7) repro, resp, psych Flashcards
ACUTE BACTERIAL PROSTATITIS
- age most commonly affected?
- most common causative pathogen? 1
- other causative organisms to consider? 2 (who in?)
- risk factors? 4
men 20-50years
E. Coli = most common
consider chlamydia or gonorrhoea in men < 35
RISK FACTORS
- recent urinary tract infection
- urogenital instrumentation
- intermittent bladder catheterisation
- recent prostate biopsy
ACUTE BACTERIAL PROSTATITIS
- where is the pain?
- other local symptoms? 3
- systemic symptoms? 3
- examination to do? what find?
- bedside tests to do? 2
SEVERE PAIN
- lower back
- perineum
- pelvic
- with defecation
- acute dysuria
- frequency
- urgency
- malaise
- fevers
- rigors
DRE (gently to avoid causing sepsis)
= tender + boggy prostate
- urine dip
- MSU
ACUTE BACTERIAL PROSTATITS
- abx management? for how long?
- possible complications? 3
PO fluroquinolone (eg ciprofloxacin) for 14 DAYS
complications
- acute urinary retention
- sepsis
- prostatic abscess (needs drainage!)
nb if acute urinary retention and persistent fever: suprapubic catheterisation
aside from acute bacterial prostatits, what other types of prostatitis can you get? 2
breifly describe how they present + mx
CHRONIC BACTERIAL PROSTATITIS
- repeated symptoms of UTI with same pathogen grown (may also get pain on ejaculation) (often don’t have fever)
- often norm prostate on DRE (may be tender/enlarged)
= same mx as acute bacterial prostatitis
CHRONIC PELVI PAIN SYNDROME
- bladder irritation symptoms, painful ejaculation, may have bloody semen
- moderate + diffuse pain in perineum, lower back, lower abdo, scrotum, penis
- prostate norm (may be mildly tender)
= anti-inflam analgesia + similar mx to BPH (alpha blockers eg tamsulosin + doxazosin and 5-alphar-reductase inhibitors eg finasteride)
BALANITIS:
- what is it?
- big risk factors regardless of cause? 2
balanitis = inflammation of the glans penis (ie the bell end)
- can happen in circumcised and non-circumcised men
- diabetes
- poor genital hygiene! (build up of smegma)
nb Balanoposthitis is inflammation of both the glans penis and the foreskin
CAUSES OF BALANITIS
- candidiasis
- contact / allergic dermatitis
- dermatitis (eczema or psoriasis)
- bacterial (+ WHICH PATHOGEN)
- anaerobic bacterial
FOR EACH
- how common? (very common, common, uncommon, rare)
- acute or chronic?
- how present? incl presence / type of discharge!
nb see other flashcard for other (rarer) causes of balanitis
CANDIDIASIS
- very common
- acute
= Usually occurs after intercourse + associated with itching + white non-urethral discharge
CONTACT / ALLERGIC DERMATITIS
- very common
- acute
= Itchy, sometimes painful + occasionally associated with a clear non-urethral discharge. Often there is no other body area affected
DERMATITIS (ECZEMA OR PSORIASIS)
- very common
- acute or chronic
= Very itchy but not associated with any discharge
= will be a PMHx of eczema/psoriasis with active areas elsewhere on body
BACTERIAL - common - acute = Painful and can be itchy with yellow non-urethral discharge = norm STAPH species
ANAEROBIC BACTERIAL
- common
- acute
= May be itchy but is most associated with a very offensive yellow non-urethral discharge
less common CAUSES OF BALANITIS
- lichen planus
- circinate balanaitis
- lichen sclerosis
- plasma cell balanitis of Zoon
FOR EACH
- how common? (very common, common, uncommon, rare)
- acute or chronic?
- how present? incl presence / type of discharge!
