4 - Male Urology Flashcards
What is phimosis?
- 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
What can be the consequences of phimosis?
- Poor hygeine so more STDs
- Pain
What is Balantis Xerotica Obliterans?
- Lichen sclerosus of the male genitalia
- A chronic, often progressive disease, which can lead to phimosis and urethral stenosis
What is paraphimosis and what are the most commonest causes?
- 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
How do you treat phimosis and paraphimosis?
- Circumsion for phimosis (be careful if have phimosis and balantis, may have underlying cancer)
- Needs reduction manually or dorsal slit may be necessary
What type of cancer is penile cancer and what are the risk factors?
- 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
Why may a male have a circumsion?
What are some of the causes of acute scrotal pain?
- Testicular torsion
- Epididymitis/Orchitis/Epididymoorchitis
- Torsion of hyatid of Morgagni
- Trauma
- Ureteric calculi (referred pain, often blood in urine)
What can epididymitis be caused by?
- UTIs
- STIs
- Mumps
How would testicular torsion present?
- 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
What would you see in the history and examination of a male with epididymo-orchitis?
- 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)
What is Fournier’s gangrene?
Type of necrotizing fasciitis affecting the external genitalia as a complication of epididymitis, more common in poorly controlled diabetes
How do you investigate suspected epididymoorchitis and treat it?
- Blood cultures and FBCs
- Mid stream urine sample
- Scrotal ultrasound if suspected abscess
What are some questions you need to ask when a male presents with a scrotal lump?
- 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?
What are some common causes of scrotal lumps?
Painless:
- Testis tumour
- Epididymal cyst
- Hydrocoele
- Reducible inguino-scrotal hernia
- Varicocoele (aching at end of day)
Painful:
- Epididymitis
- Epididymo-orchitis
- Stranfulated inguino-scrotal hernia
What is the history of a testicular tumour and what should be the treatment plan if you suspect this?
- 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
What would a hydrocele appear like on history and examination?
- 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
How does an epididymal cyst present on examination?
- Usually painless
- Separate from the testis
- Can get above the mass
- Transilluminates
How does a varicocele present?
- 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
How do we treat the following scrotal lumps?
- Testicular tumour
- Epididymal Cyst
- Hydrocele
- Varicocele
- Inguino-scrotal hernia
What are some of the causes of urinary retention? (more common in males than females)
- 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
What are the three different types of urinary retention and how do we treat them?
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
When an older man presents with eneuresis what is your initial diagnosis?
Chronic retention with overflow incontinence until proven otherwise
What are the two different categories of LUTS (lower urinary tract symptoms) and what can be some of the causes of each category?
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
What are some causes of polyuria?
Global: uncontrolled type 2 diabetes
Nocturnal: venous stasis and sleep apnoea as ANP released causing polyuria
What are some causes of bladder outflow obstruction?
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
How can we assess a patient’s LUTS, especially when suspecting BPH?
International Prostate Symptom Score (IPSS)
Apart from filling out an IPSS what do you need to investigate when a male patient presents with LUTS?
Examination
- DRE
- Is the bladder palpable
- Neurological exam
Investigations
- Dipstick ?UTI or bLOOD
- Consider PSA
How can BPH be managed in primary care?
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
What is the mechanism of action of the drugs used to treat BPH and what are their side effects?
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
How is BPH managed if lifestyle changes and drugs don’t work?
- Referred to secondary care and will do a flow rate study before surgery
- Do TURP by laser to make cavity bigger
What are the pros and cons of having the PSA test to test for prostate cancer?
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
What should a male do before having a PSA test?
How would you explain to a patient what NNT means?
Number of patients you need to treat to prevent one additional bad outcome (e.g stroke or death)
What is the definition of orchitis?
Testicular inflammation or infection
what is urinary retention?
the inability to pass urine rather than to make urine
more common in males and rare in females
what are some surgical treatments for an enlarged prostate
- transurethral resection of prostate (TURP)
- monopolar/laser/bipolar
what main diagnosis should you make when there is a sudden onset of pain in the testies
torsion
