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Senior - Urology > 4 - Penis > Flashcards

4 - Penis Flashcards

1
Q

Penis

A

Anatomy slides 7,8

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2
Q

What is balantitis and balanoposthitis?

A

Inflammation of the glans penis and/or foreskin

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3
Q

Common cause of balanitis and balanopsthitis?

A

Usually candida albicans

  • poor hygiene
  • complication of phimosis
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4
Q

What is phimosis?

A

Contracted foreskin cannot retract over glans

- can develop smegma, calculi and SCC under foreskin

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5
Q

Presentation of phimosis?

A

Pain or tenderness of foreskin

Chronic “yeast infections”

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6
Q

Tx for phimosis?

A
  • Broad spectrum abx

- Circumcision

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7
Q

What is paraphimosis?

A

Retracted foreskin is trapped behind glans penis

  • tourniquet effect
  • painful swelling of the glans
  • necrosis

MEDICAL EMERGENCY

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8
Q

Tx for paraphimosis?

A

Manual reduction (1st line)

Immediate urology referral if 1st line fails
- incision under local anesthesia

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9
Q

So you did a manual reduction (never making eye contact) now what?

A

All paraphimosis pts require urological referral for circumcision to prevent further recurrence

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10
Q

MC congenital malformation of the penis?

A

Abnormal location of the urethral meatus:

  • Hypospadias - ventral meatus (penis, scrotum, perineum)
  • epispadias - meatus opens on dorsal aspect of penis
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11
Q

Hypospadiasis characteristics?

A
  • More common
  • associated w feminization
  • excellent prognosis with repair
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12
Q

Tx for hypospadias?

A

No circumcision (used as a graft)

Repair <18mo (usually 6mo)

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13
Q

Epispadias characteristics

A
  • Rare
  • Urinary incontinence is common
  • Dorsal curvature of penis is common
  • Poorer prognosis
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14
Q

What is chordee?

A

Abnormal congenital ventral curvature of the penis
- short urethra and or fibrous tissue around the corpus spongiosum

  • commonly associated w hypospadias
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15
Q

What is peyronie’s disease?

A

Fibrous d/o of tunica albuginea, curvature, deformity, pain
- acquired malformation

Middle aged men

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16
Q

Causes of peyronie’s?

A

Probably minor penile trauma

- inflammation of corpora cavernosa -> d/o collagen disposition

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17
Q

PE for peyronie’s disease?

A

Plaque involving the tunica albuginea that is:

  • Palpable
  • Dense
  • Fibrous
  • dorsal midline (usually)
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18
Q

Peyronie’s diesase is associated with what condition?

A

Dupuytren contracture

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19
Q

Tx for peyronie’s disease?

A

10% spontaneously improve

Medical therapies

  • collagenase clostridial histolyticum inj
  • CCB or interferon

Surgery (if compromised sexual function)

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20
Q

Priapism is?

A

Erection >4hrs

- not associated w sexual arousal or desire

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21
Q

Causes of priaprism?

A

Idiopathic (60%)

  • leukemia
  • SCD
  • pelvic tumors
  • penile trauma
  • spinal cord trauma
  • meds
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22
Q

Types of priapism?

A

Non-ischemic
Ischemic

  • both need urology consult
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23
Q

Non-ischemic priapism?

A
  • High flow priapism
  • Arteriovenous shunging -> unregulated high blood flow
  • perineal or spinal cord trauma
  • may not require tx
  • ED usually spared
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24
Q

Ischemic priapism?

A
  • Low flow-> venous congestion and arterial inflow cessation -> ischemic injury to corpora cavernosa
  • painful erection
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25
Q

Tx for ischemic priapism?

A

Emergent treatment to prevent erectile function loss

  • large needle blood aspiration
  • adrenergic meds (phenylephrine)
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26
Q

How common is penile cancer?

A

Its not

<1%

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27
Q

Risk factors for penile cancer?

A 
Uncircumcised 
- poor hygiene
Phimosis
- 7-10% increase
HPV infection

Usually seen in 6th decade

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28
Q

Types of penile cancer?

A

SCC - 98%
- seen on glans

Bowen disease (SCC in situ)
- red plaque on shaft

Erythroplasia of queyrat

  • velvety red lesion w ulcerations on glans
  • bowen disease of glans
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29
Q

Penile cancer ddx?

A

Biopsy - manditory to r/o

  • syphilis
  • chancroid
  • condylomata
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30
Q

Scrotal pain, swelling and masses?

A

Pic on slide 36 shows the different types

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31
Q

Scrotal anatomy?

A

40, 41, 43

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32
Q

How is the scrotum evaluated?

A

Palpate testes between fingertips of both hands

Palpate for any suspicious masses

Transillumination -solid vs cystic lesion

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33
Q

MCC urology referral is for?