LICHEN PLANUS
- uncommon
- acute or chronic
= May be itchy, the main diagnostic feature is the presence of Wickham’s striae and violaceous papules
CIRCINCATE BALANITIS
- uncommon
- acute or chronic
= Not itchy and not associated with any discharge
= key feature is painless erosions and it can be associated with Reiter’s syndrome (ie reactive arthritis from STI)
LICHEN SCLEROSIS - aka balanitis xerotica obliterans - rare - chronic = May be itchy, associated with white plaques and can cause significant scarring
PLASMA CELL BALANITIS OF ZOON
- rare
- chronic
= Not itchy with clearly circumscribed areas of inflammation
BALANITIS
- investigation to do if possible? 1
- management for all? 1 (regardless of cause)
- additional mx if severe dicomfort? 1
- specific treatment dependent on cause? (1 candida, 1 bacterial, 1 anaerobic bacterial, 1 for lichen sclerosis + plasma cell balanitis of zoon)
clinical diagnosis
swab any discharge!!
FOR ALL
- daily retraction of foreskin and warm saline wash
- 1% hydrocortisone cream (if severe! - only use for short period)
candida = topical CLOTRIMAZOLE (2 weeks)
bacterial = oral fluclox
anaerobic = topical or oral metronidazole
high potency steroids:
- lichen sclerosis
- plasma cell balanitis of zoon
use low-potency steroids (eg 1% hydrocortisone) for dermatitis and circinate balanitis
BALANITIS
- complications? 4
- possible mx of these?
- post-inflammatory phimosis (may need circumcision)
- urinary tract obstruction (if siginificant swelling) - will need catheter
- recurrent UTIs
- penile cancer (poor genital hygiene is a risk factor!)
PHIMOSIS
- definition?
- when is this physiological?
- additional clinical features? 2
PHIMOSIS
= when foreskin can’t be pulled down (retracted) from the tip of the penis
ALL BOYS under 2 have and is normal! - may balloon as they pee - but no prioblem if there’s a miatus!
Physiological if toddler - don’t worry until over age 2 and causing probs (ie recurrent infecitons or other complicaitons!!)
- painful erection
- dyspareunia
can also get difficulty in retracting the foreskin (relative phimosis)
PHIMOSIS
- conservative mx? 2
- surgical options? 2
- main complications? 3
is a clinical diagnosis!
DON’T FORCE RETRACTION!!!
CONSERVATIVE MX
- topcial corticosteroid cream (contraindicated if recurrent infection)
- stretching exercises
SURGICAL MX
- vertical incision of constricting bands
- circumcision
COMPLICATIONS:
- paraphimosis
- foreskin tear w possible haemorrhage
- repeated infections! (balanoposthitis)
PARAPHIMOSIS
- what is it?
- three main groups of causes?
- clinical features?
PARAPHIMOSIS
= retracted foreskin in an uncircumcised male that cannot be returned to its original position
- complication of PHIMOSIS
- IATROGENIC (eg not replacing forseskin after catheterising)
- TRAUMA (vigerous sex, forceful retraction of foreskin while urinating, piercing)
- noticeable band of constricting tissue (at the coronal sulcus)
- Foreskin cannot be returned to its original position
- Edema and pain of the glans penis
- features of penile ischemia (blue penile skin and firm glans penis)
PARAPHIMOSIS IS A UROLOGICAL EMERGENCY!!!
PARAPHIMOSIS
- fully DESCRIBE conservative mx?
- surgical options? 2
- complicaiton? 1
PARAPHIMOSIS IS A UROLOGICAL EMERGENCY!
conservative = manual reduction of foreskin w adequate analgesia (local or regional block or topical lidocaine) whilst squeezing glans
- Ice, compression bandages, or gauze soaked in an osmotic agent eg 50% glucose soaked swab (to reduce edema) may assist this process
- may also need to aspirate blood/fluid from penis to assist
if conservative fails:
- dorsal slit in foreskin to allow manual reduction
- circumcision = last resort!
complication = penile necrosis!
ERECTILE DYSFUNCTION:
- what is it?
- risk factors for VASCULAR causes? 5
- NEUROGENIC causes? 5
- ENDOCRINE causes? 3
- OHER ORGANIC causes? 3
- PSYCHOGENIC causes/ risk factors? 5
Erectile dysfunction (impotentia coeundi) = inability to achieve or sustain an erection sufficient in rigidity or duration for sexual intercourse which is present for a minimum of ∼ 6 months (although may be treated before this!)
