GenitoUrinary Flashcards
what cells are found within the seminiferous tubules?
Germ cells
Sertoli cells
what is the function of germ cells?
Allow the process of spermatogenesis
describe the steps of spermatogenesis?
- spermatogonia
- spermatocytes
- spermatids
- spermatozoon
what is the function of Sertoli cells?
- They are the true epithelium of the seminiferous epithelium
- support germ cell development
- secrete inhibin -which enhances FSH biosynthesis and secretion
what are Peritubular Miotubular cells?
surround the seminiferous tubules and make up part of the smooth muscle
where our Leydig cells found?
Within the interstitium
what is a function of Leydig cells?
Secrete testosterone and other androgens as well as presenting macrophages
what is the blood supply to the testicles?
testicular arteries however it also has collateral blood supplies
describe the branching of the testicular arteries?
Arise from the abdominal aorta and descend through the inguinal canal
what blood supply supplies the scrotum and the rest of the external genitalia?
external Pudinal artery and branches of the internal Ilac artery
what is the venous drainage of the testicles?
Veins formed from the pimpiniform plexus in the scrotum
the left testicle drains into the left renal vein
the right testicle drains into the inferior VC
what tests are good for imaging the upper urinary tract?
CT with contrast
or ultrasound scan
when our ultrasound scans most commonly used when imaging the urinary tract?
in accident and emergency for acute situations as they have a lower sensitivity than CT
what investigations are indicated for anyone with haematuria that is unexplained from a simple cause such as UTI?
Either CT or ultrasound
and cystoscopy of the bladder
what type of CT is used when investigating haematuria or wanting to visualise the urinary tract?
CT urogram with IV contrast
when would you not want to use contrast?
If someone has:
- severe kidney failure
- allergies
- or if wanting to view kidney stones
what does a reducible hernia mean?
When the contents of the area can be manipulated back into its original position
What does an irreducible hernia mean?
the hernia is compressed by the defect causing it to be irreducible
what is an obstructed hernia?
mainly refers to hernias containing bowel
contents of the hernia compressed to the extent that the bowel lumen is no longer patent
causes bowel obstruction
what is a strangulated hernia?
The compression around the hernia prevents blood flow into the hernias’ content
causing ischaemia and tissue pain
what is one of the most common causes of lump in the groin?
Inguinal hernia
Describe the path of the inguinal ligament
- the inguinal ligament runs between the ASIS and the pubic tubercular
- this forms the inguinal canal
- inguinal canal allows for the passage of the spermatic cord, round ligament + ilioinguinal nerve
what is a direct inguinal hernia?
A hernia caused by a weakness in the posterior wall of the inguinal canal
causes abdominal contents to enter the inguinal canal and go to the superficial ring
but does not pass through the superficial ring
what is an indirect inguinal hernia?
the abdominal contents passes through both deep inguinal ring + through the inguinal canal to the superficial ring
what is an easy way to distinguish betweent a direct and an indirect hernia?
If you press on where deep inguinal ring is and you can reduce the hernia then it means it is an indirect hernia
what are causes of inguinal hernias?
- Increased intra-abdominal pressure
- weakness of the abdominal muscles
- chronic cough
- constipation
- heavy lifting
- being elderly
- obesity
how would you diagnose an inguinal hernia?
Diagnosis is usually clinical with examination
but ultrasound scan can be used to aid diagnosis
what is a typical presentation of an inguinal hernia?
The development of a painless swelling in the groin over time
(although can occur suddenly after heavy lifting)
what is the presentation of a symptomatic inguinal hernia?
- Pain particularly on increasing intra-abdominal pressure
- change in bowel habits such as constipation
- pain or burning sensation in the groin
- scrotal swelling
what is the management of an asymptomatic hernia?
If it is small and not increasing in size:
- it can be left alone / expectant management
otherwise:
- elective surgery
what is the management of a symptomatic inguinal hernia?
Surgery - open or laparoscopic
if anything is strangulated or obstructed:
- emergency surgery
what structures are found beneath the inguinal ligament?
- femoral artery
- femoral vein
- femoral nerve
- femoral canal
where would a femoral hernia usually occur?
The femoral canal – abdominal contents protrudes through it
why are femoral hernias particularly problematic?
They are at high risk of strangulation and obstruction as it is bordered by the lacuna ligament
what are risk factors associated with femoral hernias?
Elderly women who have had childbirth
what is the presentation of a femoral hernia?
