prostate and bladder neck
   - rapid symptom relief
2. 5a-reductase inhibitors (5ARIs e.g. finasteride))
   - shrink prostate via androgen deprivation (convert testosterone to 5-dihydrotestosterone)
   - slower symptom relief (act over several months)
   - reduces risk of retention