VASCULAR
- HTN
- diabetes
- cardiovascular disease
- hyperlipidaemia
- smoking
NEUROGENIC
- stroke
- brain or spinal cord injury
- MS
- dementia
- parkinsons
ENDOCRINE
- hypogonadism
- hyperprolactinaemia
- thyroid diseases
OTHER ORGANIC
- surgery / radiotherapy to region
- pelvic trauma / fracture
- alcohol abuse
- Peyronie disease
PSYCHOGENIC
- depression
- anxiety (performace related)
- relationship issues
- trauma from prior experiences
- stress
can get MIXED psychogenic and organic causes!!
increasing AGE is also a risk factor!
Medications that can cause erectile dysfunction? 2
- beta blockers
- SSRIs
ERECTILE DYSFUNCTION: organic vs psychogenic causes: - speed of onset of symptoms? - ability to get an erection? - libido? - premature ejaculation?
ORGANIC
- gradual onset
- can’t get an erection even overnight or when try alone
- normal libido
- no hx of premature ejaculation
PSYCHOGENIC
- sudden onset
- Good quality spontaneous or self-stimulated erections
- decreased libido
- hx of premature ejaculation
also in psychogenic
- major life events
- problems or changes in relationship
- previous psych problems
ERECTILE DYSFUNCTION
- two tests that should be done by GP to find cause? 2
- 1st line drug (class and name)? 1 (who is this CI in? 2)
- 2nd line mx? 1
- QRISK score (for all men presenting w ED)
- free testosterone measurement (between 9 and 11am)
1st line
= PDE-5 inhibitors (SILDENEFIL - ie viagra)
- prescribe to all (except CI), regardless of cause!
- CI if also taking nitrates or severe postural hypotension)
nb if taking alpha-adrenergic blockers - eg for BPH, take 4hrs apart to prevent hypotension!
2nd line if pt doesn’t want or can’t have sildenafil = VACUUM ASIST DEVICES
nb are other surgical options if those don’t work!
ALSO offer psych support if psychogenic cause!
NB for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
NB people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
EPIDIDYMO-ORCHITIS
- what is it?
- two main causes, incl specific pathogen? 2 (who gets which? 2)
inflammation of epididymis and testicles (norm as reulst of infection)
< 35 years
= norm STI
- chlamydia, gonorrhoea or rarer ones
> 35 years (or children)
= norm UTI
- E.coli (or rarely pseudomonas or other STIs)
nb can get chronic infection - but rare and often TB or weird thing like amiodarone-induced or autoimmune diseases
EPIDIDYMO-ORCHITIS:
- describe clinical presentation? (incl signs + symptoms)
Unilateral scrotal pain and swelling
- develops over several days and radiates to the ipsilateral flank
Tenderness along the posterior testis
Scrotal skin overlying the epididymis may appear red, shiny, and edematous
Low-grade fever (especially among children)
Symptoms of lower urinary tract infection (e.g., dysuria, frequency, urgency), including urethritis (urethral discharge)
EPIDIDYMO-ORCHITIS:
- main DDx to rule out?
- clincial test (incl name) to rule out?
- other symptoms/features which make DDx more likely? 3
need to rule out testicular torsion
PREHN SIGN
= elevation of the scrotum reduces testicular pain
- positive = epidydimo-orchitis
- negative (ie pain not relieved) = torsion
other signs suggestive of torsion:
- patients < 20 years
- severe pain
- acute onset
nb you can also get torsion of the epididymal appendices (more localised pain / swelling than full torsion)
EPIDIDYMO-ORCHITIS:
- bedside tests to consider? 4
- imaging? 1 (when is it indicated? 2)
if UTI suspected
- urine dip
- MSU
if STI suspected
- urethral NAAT swab
- urethral swab for culture
scrotal USS if:
- can’t rule out testicular torsion based on hx + physical
- if suspect an abscess
EPIDIDYMO-ORCHITIS:
- management if suspected UTI cause?
