Genito-urinary Flashcards
what is an epididymal cyst
usually develop in adulthood and contain clear on milky (spermatocele) fluid.
lie above and behind the testis
remove if symptomatic
what is a hydrocele
fluid within the tunica vaginalis
what is a congenital hydrocele
associated with a patent processus vaginalis, which typically resolves during the 1st year of life.
communicating:
- occurs due to the failed closure of the processus vaginalis during development.
- usually discovered in infancy
- reducible. increases in size with the valsalva manoeuvre.
non-communicating hydrocele
- no connection to the peritoneal cavity present.
- NOT reducible. doesn’t increases in size with the valsalva manoeuvre.
what is an acquired hydrocele
secondary to underlying pathology: testis tumour/ trauma/ infection/ torsion
clinical features of hydrocele
fluctuant, painless swelling of affected scrotum.
- may be present since infancy or childhood
- may or may not be reducible
positive transillumination
palpation above the swelling is possible - a normal spermatic cord and inguinal ring are present
diagnosis of hydrocele
clinical usually
ULTRASOUND every hydrocele to rule out malignancy - hypoechoic fluid confirms the diagnosis.
treatment of hydrocele
congenital hydrocele usually resolves spontneously within 6 months of birth.
indications for surgery
- if spontaneous resolution doesn’t occur by 1 year of age.
- excessive discomfort
- underlying pathology suspected
- testicle not palpable
- infertility is a concern
procedures
- surgical excision of the hydrocele sac
- percutaneous aspiration of the hydrocele fluid
what is a varicocele
abnormal enlargement and tortuosity of the pampiniform plexus in the scrotum due to proximal obstruction of the spermatic vein.
causes of primary varicoele
not fully understood.
left testicle most commonly affected (85%)
- longer course of the left spermatic vein and its insertion at a 90° angle into the left renal vein predisposes to slower drainage and increased hydrostatic pressure.
causes of a secondary varicocele
mass in the retroperitoneal space (Ormond disease, lymphoma, RCC) obstructing venous drainage into the IVC (right-sided varicocele) or left renal vein (left-sided varicocele)
clinical features of a varicocele
painless enlargement may be present.
dull, aching pain of the hemiscrotum
HEAVINESS OF THE AFFECTED SCROTUM.
soft bands/strands are palpable in the upper pole of the affected scrotum (‘bag of worms’)
symptoms worsen when standing or performing the valsalva maneouver.
negative transillumination
diagnosis of varicocele
BILATERAL ULTRASOUND (dilated >2mm hypoechoic pam-uniform vessels)
doppler ultrasonography
treatment of varicocele
conservative management - scrotal support.
invasive treatment
- laparoscopic varicocelectomy - occluded by ligation.
- percutaneous embolisation
complications of varicocele
infertility
- sperm is produced in the testicles at 2°C below the average body temp
- in a varicocele, blood stasis within the scrotum increases local temp, resulting in sub-optimal environment for spermatogenesis.
what is cryptorchidism
failure of one or both testicles to descend to their natural position in the scrotum
risk factors for cryptorchidism
prematurity
low birth weight
clinical features of cryptorchidism
palpable (80%) - testicle cannot be manually manipulated into the scrotum.
non-palpable - may be intra-abdominal or absent.
variants of cryptorchidism
inguinal testis - testicle is located between the external and internal inguinal ring, preventing adequate mobilisation (90%).
intra-abdominal testis - testicle is located proximal to the internal inguinal ring.
ascending testes - testicular retraction into the scrotal pouch is possible.
diagnosis of cryptorchidism
clinical diagnosis
laboratory tests
- testosterone (bilateral - low, unilateral - normal (normal Leydig cell function))
- low inhibin B
- high FSH, high LH
treatment of cryptorchidism
typically resolves without treatment via spontaneous descent of testicles by 6 months of age.
persistent cases (6-18 months of age)
- ORCHIDOPEXY
- Orchidectomy
(if non-viable testicular remnants or late discovery of undescended testicle (>2y).
complications of cryptorchidism
testicular cancer (germ cell tumours)
infertility - higher temp of the abdo cavity is suboptimal for spermatogenesis –> oligospermia –> infertility
testicular torsion
inguinal hernia
what are the different types of testicular tumour
Seminoma (55%) 30-65yeard olds
Non-seminomatous germ cell tumours e.g. teratoma (33%) - 20-30 year olds
mixed germ cell tumour
lymphoma
signs of testicular tumour
PAINLESS TESTIS LUMP, found after trauma/infection ± haematospermia, secondary hydrocele.
dyspnoea (lung mets)
abdominal mass (enlarged nodes) or effects of secreted hormones.