A

Mass on scrotum

They must decide if lesion is w/in testicle, related to epididymis or cord

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34
Q

Masses arising from w/in testes are?

A

Usually malignant

- so there is that…

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35
Q

What testicular masses are usually benign?

A

Epididymis and spermatic cord are usually benign

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36
Q

Describe testicular malignancies?

A

Lesion that is:

  • Painless
  • Firm
  • Solid
  • W/in substance of testicle
  • Does not transilluminate
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37
Q

Testicular mass “when in doubt?”

A

Image
- US preferred

Safe reliable method to relieve anxiety of the pt

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38
Q

List of scrotal/testicular masses

A 
Hydrocele
Varicocele
Epididymal cyst
Spermatocele
Hernia
Testicular cancer
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39
Q

What is a hydrocele?

A

Collection of fluid between the 2 layers (parietal and visceral) of tunica vaginalis

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40
Q

Causes of hydrocele?

A

2/2

  • congenital cause (patient process vaginalis)
  • infection (epididymitis)
  • trauma/testicular torsion
  • tumors (cancer)
41
Q

Describe hydrocele?

A

Young (usually 1st yr of life)
Painful (if large)
Heaviness in scrotum
Transilluminates

42
Q

Tx for hydrocele

A

Watchful waiting
Surgery
- excision of hydrocele sac

43
Q

With hydrocele?

A

DO NOT ASPIRATE

44
Q

What is epididymal cyst?

A

Cyst occuring at the caput of the epididymus

  • <2cm
  • distinct from testicle

Benign

45
Q

What is a spermatocele?

A

Benign cystic accumulation that arises from the head of the epididymis

> 2cm

46
Q

Symptoms of spermatocele?

A

Asymptomatic
- non tender on exam

If large, may feel “heavy”

47
Q

Where do you palpate a spermatocele?

A

Palpable on exam

- near upper pole of the testicle

48
Q

Tx for spermatocele?

A

Watchful waiting

Surgery (if symptomatic)

49
Q

What is a varicocele?

A

Abnormal dilation of the pampiniform plexus of the spermatic veins
- bag of worms

50
Q

Varicocele is most commonly found?

A

On the L

51
Q

Varicocele presentation?

A 
Dull ache
Size 
- increase when upright
- decrease when supine
Pain worsens w activity
52
Q

Varicocele a big deal?

A

May cause infertitlity

  • increase scrotal temp -> germ cell apoptosis
  • testicular atrophy
53
Q

PE for varicocele?

A

Bag of worms
increase W valsalva
decrease when supine
Left side

+/- US (its a clinical dx)

54
Q

Grades of varicoceles?

A

1: small - palp only w valsalva
2: moderate - nonvisible on inspection but palp on standing
3: large - visible on gross inspection

55
Q

Further eval needed (varicocele)

A
  • Unilateral right sided
  • Lesion remains dilated when supine
  • Occur abruptly (obstruction)
  • Enlarge rapidly
56
Q

R sided sudden varicocele may be?

A

Retroperitoneal malignancy

Get a CT scan

57
Q

Tx for varicocele

A

Initially -> symptomatic management

  • reassurance and watchful waiting
  • scrotal support
  • activity mod
  • NSAID

W infertility/pain
Surgery
- ligation of gonadal vein via inguinal canal, laparoscopy or microsurgery

58
Q

Types of hernias?

A

Indirect: congenital patient process vaginalis

Direct: arises from protrusion of abdominal viscera -> weakness of the posterior wall of inguinal canal (acquired)

Pics 67-69

59
Q

Which type of hernia may extend into the scrotum and goes through the deep or internal inguinal ring into inguinal canal?

A

Indirect (congenital)

60
Q

Diagnosis of hernia?

A

Palpable bulge (esp w valsalva)

US or CT

61
Q

If there is any doubt wheteher a mass is w/in or outside testicle?

A

Get a scrotal US
urologic consult

It could be cancer to dont fuck around

62
Q

MC neoplasm in men 15-35?

A

Testicular cancer

63
Q

How is testicular cancer diagnosed?

A

Orchiectomy

- damn, that escalated quickly

64
Q

What type of cancer is testicular cancer?

A

90-95% are germ cell tumors

- arise from spermatogenic cells w/in seminiferous tubules

65
Q

Risk factors for testicular cancer?

A
  • Cryptorchidism
  • Testicular trauma/torsion
  • Infection-related testicular atrophy
  • Chemical exposure/pollutants
66
Q

S/s of testicular cancer

A
  • Painless enlargement of testes
  • sense of heaviness
  • palpable mass
  • hydrocele (10%)
67
Q

Labs for testicular cancer

A

Elevated

  • hCG
  • AFP (alpha fetoprotein)
  • (LDH) lactate dehydrogenase

Advanced disease

  • CBC
  • LFT (liver mets)
68
Q

Imaging for testicular cancer?