- management if suspect STI cause? 2 (name specific drugs)
- symptomatic management? 3
UTI cause
- fluoroquinolones (eg levofloxacin)
STI cause
- ceftriaxone IM single dose PLUS doxycycline PO for 10-14 days
- NSAIDs
- scrotal elevation
- icepacks (be careful!)
TESTICULAR CANCER
- peak age group?
- commonest type of tumour?
- risk factors? 6
20-35 years
germ cell tumours (95%)
- seminomas (40%)
- non-seminomas (rest)(embryonal, yolk sac, teratoma and choriocarcinoma)
RISK FACTORS
- cryptorchidism (undescended testes)
- infertility
- mumps orchitis
- klinefelter syndrome
- trisomy 21
- FHx testicular Ca (also PMHx)
see amboss for all the slightly different types of germ cell tumours
nb if get lump in testes in man over 60 then likely to be lymphoma!
TESTICULAR CANCER
- most common presenting symptom? 1
- other possible symptoms? 3
painless lump in testicles
- pain (sometimes)
- hydrocele
- gynaecomastia
TESTICULAR CANCER
- 1st line imaging? 1
- additional imaging needed? 2
- tumour markers to do? 3
- which tumour markers are raised in which sub-type?
1st) ULTRASOUND
- do NOT do trans-scrotal biopsy! - can cause spread!!
CT of abdo pelvis + norm chest too for stagting (as can spread a lot!)
1) AFP
- always high in: yolk sac (F is for Foetal - ie in a yolk sac!)
- may be high in: mixed germ cell
2) HCG
- always high in: choriocarcinoma (C for Chorio)
- may be high in: mixed germ cell
3) LDH
- non-specific marker of cell turnover (lactate dehydrogenase)
- marker of prognosis (response to Tx) and detects relapse i.e. metastatic disease
TESTICULAR CANCER
- where do they metastasise to first?
- what to do BEFORE treatment? 1
- main treatment? 1
- other treatments that may be offered? 1
metastasise to PARA-AORTIC lymph nodes (these are retroperitoneal)
Prior to surgery: sperm cryopreservation
RADICAL INGUINAL ORCHIECTOMY (ie pull out through inguinal canal - to avoid haem spread)
if stage I (confined to testes, no lymph node spread) then can do active surveillence but most get chemo and/or radio too - and all that have spread to lymph nodes (stage II) or distant mets (stage III) get chemo!
testicular tumours are very chemo responsive and is about 95% cure rate!
BREAST FIBROADENOMA
- characteristics?
- age norm seen in?
- investigations? 3
- prognosis?
- management if large?
nb most common breast lesion!
Mobile, firm breast lumps - a ‘breast mouse’
- doesn’t getr bigger/smaller with periods, no pain!
age 20-40
triple assessment!
- exam, USS (under 40) or mammogram (over 40) and core needle biopsy
NO CANCER RISK! (except see below)
- 1/3 regress, 1/3 stay same, 1/3 enlarge
if over 3cm then tend to surgically remove!
nb rarely can get
Complex Fibroadenomas
- Moderately differentiated cells
- Slight ↑risk of Ca
MASTITIS
- what is it?
- who almost exclusively seen in? 1
- additional risk factors? 3
- most common causative organism?
inflammation of the breast parenchyma
occurs in up to 10% of BREASTFEEDING mothers (particularly 2–4 weeks postpartum)
anything that causes insufficient drainage of milk -> milk stasis:
- infrequent feeding
- quick weaning
- illness in either mother or baby
norm STAPH AUREUS
MASTITIS
- local symptoms? 3
- possible systemic symptoms? 3
- Tender, firm, swollen, erythematous breast (generally unilateral)
- Pain during breastfeeding
- Reduced milk secretion
flu-like symptoms
- malaise
- fever
- chills
is a clinical diagnosis!
can get reactive lymphadenopathy
MASTITIS
- 1st line management? 1
- symptomatic relief? 2
- indications for Abx? 3 (which abx?)