25% of seminomas and 50% of NSGCT present with metastases
gynaecomastia - if HCG high
risk factors for testicular cancer
cryptorchidism (undescended testis)
infertility
contralateral testicular cancer
family history of testicular cancer
Klinefelter syndrome; trisomy 21 (increased risk for germ cell tumours).
germ cell neoplasia in situ
tumours markers used in testicular cancer
AFP
Beta-HCG
which tumour marker is raised in testicular choriocarcinoma (NSGCT)
beta-HCG - extremely high levels
which tumour marker is raised in yolk sac tumours (NSGCT)
AFP - high
what type of nonseminomatous GCT are there
embryonal carcinoma
teratoma
testicular choriocarcinoma
yolk sac tumour
what is a teratoma in testicular cancer
commoner in children
may contain elements of muscle, cartilage, bone, teeth.
what is the most common testicular tumour in men >60 years of age
LYMPHOMA (large b-cell lymphoma) - extra-nodal non-hodgkins lymphoma
how to testicular tumours metastasise
via the lymphatic system - drain to the para-aortic lymph nodes first.
what are the paraneoplastic features of testicular cancer
hyperthyroidism
- HCG can mimic TSH, enabling weak stimulation of the TSH receptor in tumours with HCG overproduction.
investigations for testicular cancer
lab tests - AFP, HCG + LDH
imaging - ULTRASOUND
CT TAP - for staging and checking for mets
biopsy - only done following removal of testis to prevent tumour seeding.
treatment of testicular cancer
prior to surgery - sperm cryopreservation
radical inguinal orchidectomy
adjuvant chemoradiotherapy (based on histology findings and staging)
symptoms of torsion of testis
SUDDEN ONSET PAIN IN ONE TESTIS - making walking uncomfortable. typically swollen and tender testicle and/or lower abdo tenderness.
pain in the abdomen
nausea and vomiting
signs of torsion of testis
inflammation of one testis - tender, hot and swollen
lies high and transversely
ABSENT CREMASTERIC REFLEX
PREHN SIGN NEGATIVE
what is torsion of testicular appendage (hydatid of Morgagni)
causes less pain
tiny BLUE nodule may be visible under scrotum.
Mx - NSAIDs or if in doubt, surgical exploration
ddx of testicular pain
testicular torsion
epididymo-orchitis
tumour
trauma
treatment of testicular torsion
SURGERY WITHIN 6 HOURS
consent for bilateral orchidopexy and possible orchidectomy.
only do a doppler ultrasound if diagnosis is uncertain but DO NOT DELAY SURGERY!
ddx of undescended testes
cryptorchidism
retractile testis - excessive cremasteric reflex. found in external inguinal ring. mx - reassure.
maldescended testis - found anywhere from abdo to groin
ectopic testis - common in superior inguinal pouch but could be in the abdo, perineal, penile or femoral triangle.
complications of maldescended and ectopic testis
infertility
testicular cancer
testicular trauma
testicular torsion
hernias (patent processus vaginalis)
treatment for maldescended or ectopic testis
ORCHIDOPEXY
hormonal - HCG
what is balanitis
acute inflammation of the foreskin and glans
associated with strep and staph infections
MOST COMMON IN DIABETICS
often seen in young children with tight foreskin
management of balanitis
antibiotics
circumcision
hygiene advice
causes of balanitis
poor genital hygiene
contact allergies and topical irritants
drug reaction
bacterial infection e.g. STI (gonorrhoea)
yeast infection - recent hx of ABx use
trauma
clinical features of balanitis
pruritus, pain, and oedema of the glans penis
erythema and ulcerated lesions of the glans or foreskin
fever, arthralgia, malaise
thick penile discharge
investigation for balanitis
clinical usually
gram stain and culture for bacterial infection
treatment of balanitis
conservative
- daily retraction of foreskin and bathing with warm saline solution.
