4 - Male Urology Flashcards

1
Q

What is phimosis?

A
  • Foreskin cannot be fully retracted from around the tip of the penis
  • Normal to be non-retractable in adolescence, e.g 50% cannot be retracted at 1 year
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2
Q

What can be the consequences of phimosis?

A
  • Poor hygeine so more STDs
  • Pain
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3
Q

What is Balantis Xerotica Obliterans?

A
  • Lichen sclerosus of the male genitalia
  • A chronic, often progressive disease, which can lead to phimosis and urethral stenosis
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4
Q

What is paraphimosis and what are the most commonest causes?

A
  • Foreskin can no longer be pulled forward over the tip of the penis causing the foreskin to become swollen and stuck
  • Phimosis, Catheterisation (esp the elderly) and Penile Cancer are all causes
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5
Q

How do you treat phimosis and paraphimosis?

A

- Circumsion for phimosis (be careful if have phimosis and balantis, may have underlying cancer)

  • Needs reduction manually or dorsal slit may be necessary
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6
Q

What type of cancer is penile cancer and what are the risk factors?

A

- Squamous cell carcinoma

  • Really rare
  • Phimosis, hygeine and smegma are risk factors
  • HPV 16 and 18 are risk factors
  • Untreated most die in two years
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7
Q

Why may a male have a circumsion?

A
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8
Q

What are some of the causes of acute scrotal pain?

A
  • Testicular torsion
  • Epididymitis/Orchitis/Epididymoorchitis
  • Torsion of hyatid of Morgagni
  • Trauma
  • Ureteric calculi (referred pain, often blood in urine)
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9
Q

What can epididymitis be caused by?

A
  • UTIs
  • STIs
  • Mumps
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10
Q

How would testicular torsion present?

A
  • Younger patient
  • Sudden onset e.g wake to pain (sudden onset normally means vascular supply is effected)
  • Unilateral pain
  • May be vomiting and no LUTS
  • Tender testes that lie high and horizontal in scrotum

EMERGENCY SCROTAL EXPLORATION - don’t waste time with tests - must be seen within 2-6 hours

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11
Q

What would you see in the history and examination of a male with epididymo-orchitis?

A
  • Gradual unilateral onset
  • Recent history of UTI, unprotected sex, mumps, catheter
  • Age 20-40 STI (Chlaymdia) and 40/50 often UTI (E.Coli)
  • Pyrexial
  • Red enlarged tender testis or epididymis
  • May have reactive hydrocoele or fluctuant areas showing an abscess
  • Fournier’s Gangrene (high mortalitiy)
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12
Q

What is Fournier’s gangrene?

A

Type of necrotizing fasciitis affecting the external genitalia as a complication of epididymitis, more common in poorly controlled diabetes

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13
Q

How do you investigate suspected epididymoorchitis and treat it?

A
  • Blood cultures and FBCs
  • Mid stream urine sample
  • Scrotal ultrasound if suspected abscess
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14
Q

What are some questions you need to ask when a male presents with a scrotal lump?

A
  • Is it painful?
  • How quickly has it occured?
  • Can I get above it? If yes it is scrotal in origin
  • Is it in the body of the testes? If yes it could be a tumour
  • Is it separate to the testis?
  • Does it fluctuate and transilluminate?
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15
Q

What are some common causes of scrotal lumps?

A

Painless:

  • Testis tumour
  • Epididymal cyst
  • Hydrocoele
  • Reducible inguino-scrotal hernia
  • Varicocoele (aching at end of day)

Painful:

  • Epididymitis
  • Epididymo-orchitis
  • Stranfulated inguino-scrotal hernia
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16
Q

What is the history of a testicular tumour and what should be the treatment plan if you suspect this?

A
  • Usually a painless lump you can get above
  • Usually a germ cell tumour if aged<45 and risk factor of a history of maldescended testis. In older men can be lymphoma

- Urgent 2 week referral to urology for testis tumour markers (aFP, hCG, LDH) and arrange urgent ultrasound

17
Q

What would a hydrocele appear like on history and examination?

A
  • Slow or suddent onset and can be bi/unilateral
  • Imbalance in the fluid production and resorption between tunica albuginea and tunica vaginalis
  • Testis may not be palpable separately

- Transilluminates

  • Can get above
18
Q

How does an epididymal cyst present on examination?

A
  • Usually painless
  • Separate from the testis
  • Can get above the mass
  • Transilluminates
19
Q

How does a varicocele present?

A
  • Dull ache at the end of the day
  • Bag of worms above testis
  • Not tender
  • More common in left than right
  • Can be associated with reduced fertility or renal pathology so check for palpable abdominal mass

→ transilluminate

20
Q

How do we treat the following scrotal lumps?