- possible complciation? 1
CONTINUE BREASTFEEDING (baby already has the bug!) - if can't then use breast pump but breastfeeding better!
- NSAIDs (fine for breastfeeding)
- cold comresses
fluclox 10-14 days if:
- systemically unwell
- nipple fissure present
- symptoms don’t improve after 24hrs of effective milk removal
^keep breastfeeding while have abx!
can develop a BREAST ABSCESS (norm if they stop breast feeding)
nb if inadequate response to treatment, do breast milk cultures
BREAST ABSCESS
- how presents? (describe the mass and other symptoms)
- management? 2
complicaiton of mastitis
a TENDER, FLUCTUANT mass
- Breast pain, erythema, and oedema
- Purulent discharge from the nipple of the affected breast
- Fever
- nausea
mx
- antibiotics
- incision + drainage!
nb Overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula
FAT NECROSIS OF BREAST
- peak age incidence?
- other risk factor? 1
- cause? 1
- pathophysiology?
- what it feels like?
- investigations? 3
around 50
typically obese women with large breasts
trauma (although many women don’t report any or it may be very minor trauma!)
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
- norm painless
- may get associated skin and nipple changes
triple assessment
- clinical exam
- imaging
- core biopsy
is rare and often presents very similar to breast Ca so always fully investigate!
FIBROCYSTIC DISEASE:
- aka? 2
- what is it?
- typical age affected?
- clinical presentation?
- 1st line management? 1
- management if persistent or affecting ADLs? 1
- aka fibroadenosis
- aka benign mammary dysplasia
benign changes characterised by the formation of fibrotic and/or cystic tissue
middle aged pre-menopausal women
- Premenstrual bilateral multifocal breast pain
- Tender or nontender breast nodules
- may have Clear or slightly milky nipple discharge
Mx = Mainly supportive with analgesia for pain control
Hormone therapy can be considered for those with >6m symptoms of severe breast pain + impact on ADLs. These treatments are infrequently used bc of adverse effects.
CAUSES OF NIPPLE DISCHARGE:
describe presentation + cause of each:
- physiological?
- galactorrhoea?
- hyperprolactinaemia?
- intraductal papilloma?
- mammary duct ectasia?
- carcinoma?
also what driugs can cause high prolactin?
PHYSIOLOGICAL
- during breast feeding
- can also get a bit during pregnancy
GALACTORRHOEA
- Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated (can also get in end-stage kidney disease)
HYPERPROLACTINAEMIA
- Commonest type of pituitary tumour
- – Microadenomas <1cm in diameter
- – Macroadenomas >1cm in diameter
- Pressure on optic chiasm may cause bitemporal hemianopia
INTRADUCTAL PAPILLOMA
- Commoner in younger patients but also middle-aged women!
- May cause blood stained discharge
- There is usually no palpable lump
MAMMARY DUCT ECTASIA
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
CARCINOMA
- Often blood stained
- May be underlying mass or axillary lymphadenopathy
any antidopaminergic drugs
- metoclopramide
- 1st gen (and 2nd gen) antipsychotics
NIPPLE DISCHARGE
- first line investigation to do if galactorrhoea (ie milky discharge from both nipples)?
- bedside test for all? 1
- if this is high, what further simple tests could you do? 3
- if all these further tests are negative, what imaging to do? 1
measure PROLACTIN
if not high, no pathological cause for galactorrhoea
do VISUAL FIELD test (looking for bitemporal hemianopia)
if elevated do:
- TSH (primary hypothyroidism)
- bHCG (pregnancy)
- creatinine (chronic kiney disease)
^if these three tests are normal and priolactin is high: do MRI of head (to look for pituatory adenoma)
NIPPLE DISCHARGE
- investigation if discharge is one-sided OR non-milky? 3
- if this comes back negative? 1
send for triple assessment - incl biopsy
if this negative: measure prolactin and then see previous flashcard for other investigations!
nb signs that suggest malignancy:
- Spontaneous, unilateral, uniductal, and bloody discharge
- Presence of a breast mass or abnormalities in imaging
- Age > 40 years
management of causes of nipple discharge
- galactorrhoea?
