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RGU Exam 3 > Diseases Penis, Urethra, Scrotum > Flashcards

Diseases Penis, Urethra, Scrotum Flashcards

1
Q

Male urethra total length

A
  • 15-25cm long
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2
Q

Distal portion of the male urethra

A
  • Fossa navicularis
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3
Q

Portion of urethra that stretches during erection

A
  • Pendulous urethra
  • Longest segment of male urethra
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4
Q

Male urethral site of voluntary control during voiding

A
  • Membranous urethra
  • Site of external urinary sphincter
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5
Q

Dual blood supply of urethra

A
  • Corpus spongiosum/urethra

*antegrade: bulbar artery

*retrograde: dorsal artery

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6
Q

Prostatic urethra blood supply

A
  • Inferior vesical artery
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7
Q

Membranous, anterior urethra blood supply

A
  • Bulbourethral artery
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8
Q

Retrograde perfusion of the urethra artery

A
  • Deep dorsal artery
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9
Q

Urethral stricture

A
  • Circumferential spongiofibrosis from scar or stenosis as ar esult of trauma
  • Etiology

*trauma: pelvic fx. straddle injury

*iatrogenic: foley catheter, transurethral instrumentation

*infection: gonococcal urethritis

*inflammatory: lichen sclerosis/BXO

*congenital: Cobb’s collar- smooth muscle proliferation of bulbar urethra

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10
Q

Urethral stricture presentation

A
  • Spraying/splitting stream, weak stream, incomplete emptying, straining
  • High voiding pressure w/ bladder remodeling over time
  • Infection: UTI, prostatitis
  • Urethrocutaneous fistula
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11
Q

Urethral stricture dilation

A
  • Surgical treatment for stricture
  • Goal is to dilate stricture w/o tear
  • High failure rates

*<2cm: 40% failure 1yr

*2-4cm: 50% failure 1yr (75% 4yr)

*>4cm: 80% at 1yr

  • Repeat dilations increase risk of failure and stricture progression
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12
Q

Urethral stricute DVIU

A
  • Surgical treatment for stricture
  • Laser or cold knife

*incise at 4 and 8 o’clock to avoid corporal injury

  • Foley for 72hrs
  • 100% failure at 48months

*related to degree of fibrosis

  • Proceed to urethroplasty if (when) pt fails
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13
Q

Excision and primary anastomosis (EPA)

A
  • Treatment for urethral stricture
  • Resect scar, spatulate ends, and tension free anastamosis
  • Bulbar urethra: <3cm
  • Penile urethra: <1cm

*can cause ventral chordee if too much penile urethra is excised

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14
Q

Buccal mucosal graft Urethroplasty

A
  • Treatment for urethral stricture
  • Graft taken from oral cavity
  • Dorsal onlay: penile urethra
  • Ventral onlay: bulbar urethra
  • Excellent long-term success (up to 85%)
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15
Q

Urethral carcinoma

A
  • Very rare
  • HPV 16/18, STD, urethral stricture
  • Squamous cell variant is most common
  • Bulbomembranous junction is most common site
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16
Q

Urethral carcinoma presentation

A
  • Hematuria
  • Palpable mass
  • LUTS
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17
Q

Urethral carcinoma diagnosis

A
  • Cystoscopy
  • Urethral biopsy
  • Penile MRI
  • CT abdomen and pelvis
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18
Q

Anterior urethra carcinoma treatment

A
  • Partial penectomy w/ 2cm neg. margin
  • Inguinal LN dissection if palpable nodes and no distant mets
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19
Q

Posterior urethra carcinoma treatment

A
  • Total penectomy
  • Cystoprostatecomy
  • Pelvic LN dissection if no distant mets
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20
Q

Penis clincal anatomy - structure

A
  • Layers

*skin, dartos fasica, superficial dorsal v., Buck’s fascia, dorsal NVB, tunica albuginea, corpora cavernosa, cavernosal a.

  • 2 corpora cavernosa

*erectile bodies

  • 1 corpus spongiosum

*urethra

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21
Q

Penis clinical anatomy - vascular

A
  • External pudendal artery

*skin/prepuce

  • Internal pudendal artery

*bulbar a.: bulbar urethra

*bulbourethral a: corpus spongiosum/urethra, glans

*cavernosal a: corpora cavernosa—>erections

-Dual blood supply: corpus spongiosum/urethra

*antegrade: bulbar artery

*retrograde: dorsal artery

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22
Q

Papilloma (pearly papules) of the penis

A
  • Benign lesion
  • 1-2mm papules on glans/coronal edge
  • Does NOT contain HPV
  • NOT transmissible
  • Tx: reassurance, observe
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23
Q

Condyloma acuminatum/HPV

A
  • Benign lesion
  • Non-tender, papillary
  • STD, caused by HPV
  • 90%: HPV 6, 11
  • Malignancy: 16, 18