Swelling can be in the groin like an inguinal hernia
however
it is usually closer to the upper thigh
can cause hip pain as well as pain at the site of herniation
what other benefits of laparoscopic surgery, and what are its cons?
PRO:
- Involves less pain
- less scarring
- shorter recovery times
CON:
- more expensive than open surgery
what other most common causes of uro sepsis?
UTI
obstruction in urinary flow causing urinary stasis
Were the most common locations for an obstructed kidney?
- pelvicureteric junction
- vesicoureteric junctionn
- ureter
what investigations do you need to perform in urosepsis?
sepsis six :
- taking blood cultures
- urine cultures
- rest
finding out if there is any obstructive cause - using CT (no contrast)
what is the management of urosepsis?
starting empirical antibiotics until cultures come back
if there is obstruction:
- ureteric stent or…
- nephrostomy
- until obstruction is removed
what do you need to ensure in the management of over 65’s for UTI?
That you ensure gram-negative pseudomonas is covered
- penicillin or cephalosporins with gentamicin
what is a femoral aneurysm?
classed as ileo femoral aneurysm
can either be on the Ilac or femoral artery
what is the most common cause of of femoral aneurysm?
Atherosclerosis
how does atherosclerosis lead to aneurysm?
- inflammation associated with the atherosclerosis leads to the destruction and thinning of a vascular wall
- making it weaker
- specifically the tunica media is weekend
- leading to dilation of the vessels forming an aneurysm
what is the presentation of a femoral aneurysm?
usually asymptomatic
until there is embolisation or rupture
however sometimes a pulsatile mass may be felt at the groin
what is an easy way to distinguish between an aneurysm and a hernia?
They may feel very similar
but
in aneurysm you would hear bruit and vascular flow
patient presents with:
- acute groin pain
- signs of tachycardia
what should be one of your initial diagnoses?
ruptured femoral aneurysm
apart from groin pain what other symptoms can a ruptured femoral aneurysm cause?
- Weakness of the leg
- swelling and numbness (due to compression of nerves and obstructions nearby)
- those of acute limb ischaemia (pain paraesthesia paralysis pulselessness pallor perishing with cold)
if you suspect a ruptured femoral artery what investigations should you perform?
Duplex ultrasound scan
- looking at proximal and distal arteries
CT angiography is then used
+ bloods for shock
what is blue toe syndrome?
tissue ischaemia
secondary to cholesterol or great embolus
can occur if a clot forms due to an aneurysm and then dislodges
what is the management of a femoral aneurysm?
if symptomatic or larger than 3 cm
rapidly expanding
coexisting AAA
any complications present -give surgery
what is testicular torsion?
an emergency caused by the twisting of testicles
on the spermatic cord
leads to constriction of the vascular supply
causes rapid ischaemia and necrosis
what is the presentation of testicular torsion?
sudden onset of severe scrotal pain
associated nausea and vomiting
no relief of pain upon elevation of scrotum
what can cause testicular torsion?
Trauma
inflammatory
infective causes
what symptoms would indicate that infection/inflammation has caused testicular torsion?
- fever
- dysuria
- frequency
- pain
- discharge
what features in the history of testicular torsion would support your diagnosis?
(apart from symptoms)
history of intermittent or acute on and off pain
how would testicular torsion present in a patient with undescended testes?
sudden abdominal pain
what features might you find on examination of testicular torsion?
Severe tenderness
testis higher than the unaffected testes
what physical features may be present in a delayed presentation of testicular torsion?
Erythema and oedema and reactive hydrocele
how would you diagnose testicular torsion?
any indication of testicular torsion = ASAP exploratory laparoscopy surgery
do not waste time with ultrasound and Doppler’s
what is the management of testicular torsion?
aim to treat within 4 to 6 hours
immediate urological consultation for emergency scrotal exploration
then surgery + orchidoplexy
- however if there is no reperfusion orchidectomy
what is epididymitis?
Inflammation of the epididimis
what are the most common agents which cause epididymitis?
Chlamydia
nessieria gonorrhoea
Mycoplasma genitalium
What is the presentation of epididymitis?
unilateral pain and swelling
erythema and tender enlargement of the epididymis
systemic features may be present
what is an important differential to exclude in epididymitis?
Testicular torsion
- consider if there is a sudden and severe onset with initial examination showing no evidence of inflammation or infection
what conditions usually accompany epididymitis?
Epididymoorchitis or urethritis
how would you investigate Epididymitis?
