10 - Prostate and Genital Tract Flashcards

Question

What are some of the symptoms of prostate cancer what are some differential diagnoses for this? 3

Answer 1

**- LUTS**: weak urinary stream, increased urinary frequency, and urgency **- Advanced localised disease:** haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain, rectal tenesmus (incomplete feeling) **- Metastatic:** bone pain, lethargy, anorexia, and unexplained weight loss. **- DRE:** asymmetry, nodularity, or a fixed irregular mass **DD:** BPH, prostatitis, bladder cancer

Answer 2

**- PSA:** however may be artifically raised **- Free:total PSA ratio** **- PSA density:** which is the serum PSA divided by prostate volume determined by imaging (i.e. TRUS, CT, or MRI) **- Transperineal (Template) biopsy:** general anaesthetic and less infection **- TRUS biopsy:** local anaesthetic, 12 cores, risk of sepsis

Answer 3

- Repeat if negative biopsy but rising PSA or suspicious DRE - Repeat if atypical small acinar proliferation (ASAP) or \>3 sites of high-grade prostatic intraepithelial neoplasia (HGPIN),

Answer 4

Low grade: 3+3 = 6 Intermediate: 3+4 = 7 High grade: 7,8,9, 10

Answer 5

**- Multi-parametric MRI** can identify abnormal prostate so you can biopsy **- Abdomino-pelvic CT imaging** and **bone scan**

Answer 6

Risk stratification based on PSA levels, Gleason score, and T staging (from TNM). **Low risk:** active surveillance, if signs of progression then radical prostatectomy **Intermediate and high risk disease:** radical prostatectomy, some intermediate can have surveillance **Metastatic disease:** chemotherapy agents and anti-hormonal agents **Castrate–resistant disease:** further chemotherapy agents such as Docetaxel. Corticosteroids are used as third line if androgen deprivation therapy and anti-androgen therapy doesn't work

Answer 7

**- Radical prostatectomy:** removal of the prostate gland, resection of the seminal vesicles, along with the surrounding tissue +/- dissection of the pelvic lymph nodes **- External-beam radiotherapy:** focused radiotherapy just to target prostate gland **- Brachytherapy:** transperineal implantation of radioactive seeds

Answer 8

- Erectile dysfunction (affecting 60-90% of men) - Stress incontinence - Bladder neck stenosis

Answer 9

- 3-monthly PSA - 6 month to yearly DRE - Re-biopsy at 1-3 yearly intervals Look for active progression

Answer 10

**_Chemotherapy_** - Used in metastatic diease - **Docetaxel** (recommended in men with testosterone-resistant cancer) and **Cabazitaxel** (used with prednisolone, recommended for treating relapsed prostate cancer) **_Anti-androgen Therapy_** **- LHRH agonists** (e.g. goserelin or triptorelin) stops LH production **- GnRH receptor antagonists** (e.g. degarelix) - Orchidectomy for androgen deprivation - Enzalutamide and Abiraterone lower testosterone in metastatic disease

Answer 11

- Acute bacterial prostatitis - Chronic bacterial prostatitis - Nonbacterial prostatitis - Prostatodynia

Answer 12

Usually from **ascending urethral infection** but can be from bacterial sepsis, lymph nodes from rectum Usually due to **E.Coli** but also due to Enterobacter, Serratia, Pseudomonas, Proteus and Chlamydia/Gonorrhea rarely

Answer 13

**Acute:** LUTS, pyrexia, perineal or suprapubic pain, or urethral discharge, tender boggy prostate on DRE, inguinal lymphadenopathy **Chronic:** pelvic pain for at least 3/12 (Prostatodynia) alongside LUTS with pain usually in perineum but can be in suprapubic, lower back and rectum

Answer 14

**- 1st line:** urinalysis to guide abx choice **- STI and routine blood screening** - If fails to respond to abx need to do TRUS or CT to rule out perineal abscess

Answer 15

Acute **- Prolonged abx** (usually quinolone like ciprofloxacin as good prostate penetration) **- Analgesia** (paracetamol and NSAIDs) - Alpha blockers of 5a-reductase inhibitors for second line **_Chronic_** - 6 week abx if present for less than 6/12 - Symptom control with analgesia, stool softeners, alpha blockers - If pain persists chronic pain specialist