  • Testicular tumour
  • Epididymal Cyst
  • Hydrocele
  • Varicocele
  • Inguino-scrotal hernia
A
21
Q

What are some of the causes of urinary retention? (more common in males than females)

A
  • Prostatic enlargement e.g BPH or prostate cancer
  • Phimosis/Urethral Stricture/Meatal stenosis
  • Constipation
  • UTI
  • Anticholinergic drugs (e.g schizophrenia drugs and drugs for overactive bladder)
  • Over distension e.g drunk too much at party
  • Following abdominal surgery (from nerve damage or the anaesthesia)
  • Neurological
22
Q

What are the three different types of urinary retention and how do we treat them?

A

Acute: TWOC after fixing the main cause e.g constipation (pain relived by drainage)

Chronic: intermittent self catheterisation , painless/less painful. Abdominal swelling

Acute-On-Chronic: long term catheter or surgical intervention. Painful

23
Q

When an older man presents with eneuresis what is your initial diagnosis?

A

Chronic retention with overflow incontinence until proven otherwise

24
Q

What are the two different categories of LUTS (lower urinary tract symptoms) and what can be some of the causes of each category?

A

Storage: irritative (stones), overactive bladder (idiopathic or neuropathic e.g MS), low compliance of bladder from scarring (TB and schistomiasis), polyuria

Voiding: bladder outflow obstruction (e.g phimosis, BPH), lack of coordination between bladder and urinary sphincter due to upper motor neurone lesion, reduced contractility due to lower motor neurone lesion

25
Q

What are some causes of polyuria?

A

Global: uncontrolled type 2 diabetes

Nocturnal: venous stasis and sleep apnoea as ANP released causing polyuria

26
Q

What are some causes of bladder outflow obstruction?

A

Physical

  • Phimosis
  • Urethral stricture
  • BPH / bladder neck

Dynamic

  • High sympathetic smooth muscle tone by A1 receptors, prostate and bladder neck

Neurological

  • UMN lesion so lack of coordination between bladder and urinary sphincter
27
Q

How can we assess a patient’s LUTS, especially when suspecting BPH?

A

International Prostate Symptom Score (IPSS)

28
Q

Apart from filling out an IPSS what do you need to investigate when a male patient presents with LUTS?

A

Examination

  • DRE
  • Is the bladder palpable
  • Neurological exam

Investigations

  • Dipstick ?UTI or bLOOD
  • Consider PSA
29
Q

How can BPH be managed in primary care?

A

Lifestyle changes:

  • Avoid fizzy drinks
  • Reduce caffeine intake
  • Don’t drink more than 2.5L a day

Drugs:

  • Alpha Blockers → reduce smooth muscle in the neck of the bladder and prostate / rapid symptom relief
  • 5-Alpha-Reductase Inhibitors
30
Q

What is the mechanism of action of the drugs used to treat BPH and what are their side effects?

A

Alpha Blockers (Tamsulosin)

MOA: relax smooth muscle within the prostate and bladder neck. rapid symptom relief

Side effects: postural hypotension so can cause falls in elderly, headache, dizziness, problems ejaculating

5ARIs (Finasteride or Durasteride)

MOA: shrink the prostate by preventing the conversion of testosterone to DHT. slower symptom relief but reduces the risk of retention

Side effects: ED, loss of libido, difficulty orgasming, dizziness

31
Q

How is BPH managed if lifestyle changes and drugs don’t work?

A
  • Referred to secondary care and will do a flow rate study before surgery
  • Do TURP by laser to make cavity bigger
32
Q

What are the pros and cons of having the PSA test to test for prostate cancer?

A

3 out of 4 men with a raised PSA will not have prostate cancer and PSA will miss 15% of cancer diagnoses

+ May be reassurance if the test is normal

+ Can find early signs of cancer

  • Can miss cancer and provide false reassurance
  • Cannot tell the difference between fast and slow growing cancers and may make you worry about a slow growing cancer that would cause no harm anyway
  • May mean you have lots of tests you don’t really need
33
Q

What should a male do before having a PSA test?

A
34
Q

How would you explain to a patient what NNT means?

A

Number of patients you need to treat to prevent one additional bad outcome (e.g stroke or death)

35
Q

What is the definition of orchitis?

A

Testicular inflammation or infection

36
Q

what is urinary retention?

A

the inability to pass urine rather than to make urine

more common in males and rare in females

37
Q

what are some surgical treatments for an enlarged prostate

A
  • transurethral resection of prostate (TURP)
  • monopolar/laser/bipolar
38
Q

what main diagnosis should you make when there is a sudden onset of pain in the testies

A

torsion