Urine dipstick
first void urine sample for N AAT
- (chlamydia and gonorrhoea)
urethral swab + Gram stain if also urethritis
what is the management of epididymitis?
Once the cultures come back
with antibiotics
stop and discontinue amiodarone if used
patient presents with:
- a hot swollen erythema to one scrotum
- the testicle and the epidermis is very tender t
- discharge and some symptoms of UTSI
- he reported having had a fever a few days ago
what is most likely diagnosis?
epididimoorchitis
what is Epididimoorchitis?
an infection of both the epididymitis and the testicle
what pathogenusually causes epididymal orchitis?
E. coli or STIs
how would you investigate epididymoorchitis?
full STI screen
with urine dipstick + urine cultures
what antibiotics would you give to cover E. coli?
Ciprofloxacin
how long should you give antibiotics to cover epididymo orchitis?
10 – 14 days
a patient presents with:
- LUTS
- dysuria and urinary frequency
- perineal + genital pain
- urinary stream diminished + slowing stream
- a low-grade fever
what is the most likely diagnosis?
prostatitis
as well as pain in the perineal or genital regions where else can prostatitis cause pain?
- Scrotum
- testes
- suprapubic
- lower back
what is the most common cause for prostatitis?
E coli or STIs - if untreated and ascend
what findings would be present on DRE in a patient with prostatitis?
Intensely tender prostate
may also feel abnormally soft and boggy
what investigations need to be performed in prostatitis?
urinalysis urine cultures blood cultures- in febrile patients with acute symptoms PSA may be performed- raised
what is the management of prostatitis?
Antibiotic therapy – quinolone PO,
signs of sepsis: parenteral antibiotics:
- broad-spectrum penicillin
- cephalosporins
- or quinolone with gentamicin
What is the name of the pathogen that causes chlamydia?
Chlamydia trachomitis
what are the symptoms of chlamydia in women?
- 85% of women are asymptomatic
- post coital or inter menstrual bleeding
- odourless vaginal discharge
- dysuria
- pelvic pain
what are symptoms of chlamydia which goes untreated in females?
pelvic inflammatory disease
- ascends urogenital tract
- causing fever myalgia nausea and vomiting pelvic or abdominal pain
what are the symptoms of chlamydia in a male?
Dysuria
clear white urethral discharge
what are the complications of untreated chlamydia in males?
epididymitis
prostatitis
epididimoorchitis
+systemic symptoms
how do you test for chlamydia?
First pass urine test
swabs from high vagina or urethra
NAAT testing
what is the management of chlamydia?
If there is a high index of suspicion you don’t have to wait until test results
- doxycycline
- 7days (azithromycin is another option)
what is involved in a full STI screen?
First pass urine
high vagina charcoal swab
endocervical charcoal swab
endocervical NAAT test
swab or urethra - in males
what pathogen causes gonorrhoea?
Gram-negative diplococcus Neisseria gonorrhoea
what is the presentation of gonorrhoea in a male?
Thick green yellow discharge
muco purulent
dysuria + urethral pruritus (sx of urethritis)
if it ascends can cause symptoms of prostatitis and epididimoorchitis
what are the symptoms of gonorrhoea in females?
Yellow green vaginal discharge
pelvic pain
fever
pain on urination
intermenstrual bleeding
What would be the rectal presentation of gonorrhoea?
rectal pruritus
muco purulent discharge
- usually with bowel movements
rectal pain and sometimes rectal bleeding
what is a common complication of untreated gonorrhoea?
PID
What is disseminated gonococcal infections?
skin and synovium
as well as systemic features
what is the management of gonorrhoea?
Ceftriaxone and azithromycin
what is the pathogen which causes syphilis?
Trepenema pallidum
How is syphilis spread?
Contact with a syphilitic lesion
(on genitals or mucous membrane)
it can also be passed on congenitally
what is the presentation of syphilis and which is the main symptom to be aware of?
Solitary painless genital ulcer!
In the anogenital or cervical area
mouth ulcers may also be present
regional lymphadenopathy are all features of primary infection
what does a painful lesions suggestive of syphilis indicate?
Coinfection with genital herpes
what do multiple vesicles in primary syphilis indicate?
Coinfection of HIV
when does secondary syphilis occur?
4 to 8 weeks after primary syphilis
what is the presentation of secondary syphilis ?