- intraductal papilloma?
- mammary duct ectasia?
- carcinoma?
nb see endocrinology cards for mx of prolactin secreting tumours
if bilateral galactorrhoea with NORMAL prolactin and non lump then can reassure!
intraductal papilloma:
- if troubling can have: microdochectomy (if young) or total duct excision (if older)
mammary duct ectasia - smoking cessation advice - mx usually not needed - if troubling can have: microdochectomy (if young) or total duct excision (if older) (nb may progress to breast abscess)
BREAST LUMP DDx
briefly describe how each of these would present / a little about them
- fibroadenoma
- fibrocystic changes / fibroadenosis
- breast cysts
- phyllodes tumour
- fat necrosis
- galactocele
- intraductal papilloma
- mammary duct ectasia
- breast cancer
FIBRADENOMA
- Solitary, well-defined, non-tender, rubbery, and mobile mass
FIBROCYSTIC CHANGES
- Premenstrual breast tenderness
- Multiple breast nodules bilaterally
BREAST CYSTS
- well circumscribed (may feel like a grape, or water-balloon in the breast)
- usually firm but not hard, and mobile
- may get larger and smaller depending on stage of menstrual cycle
PHYLLODES TUMOUR
- Painless, smooth, multinodular lump
- Variable growth rate
- Generally > 3 cm
- needs surgical excision!
FAT NECROSIS
- Irregularly defined and dense periareolar breast mass
- Skin retraction, erythema, and ecchymosis
GALACTOCELE
- Painless, firm mass
- most common lesion in breast feeding women
INTRADUCTAL PAPILLOMA
- Solitary lesions
- Bloody nipple discharge
- Palpable breast lump close to or behind the nipple
- nb Multiple lesion are usually asymptomatic
MAMMARY DUCT ECTASIA
- Unilateral greenish or bloody discharge
- Nipple inversion
- Firm, stable, painful mass under the nipple
BREAST CANCER
- hard, painless (90%), irregular margins, fixed to skin or chest wall
- skin dimpling may occur, may have unilateral nipple discharge +/or nipple retraction
BREAST LUMP REFERRAL:
- criteria for 2WW? 2
- consider 2WW? 2
- criteria for non-urgent referral? 1
2WW
1) aged 30 years or more
- unexplained breast lump (with or without pain)
2) aged 50 or more
- UNILATERAL discharge, retraction, any other nipple changes
also consider 2WW for:
- pt w skin changes that suggest breast cancer
- 30 years and over with an unexplained lump in the axilla
non-urgent referral:
- under 30 with unexplained breast lump
PAINLESS TESTICULLAR SWELLING DDx
briefly describe how each of these would present / a little about them
- AND finding on ultrasound (+ whether transilluminate)
- hydrocele
- spermatocele
- varicocele
- scrotal hernia
- testicular tumour
HYDROCELE - Fluctuant swelling of the scrotum - transilluminates - nb MAY be presenting feature of testicular Ca! = Hypoechoic mass around the testis
SPERMATOCELE
= aka EPIDIDYMAL CYSTS
- Fluctuant swelling of the upper testicular pole
- transilluminates
= Hypoechoic dilation of epididymal duct or rete testis
^ie hydrocele is fluid surrounding testes, spermatocele is fluid filled sac on top iof epididymis
VARICOCELE
- Usually painless (can be a dull pain) swelling may be reduced when supine
- norm on Left (may be 1st presentation of renal Ca)
- Visible or palpable strands and “bag of worms” sensation
- bilateral varicoceles may affect fertility
- doesn’t transilluminate
= Dilated hypoechoic pampiniform vessels
SCROTAL HERNIA - can't get above it on exam! - cough impulse may be present + may be reducible - doesn't transilluminate = Herniated bowels on USS
TESTICULAR TUMOUR - Usually painless mass (however, may feel dull ache or "heavy" sensation in the testicle) - Palpation of solid mass - doesn't transilluminate = Solid mass with variable echogenicity