*cervical, penile, anal

  • Dx: PE, biopsy (some pts)
  • Tx: imiquimod, podofilox, excision, laser ablation

*topical may take 3months

  • Prevention: quadrivalent HPV recombinant vaccine (types 6, 11, 16, 18)
24
Q

Zoon’s balantis

A
  • Benign penile lesion
  • Glans of uncirced males
  • PE: asx, macular, well defined erythema, pinpoint “cayenne pepper”
  • Dx: biopsy (plasma cells)
  • Tx: topical steroids, circumcise, laser ablation
25
Q

Buschke-Lowenstein tumor

A
  • Pre-malignant penile lesion
  • “Giant conyloma”, cauliflower appearance
  • May be locally invasive, but no metastasis
  • Rare malignant conversion

*HPV 6, 11

  • Tx: wide, completeexcision

*high recurrence rates

26
Q

Bowenoid papulosis

A
  • Pre-malignant penile lesion
  • Red brown papules on the shaft of younger circumcised pts
  • Malignant transformation in immunosuppressed pts
  • Dx: biopsy (+HPV)
  • Tx: surveillance, topical 5-FU, or ablation
27
Q

Lichen sclerosis

A
  • Pre-malignant penile lesion
  • Arises from chronic infection or inflammation
  • Flat, white mosaic patches
  • Meatal stenosis/urethral stricture—> voiding sx/LUTS
  • Consider cystoscopy
  • Bx if spreading rapidly
  • 2-8% malignat
  • Tx: observe if asx, topical steroids, circumcision if phimotic, meatotomy, urethroplasty
28
Q

Penile carcinoma in situ

A
  • Involving either the shaft or the glans
  • Shaft—> Bowen’s dx (top image)
  • Glans/prepuce—> erythroplasia of Qeuyrat (bottom image)
  • Uncirc. male, 50-60
  • Red, velvety plaques
  • 10% develop penile ca
  • Dx: biopsy
  • Tx: topical 5-FU, laser ablation, excision
29
Q

Penile cancer

A
  • Rare, <1% of all adult cancer in US
  • Annual incidence: 2120 new cases in US 2017

*1:100,000 adult males

  • 360 disease-specific deaths per year
  • More common in Africa, Asia, and South America
  • Males, 50-70
  • Squamous cell carcinoma is the most common type
  • Most common paraneoplastic syndrome: hypercalcemia
30
Q

Penile cancer risk factors

A
  • Uncircumcised, smoking, phimosis, chronic inflammation, HPV (16, 18), pre-malignant lesions

*neonatal circ virtually eliminates risk (postpubertal circ does not change risk)

31
Q

Squamous cell carcinoma of penis

A
  • HPV 16, 18
  • Location: glans (50%), shaft (30%), prepuce (20%)
  • Sx: non-healing wound, papule, wart, induration, fungating lesion, ulcer
  • Can invade locally and metastasize
32
Q

Squamous celll carcinoma of the penis metastasis

A
  • Inguinal lymph nodes

*superfical

*b/l

  • Distant mets (<10%)

*lung (#1 site of distant mets)

*liver, bone, brain

33
Q

Squamous cell carcinoma of the penis workup

A
  • +/- biopsy if unclear
  • Chest x-ray
  • CT of abdomen/pelvis
  • Labs: CMP, LFTs
  • MRI/penile US: organ sparing surgery (corporal involvement)
  • Bone scan: bone pain, hypercalcemia, inc. alk phos
34
Q

Squamous cell carcinoma clinical staging

A
  • Depth of invasion (T) and node (N)/Met (M) status
  • Ta: no-invasive
  • T1a: low grade subepithelial
  • T1b: lymphovascular invasion or any high grade
  • T2: cavernosa/spongiosum invasion
  • T3: urethral invasion
  • T4: into adjacent organs
35
Q

Squamous cell carcinoma of the penis treatment

A
  • Surgical excision = gold standard

*partial penectomy: must maintain 2cm of phallic length for voiding function

*must resect to neg. margin

*total penectomy: >T2 disease

*penil sparing: Tis, Ta, T1a

  • Chemo/radiation: pelvic nodes, b/l inguinal nodes, distant mets

*paclitaxel, ifosfamide, cisplatin

  • Intensive follow up first 2yrs, then annually (CT, CXR, PE)
36
Q

Scrotal layers

A
  • Skin
  • Dartos fascia
  • External spermatic fascia
  • Cremaster muscle and fascia

*regulates the tonicity of the skin

  • Internal spermatic fascia
  • Tunica vaginalis
37
Q

Testicular blood supply

A
  1. Testicular artery

*aorta

  1. Cremasteric artery

*inferior epigastric artery

  1. Deferential artery

*internal iliac artery

38
Q

Spermatocele

A
  • Benign aquired cyst of the testicle
  • Dilation of the efferent ductules of the epididymal head
  • Painless, slow growing
  • Dx: PE, U/S
  • Tx: observe, elective excision