- Systemic features
- arthralgia
- generalised lymphadenopathy
- symmetrical maculopapular rash on palms, soles of feet, trunk and scalp
- rash may ulcerate
- mucosal ulceration causing snail track
- painless ulceration on genitals
- patchy alopecia
what is neuro syphilis?
specific organ involvement of the brain causing headaches, meningismus, hearing loss and seizures
what are some areas of specific organ involvement which can occur in secondary syphilis?
Neurological
ophthalmological - iritis uveitis and choridoretinitis
vasculitis - causing nephrotic syndrome or hepatitis
what is the opthalmological involvment syphilis can have?
iritis uveitis and choridoretinitis
what vasculitic consequences can occur due to syphillis?
nephrotic syndrome or hepatitis
what is the definition of latent syphilis?
A patient is seropositive with the absence of any clinical features
how do you diagnose syphilis?
swab testing and PCR from lesion and additional serological testing / if anyone is presenting with neurological symptoms than a CSF PCR should be performed
What is management syphilis?
IM benzylpenicillin
- unless is neurological involvement in which case give IV
what is trichomoniasis?
Infection caused by protozoan parasite ‘trichomonal vaginalis’
what is the presentation of trichomonas in women?
- Usually asymptomatic but can cause:
- itching
- burning
- redness
- soreness of the genitals
- discomfort urinating
- changing vaginal discharge
- discomfort during sex
what is the presentation of trichomonas in men?
- usually is asymptomatic:
- Itching or irritation inside the penis
- burning after urinating or ejaculating
- discharge
- soreness, swelling, redness of the head of the penis or the foreskin
how do you diagnose trichomonas?
swabbing either the penis or the vagina and looking for the parasite under the microscope
How do you manage trichomonas?
metronidazole
What is the presentation of Thrush in women?
white discharge
- cottage cheese appearance
no unusual smell
itching and irritation around the vagina and vulva
soreness + stinging during sex or urinating
what is a presentation of Thrush in men?
irritation or burning
redness around the head of the penis
under the foreskin
white discharge like cottage cheese
unpleasant smell
difficulty pulling back the foreskin
what are some signs of severe vulvovaginal candidiasis?
erythema -can extend to the labia majora and perineum
vaginal fissuring or oedema
excoriation of the vulva
is thrush an STI?
Technically no but can still be spread from sexual partners
what investigations are necessary in thrush?
high vaginal carbon swab
can be a swab taken from patient
what is the management of thrush?
pessary- clotramiozloe or fluconazole PO
younger than 15:
- prescribe topical cream only
only vulval symptoms:
- then prescribe topical only - top clotramidazole
what should you check in a patient who has recurrent or severe infections of thrush?
HbA1c and offer STI screening
What is a hypospadias?
Abnormality of the penis
ureteric opening is not in its normal position
it is a congenital condition
on newborn examination of the male genitals you notice that the urethra has its opening on the mid shaft what is this?
ventral urethral meatus – hypospadias
on newborn examination of male genitalia you noticed that there is failure of the foreskin to fuse ventrally - what is this?
hooded dorsal foreskin hypospadias
a 16 year old patient presents to you worried because they noticed that on erection there is a severe ventral curvature of the shaft of their penis what is this??
Chordee hypospadias
what are some complications of hypospadias?
Inability to mictuate in a normal direction
erectile dysfunction
deformity
What is the management of a hypospadias??
corrective surgery in patients younger than 2y
aims of surgery:
- terminal urethral meatus
- a straight urinary flow
- straight erection
- normal cosmetic appearance
what are storage symptoms of LUTS?
Frequency
urgency
nocturia
what are voiding systems of LUTS
- weak stream
- hesitancy
- intermittency
- straining
- incomplete emptying
- post void dribbling
a 60-year-old man presents to you complaining of LUTS
- what are the most likely diagnoses?
BPH
UTI
Prostate cancer
what is benign prostatic enlargement / hyperplasia?
smooth muscle hyperplasia
causing prostatic enlargement
symptoms also arising because of central nervous system dysfunction + blood flow dysfunction
describe the pathophysiology of benign prostatic enlargement
- Increase in the number of epithelial and stromal cells within the prostate gland
- usually within the transitional zone of the prostate
- testosterone is converted to dihydrotestosterone by five alpha reductase
- dihydrotestosterone receptors inside the prostate cells
- causing them to increase their secretions and increase cell division
- eventually resulting in gland enlargement
what is the main hormone that drives BPH? And what enzyme is involved?
dihydrotestosterone (testosterone converted by five alpha reductase)
which area of the prostate is most affected by BPH?
The transitional zone
what examination should you perform on a male presenting with L UTS and what is the result for BPH?