Answer 16

- Bimodal common age distribution **aged 15-30** then **\>60 years** - **Extension of infection from lower urinary tract** (bladder and urethra), either via enteric (i.e. classic UTI) or non-enteric (i.e. sexually transmitted) organisms. - **\<35 usually due to sexual transmission** of N. gonorrhoeae and C. trachomatis (if anal intercourse then E.Coli) - **\>35** usually due to enteric bacteria like E. coli, Proteus spp, Klebsiella pneumoniae, Pseudomonas aeruginosa due to **bladder outflow obstruction due to enlarged prostate** so allows organisms to travel retrograde

Answer 17

**Non-enteric:** males who have sex with males, multiple sexual partners, sex with known contact of gonorrhea **Enteric:** recent instrumentation or catheterisation, bladder outlet obstructuon (e.g prostate enlargement or urethral stricture) or immunocompromised state

Answer 18

**_Symptoms_** ## Footnote - **Unilateral scrotal pain** and swelling with possible **fever** and rigors - May have **LUTS** due to underlying cause e.g dysuria, urethral discharge - Find out sexual history **_Examination_** - Red and swollen - Tender on palpation with possible associated hydrocele - Cremasteric reflex in tact - Prehn's sign **_Differentials_** - Testicular torsion - Testicular abscess or tumour - Epididymal cyst - Hydrocele

Answer 19

**- Urine dipstick** and possible MSU (if non-enteric suspected take **first void urine** then **NAAT** for G,C and M.Genitalium) - Further **STI screening** **- Routine bloods** (CRP and FBC) and **blood cultures** if signs of systemic infection **- US Doppler** to confirm and rule out complications. If suspect torsion from this urgent scrotal exploration

Answer 20

**- Abx** (see image) **- Analgesia** - Bed rest and scrotal support - Abstain from sex until abx done - If chronic or persisting with pain then may warrant orchidectomy

Answer 21

- Reactive hydrocele - Abscess - Testicular infection

Answer 22

**- Mobile testis rotates on spermatic cord,** reduced arterial flow, impaired venous return so oedema and infarction to testes - Men with **Bell-Clapper deformity** more likely to twist as testis lacks normal attachment to tunica vaginalis so more mobile **_- Risk Factors:_** Age (12-25), previous testicular torsion, FHx, undescended testes

Answer 23

**_Symptoms_** ## Footnote - Sudden onset severe unilateral testicular pain - Nausea and vomiting due to pain - Referred abdominal pain **_Examination_** - Testis will have a high position - Swollen and tender to touch - Cremasteric reflex absent - Prehn's sign negative

Answer 24

- Epididymo-orchitis (gradual onset of pain, LUTs, Pyrexia) - Trauma - Incarcerated inguinal hernia - Renal colic - Hydrocele - Torsion of hyatid of Morgagni

Answer 25

**_Ix_** ## Footnote - If suspected take straight for **scrotal exploration** with **strong analgesia, anti-emetics** and **NBM** - If not enough evidence **Doppler US** to see if compromised blood flow - Urine dipstick **_Mx_** - Surgical emergency with 4-6 hour window **- Bilateral orchidopexy** once confirmed intra-operatively to prevent further torsion - If tissue non-viable **orchidectomy** and **possible prosthesis**

Answer 26

- Testicular infarction if \>6hrs till treatment - Atrophy - Chronic pain - Palpable suture - Risk to future fertility - Risk of another torsion

Answer 27

- Most common in men aged 20-40 years or that are Caucasian - Germ Cell (malignant) or Non-Germ Cell (Benign) - Seminoma (better prognosis) or Non-Seminoma

Answer 28

**- Cryptorchidism** - Previous testicular malignancy - FHx - Kleinfelter’s syndrome

Answer 29

**- Unilateral painless testicular lump** - Irregular, firm, fixed lump that does not transilluminate - No lymphadenopathy as metastasises to paraaortic nodes - Evidence of metastases: weight loss, back pain (retroperitoneal metastases), or dyspnoea (lung metastases) **_Differentials:_** epididymal cyst, haematoma, epididymitis, or hydrocoele