*excision will not improve fertility in subfertile male

39
Q

Hydrocele

A
  • Serous fluid collection of tunica vaginalis
  • 1% of males
  • Sx: painless, “heavy” sensation
  • PE: translucent swelling of scrotum, may extend into inguinal canal
  • 2 types:

*congential

*acquired

40
Q

Hydrocele types

A
  • Congenital: due to patent processus vaginalis, communicating, fluctuates in size (w/ valsalva), bulges into inguinal crease
  • Acquired: defective fliuid absorption or excess production within tunica vaginalis
  • Hydrocele of cord: isolated, often subclinical
41
Q

Hydrocele treatment

A
  • Always assess the contralateral testicle, scrotal US
  • Observation, elective resection

*peds: will often resolve by 1yo

*DO NOT ASPIRATE: recurrence

42
Q

Varicocele

A
  • Group of dilated veins in the pampiniform plexus
  • Most common finding in subfertile males
  • Inguinal or scrotal pain, testicular atrophy, infertility, “bag of worms”

*stress pattern: decreased motility, low sperm count, abnormal morphology

  • Left testicle

*more common ~85%

*gonadal v inserts into left renal v (longer course, more back pressure)

  • Right testicle

*gonadal v inserts directly into IVC

*consider abdominal, retroperitoneal, or IVC mass w/ unilateral right varicocele (especially if acute onset)

43
Q

Varicocele grades

A
  • Grade 1: not visible, only palpable with valsalva
  • Grade 2: not visible, but easily palpated standing
  • Grade 3: large, grossly visible
44
Q

Varicocele treatment

A
  • Indications for surgery: symptomatic, abnormal semen analysis, adolescent w/ ipsilateral atrophic testicle (may reverse atrophy)

*highest rate of success: Microsurgical surgery approach (lowest recurrence rate)

*highest rate of recurrence: retroperitoneal surgery approach

  • Observe: consider annual semen analysis for men wishing to father children
45
Q

Varicocele surgical treatment side effects

A
  • Hematoma (microsurgical)
  • Hydrocele (RP, inguinal, laparoscopic)
  • Repair will improve semen anlysis in 70% of subfertile males after 3-6 months
46
Q

Testicular cancer

A
  • Males 20-40

*can occur at any age

  • Incidence 1:300 (white>black)
  • High cure rate
  • PE: painless mass or lump in testes
  • Risk factors:

*family hx

*cryptochidism

*klinefelter’s

*androgen insensitivity syndrome

47
Q

Testicular cancer metastasis

A
  • Usually metastasize via lymphatics

*most common site: retroperitoneal lymph nodes

  • Choriocarcinoma and yolk sac tumor spread hematogenously

*choriocarcinoma: brain mets

  • Distant, non-LN sites: lung, liver, brain, bone
48
Q

Testicular cancer work up

A
  • Scrotal US
  • Tumor markers

*B-hCG, AFP, LDH

  • CT abdomen and pelvis
  • CXR
  • CBC, LFTs, BMP, LDH

- Radical inguinal orchiectomy

49
Q

Testicular cancer tumor markers

A
  • Draw before AND after radical orchiectomy
  • Obtain post-orchiectomy tumor markers after 5 half lives (they should normalize if orchiectomy has completely resected disease and there are no mets)
  • B-hCG: secreted by syncytiotrophoblasts

*may be elevated in choriocarcinoma, embryonal, and 20% of seminoma

*falsely elevated: marijuana use, hypergonadotropic hypogonadism

*t1/2: 2 days

  • AFP: secreted by fetal yolk sac, liver and intestine

*NEVER elevated in pure choriocarcinoma or pure seminoma

*t1/2: 5 days

  • LDH: marker of bulky disease
50
Q

Seminoma

A
  • “Fried egg” nucleus
  • Sensitive to chemo and radiation

*only germ cell tumor sensitive to radiation

  • 20% have B-hCG elevation
  • If pathology reveal seminoma mixed w/ NS-GCT, treat as seminoma
51
Q

Embryonal testicular cancer

A
  • Papillary projections
  • B-hCG and AFP elevated
52
Q

Yolk sac tumor

A
  • Schiller-Duval bodies
  • Always AFP elevated
  • Most common pediatric testicular tumor
53
Q

Choriocarcinoma

A
  • Syncytiotrophoblasts
  • Always HCG elevated
  • Brain mets common
  • Worst prognosis of testicular tumors, but rare
54
Q

Teratoma

A
  • Cystic
  • Endoderm, mesoderm and ectoderm elements
  • Chemo and radiation resistant—> surgical excision
55
Q

Testicular cancer treatment

A
  • Always begins w/ a radical inguinal orchiectomy

*trans-scrotal approach risks tumor seeding

  • Radiation: seminoma only
  • Chemotherapy: B.E.P.

*bleomycin, etoposide, and cisplatin

  • Retroperitoneal lymph node dissection
  • Pt may require multimodal therapy

RGU Exam 3 (19 decks)

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