- avoid known irritants e.g. soap
- topical anti fungal e.g. clotrimazole
- Abx for bacterial infection
- topical corticosteroid cream for irritant contact or drug reaction.
- treat underlying chronic condition (psoriasis, reactive arthritis, diabetes)
surgery
- circumcision in recurrent cases
complications of balanitis
post inflammatory phimosis
UTI
recurrent UTI
penile cancer
what is phimosis
tight foreskin that cannot be completely retracted over the glans penis
causes of phimosis
post-infection of balanitis
congenital
scarring after trauma or circumcision
sx of phimosis
difficulty in retracting the foreskin posteriorly
painful erection and/or dyspareunia
treatment of phimosis
conservative - topical corticosteroid cream
stretching exercises
surgical
- vertical incision or circumcision
complication of phimosis
foreskin tear - haemorrhage
paraphimosis
what is paraphimosis
urological emergency
tight foreskin is pulled back behind the head of the penis and then becomes stuck.
it cannot be placed forward again to its usual position covering the tips of the penis.
causing swelling, pain and loss of blood flow to the tip of the penis.
causes of paraphimosis
complications of phimosis
iatrogenic - following bladder catheterisation
trauma
features of paraphimosis
noticeable band of constricting tissue
foreskin cannot be returned to original position.
oedema and pain of the glans penis
features of penile ischaemia (blue skin)
treatment of paraphimosis
conservative - manual reduction with adequate pain control (topical anaesthesia, local anaesthesia, regional block)
surgery
- dorsal slit reduction surgery
- circumcision (last resort)
complication of paraphimosis
penile necrosis
what is prostatitis
inflammation of the prostate gland which may be infectious (acute and chronic bacterial prostatitis) or non-infectious (chronic pelvic pain syndrome).
common cause of acute bacterial prostatitis
E. COLI
gonorrhoea and chlamydia - consider in men <35y of age.
common cause of chronic prostatitis
bacterial - e.coli
non-bacterial
- immune response to a prior UTI
- nerve damage in the pelvic region
- chemical irritation
- pelvic floor muscle dysfunction
- parasitic or viral infection
causes of both acute and chronic bacterial prostatitis
UTI - urethritis, cystitis, epididymitis
genitourinary tract interventions - catheter, prostate biopsy
voiding dysfunction and bladder outlet obstruction
clinical features of acute bacterial prostatitis
spiking fevers, chills, malaise
acute dysuria, frequency, urgency
severe pain in lower back, perineal, pelvic and with defecation
prostate - tender, boggy, warm and swollen
clinical features of chronic bacterial prostatitis
low-grade fever in some patients.
dysuria, frequency, urgency, ED, bloody semen
mild genitourinary pain
prostate - normal, may be enlarged or tender
clinical features of chronic pelvic pain syndrome
possibly ED
painful ejaculation
bloody semen
moderate, diffuse pain in the lower abdo, lower back, perineum, scrotum and penis.
prostate - normal usually.
laboratory tests for acute bacterial prostatitis
urinalysis - MSU - high WCC
urine culture - e.coli most common
urine gram statin
bloods - raised WCC, CRP.
blood cultures - if septic
treatment of bacterial prostatitis
first line - Antibiotic therapy for 6 weeks (ciprofloxacin, co-trimoxazole)
if acute retention and persistent fever - suprapubic catheterisation
treatment of chronic pelvic pain syndrome
alpha-blockers - tamsulosin
5-alpha reductase inhibitors - finasteride
NSAIDs
psychological support and treatment
physiotherapy
complication of prostatitis
prostatic abscess (antibiotics + transrectal USS-guided drainage)
acute urinary retention
pyelonephritis and sepsis
epididymitis