Answer 30

**_Tumour markers:_** **- b-hCG** in NSGCTs and seminomas or **AFP** in non-seminomas **- LDH** for tumour volume usually seminomas **_Scrotal US_** for inital lump investigation then **_CT with contrast of chest/abdo/pelvis_** Diagnosis purely on markers and imaging. **Biopsy not done due to seeding!!!**

Answer 31

Dependent on tumour subtype, disease stage, and risk scoring. Most will have **inguinal radical orchidectomy** (remove testes, spermatic cord and lymph) **_NSGCTs_** - **Orchidectomy** then if **low risk** (no vascular invasion) just **surveillance**. If **high risk**, give **adjuvant chemotherapy** before surveillance - If **metastatic** give **cycles of chemotherapy** if intermediate prognosis but if poor prognosis just **one cycle of chemo** **_Seminomas_** - **Orchidectomy** and **surveillance monitoring.** If high chance of relapse consider chemo - If **metastatic chemo** or **radio**

Answer 32

- Pretreatment fertility assessment with semen analysis - Cryopreservation This is because cancer often causes sperm abnormalities and Leydig cell dysfunction and then chemo/radio can also reduce fertility

Answer 33

- Risk of secondary malignancies due to chemo and radio exposure e.g leukaemia - High rate of complete remission

Answer 34

**Gonococcal urethritis:** N.Gonorrhoeae **Non-Gonococcal urethritis:** C.Trachomatis, M.Genitalium, T.Vaginalis **Risk factors:** men aged \<25, men who have sex with men, new sexual partner, more than one sexual partner in a year, previous STI

Answer 35

**Dysuria, penile irritation,** **discharge from urethral meatus** Can present with complications like **reactive arthritis** or **epididymitis**

Answer 36

**_Ix:_** ***- Gold standard:*** First void urine sent for NAAT for N.Gonorrhoeae, C.Trachomatis, M.Genitalium **- Urethral gram stain** from swab. Triple site testing if suspect gonorrhoeae **- MSU dipstick** **- Further STI screening** for HIV/syphillis

Answer 37

**- Abx therapy** **- Abstain from sexual activity** for 7 days after antibiotics, symptoms have resolved and sexual partners are treated **- Test of cure** if gonorrhoea - Counsel on condom use and contact tracing

Answer 38

**Necrotising fascitis of the perineum** that is a urological emergency Can be mono or polymicrobial (**Group A Strep, C.Perfringes, E.Coli)** **Anatomic barriers** stop testes and epididymis being involved (Dartos fascia of the penis/scrotum, Colles fascia of perineum, Scarpa fascia of anterior abdominal wall)

Answer 39

- Initially **pain out of proportion to findings** or **pyrexia and small amount of cellulitis** - As progresses **crepitus, skin necrosis, haemorraghic bullae** and **sensory loss** of overlying skin - Patient rapidly deteriorates and can go into septic shock - **_Risk factors_**: Type 2 DM, excess alcohol, poor nutritional state, steroid use, haemotological malignancies, recent trauma to area

Answer 40

**_Dx_** - Clinical diagnosis - Can take blood **routine bloods, cu****ltures**and work out**LRINEC**to see if**6 or more** **_Mx_** **- Urgent surgical debridement** **- Partial or total orchiectomy** **- Broad spectrum abx** - Transfer to high dependency unit - Further surgical debridement and skin grafts to recover scrotum Laboratory Risk Indicator for Necrotizing Fasciitis score

Answer 41

- **Inability to pull retracted foreskin over glans penis which is an emergency** - Glans becomes oedamtous which can reduce venous return and lead to vascular engorgement so **penile ischaemia, worsening infection, Fournier's gangrene** **_- Risk factors:_** phimosis, indwelling urethral catheter, poor hygeine, previous paraphimosis

Answer 42

**_Presentation_** - Progressive pain and swelling with inability to retract foreskin - May occur often if cause not managed **_Management_** **- Reduce ASAP** with **penile block** with local anaesthesia for analgesia **- Definitive management** such as circumsion can occur as **outpatient**

Answer 43

Painful erection not associated with sexual desire that lasts for more than 4 hours **_High Flow (Non-ischaemic)_** - **Arterial blood rapidly enters** the **corpus cavernosum quicker than it can be drained**. Associated with trauma and can be triggered by sexual stimulation - PAINLESS AND NOT FULLY RIGID **_Low Flow (Ischaemic)_** **- Blockage of the venous drainage of the corpus cavernosum** so blood collects here, causes ischaemia and can lead to fibrosis and impotence - Urological emergency - Glans and Spongiosum not affected - PAINFUL AND RIGID