DRE will reveal soft enlarged gland
what investigations should you perform in someone with LUTS?
PSA / U+E - check for renal causes of LUTS (may also want to do urine dipstick)
why is the PSA not very specific for prostate cancer?
Because it can be raised in normal BPH as well as UTIs prostatitis urinary retention catheterisation and ejaculation
what is the most important risk factor for developing BPH?
Being over 50
describe a diagnostic questionnaire which can be used for LUTS?
the international prostate scoring symptom score: questionnaire which helps assess the severity of symptoms from mild (0 – 7) moderate (8 – 19) severe (20 – 35)
how would you manage mild L UTS?
Managed conservatively with lifestyle factors
how would you manage moderate L UTS?
Alpha blockers (tamsulosin) +/- five alpha reductase inhibitors (finasteride)/if any storage symptoms are present add an antique cholinergic drug (oxybutanine)
What are side effects of alpha blockers?
Anterograde ejaculation dizziness hypertension
how do alpha blockers work in terms of BPH?
Is an alpha one adrenoceptor antagonist so relaxes smooth muscles
how do five alpha reductase inhibitors work?
inhibit the conversion of testosterone to dihydrotestosterone thus reducing prostatic growth it takes six weeks to 6 months to work
what are side effects of five alpha reductase inhibitors?
Erectile dysfunction reduced libido ejaculatory disorders
what is the management of severe L UTS?
surgical intervention TURP if this is not possible long term catheter
what type of cancer is prostate cancer?
Glandular cancer
apart from LUTS what other symptoms may be present in prostate cancer and when with these be present ?
In more advanced disease the symptoms such as haematuria lethargy bone pain palpable lymph nodes and weight loss
what are the indications for referring men for a two-week wait pathway in terms of prostate cancer?
Abnormal/malignant DRE or elevated PSA above age specific range
when should you offer PS a and D R E testing?
any man with L UTS erectile dysfunction or visible haematuria
what investigations are done in the q. week weights pathway?
MRI is offered before biopsy in order to limits invasive tests But the biopsy is diagnostic/confirms diagnosis
what is the management of prostatic cancer?
low risk: watchful waiting / elective prostectomy Intermediate risk: radical prostectomy or watchful waiting High risk: NO WATCHFUL WAIT radical prostectomy or chemo + long term androgen deprivation therapy (also needs cancer scores T3/4 or PSA > 40 and NO co morbidities), radio therapy also offered.
what are side effects of androgen deprivation therapy?
hot flushes sexual dysfunction gynaecomastia and more
a young adult male (25) presents to GP with a palpable lump in the testicle which is painless on examination there is no discharge no erythema the lump is non-trans illuminable - what is the most likely diagnosis
Testicular cancer
what type of cancer is testicular cancer?
can be in germ-cell (90%) or non-germ-cell tumours
what are examples of germ-cell tumours?
seminomas / teratoma/ choriocarcinoma / yolk sac
what are red flags for testicular cancer?
Haemoptysis / bone or back pain / weight loss/ fatigue / night sweats / loss of apetite
what are risk factors associated with testicular cancer?
Aged 20 – 45/Caucasian/cryptoorchidism/previous testicular cancer/HIV/family history of testicular cancer
if you suspect testicular cancer what is the first line investigation?
ultrasound scan of the testis
after you have confirmed testicular cancer what other imaging should be performed?
Abdominal CT pelvic CT chest x-ray if you suspect any extra testicular mets
what markers may be raised in testicular cancer?
Alpha-fetoprotein (teratoma and yolk sac) serum beta hCG (chorio carcinoma) lactate dehydrogenase (in half of cases)
what is the management of testicular cancer?
radical inguinal orchidectomy with seeming cryopreservation and testicular prosthesis may be offered
what muscle allows for micturition?
detrusor
Describe the physiology of micturition
the detrusor muscle fills and stretches allowing for a constant intra-vesicular pressure (known as stress relaxation) / urine is passed through parasympathetic control / using pelvic nerves S2 – four releasing a CH which works on M3 muscarinic receptors causing the detrusor muscle to contract there is also inhibition in a different pathway resulting in the re-used sympathetic stimulation of the inner urethral sphincter causing relaxation in females urination is assisted by gravity whereas in males there is bulbospungiosus contractions
which parasympathetic nervous control micturition?
S2-4
What receptors are involved in detrusor micturition?