A

Scrotal US

CT/PET after orchiectomy for staging

69
Q

Treatment for testicular cancer?

A

Radical orchiectomy

- further tx depending on what path says

70
Q

Prognosis for testicular cancer?

A

Stage I-III : 5 yr = 95-100

Bulky retroperitoneal malignancy or advanced = 55-80%

71
Q

Secondary testicular tumors are?

A

Rare

Lymphoma (usually)

72
Q

USPSTF says

A

No testicular self exam

  • i say what you do in the privacy of your own home is your own business
73
Q

Age prevalence of testicular torsion?

A

Neonates - MC
Post-puberty 60%
Men >21 40%

74
Q

Presentation of testicular torsion?

A

Sudden onset of pain

  • several hours after activity/trauma
  • after cremasteric contraction during REM sleep (well damn)

Pain, N/V

75
Q

PE for testicular torsion?

A

Classic sign:
- high riding testes w long axis oriented transversely

Early: profound swelling

Late: after 12hr reactive hydrocele and scrotal erythema

Exquisite tenderness

Absent cremasteric reflex

Neg phren sign

76
Q

Testicular torsion is MC associated w?

A

Bell clapper deformity

77
Q

Test of choice for testicular torsion?

A

Doppler US

- if you dont have it just do the surgery

78
Q

Tx for testicular torsion?

A

Surgery - life limb or eyesight

Removal or orchipexy

79
Q

Manual detorsion?

A

Its a thing but should you?

Either way, its call “open book” R - counterclockwise and L - clockwise

30-70% success

80
Q

You did the open book and it worked what now?

A

Still surgery

81
Q

MCC of scrotal pain in adults

A

Epididymitis and epididymo-orchits

82
Q

Epididymitis and epididymo-orchits are usually caused by?

A

Infection (2 types)

STI

  • Men <40
  • urethritis
  • N gonorrea/chlamydia

Non-STI

  • older men
  • UTI and prostatitis
  • Gram-neg rods
83
Q

Acute presentation of Epididymitis and epididymo-orchits?

A

Follows physical strain (heavy lifting), trauma, or sex

Fever

Exquisite tenderness and swelling of epididymis, testicle and or scrotum

Irritative voiding symptoms

84
Q

PE for Epididymitis and epididymo-orchits?

A

Induration
Swelling
TTP (exquisite)
+ phren sign

Epididymo-orchitis also have testicular swelling and pain w scrotal wall erythema and may have reactive hydrocele

85
Q

What does phren sign differentiate?

A

Phren sign relieves pain w epididymitis

Does not relieve pain w testicular torsion

86
Q

Diagnostic tests for Epididymitis and epididymo-orchits?

A

Diagnosed by PE

Also get:

  • CBC
  • UA
  • Urine culture
  • Gram stain of urethral discharge
  • US (Equivocal exam)
87
Q

Tx for Epididymitis and epididymo-orchits?

A

STI

  • ceftriaxone + doxycycline
  • treat the partner

Non-sexually transmitted form

  • ciprofloxacin/levofloxacin
  • eval urinary tract

Viral/non-infectious
- symptomatic care

Everybody:

  • bed rest
  • scrotal elevation
88
Q

Direct blow or straddle type injury to the testicles can cause?

A

Hematocele

Rupture

Surgery referral

89
Q

Blue dot sign?

A

Torsion of appendix testis

infarction/necrosis

90
Q

Torsion of appendix testis presentation?

A

Similar to testicular torsion (more gradual)
Blue dot sign
+ US

91
Q

Tx for torsion of appendix testis?

A

Conservative tx

  • rest
  • scrotal elevation
  • analgesics
92
Q

Referred testicular pain?

A 
Stones
Uti
Pyelonephritis
Low back pain
AAA
Post surgical (herniorrhaphy)
93
Q

What does mumps do to the testicles?

A

Orchitis

- fever, Parotitis usually precede orchitis

94
Q

What os fournir’s gangrene?

A

Necrotizing fasciitis of perineum and scrotal skin

- Diabetics

95
Q

Fournier’s gangrene tx?

A

Urgent surgical debridement

96
Q

What is PVPS?

A

Post-vasectomy pain syndrome

  • chronic pain following vasectomy
  • painful granuloma palpable at site of vas
  • foreign body reaction

Blessedly uncommon

97
Q

How is chronic orchalgia diagnosed?

A

Diagnosis of exclusion

98
Q

Id like to give a big shout out to all the sidewalks

A

For keeping me off the streets

Senior - Urology (7 decks)

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