Answer 44

**- Idiopathic** in half of patients **- Non ischaemic:** penile/perineal trauma, spinal cord injury **- Ischaemic:** see image

Answer 45

- Once initial management done obtain **corporeal blood gas** to determine if **ischaemic** or **non-ischaemic** **- Routine bloods** to find underlying cause (FBC, CRP, ESR, coagulation screen, bone profile, haemoglobin electrophoresis) - If non-ischaemic do work up for potential spinal cord injury

Answer 46

**Corporeal Aspiration!** If no response give **intracavernosal injection of sympathomimetic agent** like phenylephrine If above not working promt **surgical shunt** between corpus cavernosa and glans. **Can cause ED** - If priapism lasts \>24 hours most people do not regain ability to have sexual intercourse so consider penile prosthesis

Answer 47

- Most common in men\>60 - Strong association with **HPV 16, 6** and **18** **- SCC** from the epithelum of the **inner prepuce or glans** in 95% of cases **_Risk factors:_** HPB, phimosis, smoking, lichen sclerosis, untreated HIV, previous PUVA for psoriasis **_Protective factors:_** Circumsion

Answer 48

- **Palpable or ulcerating lesion** on penis most commonly on **glans** - Lesion is **painless** but **may discharge or bleed** **- Inguinal lymphadenopathy**

Answer 49

**- Malignancy** **- Infections** e.g Herpes Simplex or syphilis **- Inflammatory conditions** e.g balanitis, psoriasis, lichen planus **- Premalignant** e.g Condylome acuminatum (genital warts), Bowens disease, Lichen sclerosus

Answer 50

**- Penile biopsy** **- PET-CT imaging of inguinal lymphadenopathy** once diagnosed with biopsy **- CT chest/abdo/pelvis for staging**

Answer 51

Combination of surgery, radio, chemo - If **superficial non-invasive** can give **topical chemo** (e.g imiquimod or 5-FU) then **follow up with repeat biopsy**. Or can use **laser treatment** or **glans resurfacing** - If i**nvasive but confined to the glans** can do **organ sparing treatment** with 5mm tumour margins. **Local excision, partial glansectomy** or **total glansectomy with reconstruction**. Radical circumsion if confined to foreskin - If **invasive partial amputation** or **total penectomy with perineal urethrostomy**. Afterwards **phallic reconstruction** with forearm phalloplasty May need **neoadjuvant chemo or radio** - If in inguinal nodes may need **radical inguinal lymphadenectomy**, neoadjuvant chemo or radio

Answer 52

Urological emergency common in 30-40 year olds and more commone to occur damage on the right side **Rupture of corpus cavernosa and the tubica albuginea** in an **_erect penis_** Due to **blunt trauma** up to pressure of 1500mmHg where **penis is violently deviated from axis** e.g forceful masturbation, falling from bed with erect penis, partner on top

Answer 53

**- Popping sensation** with **immediate pain, swelling, detumescence** after forceful thrusting into pubic bone of partner **_- Aubergine Sign_:** penile swelling and discolouration (due to haematoma) with deviation to opposite side of lesion **_- Rolling Sign:_** firm immobile haematoma palpated in the shaft May be **butterfly shaped haematoma** in the perineum may suggest a **urethral injury**

Answer 54

- Rupture of the dorsal artery or veins - Rupture of suspensory ligaments These do not have a popping sensation felt

Answer 55

**_Ix/Dx_** - Diagnosed clinically **- Cavernosography** can be used to identify rupture site but associated with complications like priapism and fibrosis of corpus cavernosum **- Retrograde urethography** if patient has symptoms suggesting urethral injury e.g voiding difficulties or blood at meatus **_Mx:_** - **Analgesia and anti-emetics** before **urgent surgical exploration and repair** - Surgical exploration involves circumferential incision and **penile skin degloved** proximally up to base, **haematoma evacuated** then **tear identified and repaired with absorbable sutures** **- Abstinence** from all sexual activities for 6-8 weeks post op

Answer 56

- Penile curvature during erection - Penile paraesthesia - Dyspareunia Painful sex - Painful erection