ACH controlled M3 Muscarinic
what drugs are associated with urinary retention?
antiarrhythmic’s anticholinergic (atropine Oxley Peter Nina) antidepressants (amitriptyline) antihistamines (chlorofrenamine) antihypertensives (nifedipine) auntie parkinsonian drugs (amantadine levodopa) antipsychotics (haloperidol) hormonal agents (oestrogen progesterone testosterone) muscle relaxants (baclofen diazepam) anti-adrenergic drugs (phenylphrine) beta-adrenergic drugs - plus carbamazepine dopamine morphine NSAIDS amphetamines
what are common causes of obstruction of the urinary tract in males?
BPH prostatic cancer for most this paraffin meiosis urethral strangulation stones infection prostatitis clots
what are common causes of obstruction of the urinary tract in women?
stones cystocele ovarian tumours uterine tumours complication of incontinence surgery PID lblood clots
what are some common causes of urinary retention?
See image below - in acute urinary retention page
describes the difference between acute and chronic presentations of urinary retention?
Acute: painful smaller volumes of urine and no long history of LUTS chronic: painless very large volumes of urine insidious onset with often a long history of LUTS
what is acute on chronic urinary retention?
A history of progressive L UTS followed by an episode of acute retention due to a precipitating event such as UTI or surgery
patient presents with difficulty passing urine (possibly anuric) abdominal/suprapubic pain they are restless on examination you note a palpable bladder what is most likely diagnosis?
Acute urinary retention
what examinations are important to assess in a patient with acute urinary retention?
Examine bladder which may be palpable performance DRE to check for an enlarged or abnormal prostate always take neurological examination to see for abnormalities to rule out cauda equina
what is the acute management of acute urinary retention?
A senior should be informed do ABCDE and gain IV access, insert a two-way catheter unless there is a history of haematuria in which case a three-way catheter, record residual volumes and send urine samples from the catheter
what investigations are required in acute urinary retention?
Urine sample after catheter is inserted, FBC and Urea, creatinine + electroytes, con do imaging USS/Ct to try and find cause
what is a TW OC?
trial without catheter
what drug is required by patients with L UTS history to help them pass their TW OC?
Alpha blockers (tamsulosin) +/- five alpha reductase inhibitors (finasteride)/if any storage symptoms are present add an antique cholinergic drug (oxybutanine)
why can diuresis occur in some patients after having a catheter inserted?
Occurs as the bladder is being decompressed
what are indications for high pressure chronic urinary retention?
large residual volume (1L+) deranged renal function
what is the discharge of a patient with high pressure chronic retention?
go home with a catheter in situ may need overnight observation as patients often develop haematuria and diuresis
what is a hydrocele?
an accumulation of fluid within the tunica vaginalis
What causes of secondary hydrocele?
malignancy trauma infection torsion
what other different types of hydrocele?
primary secondary/ communicating or non-communicating
what are non-communicating hydrocele caused by stroke their pathophysiology?
and increased production of fluid by the tunica vaginalis / reduce resorption of fluid / impairment in lymphatic drainage
what is the pathophysiology of communicating hydrocele?
they communicate with the peritoneum due to a patented processus vaginalis / these can change in size when standing versus lying down/ due to increased intra-abdominal pressure
what is the main diagnostic feature of a hydrocele?
painless swollen scrotum in one or both sides which feels like a water-filled balloon
which type of patients develop primary hydrocele?
male infants and newborns - usually resolved within first year of life
what is the management of hydrocele?
if over 2 y + discomfort : surgery otherwise watch and wait
what is a variocele?
a dilatation of the testicular veins which van be unilateral or bilateral
what usually causes a variocele?
usually caused by an incompetent valce of the spearmatic verin however can also be a feature of renal cancer (L sided renal cancer)
why does L sided renal cancer cause variocele?
as it can involve the L renal vein causing obstruction of the L spermatic vein auseing L sided hydrocele
what all complications of as it can involve the L renal vein causing obstruction of the L spermatic vein auseing L sided hydrocele ?
may impede asked that adolescents testicular growth - large variocele is associated with small testes - and affect adults and their reproduction - 40% of men being evaluated in fertility clinics will have variocele
what is a presentation of variocele?
feels like a bag of worms/feels like a dragging sensation/aching
how do you diagnose a variocele?
using ultrasound
what is the management of variocele?
small and not causing many disturbances: conservative watch and wait / if there is a large size difference between the two testicles ports affecting fertility/testicular growth: surgical ligation or embolisation
what are the different ways you can classify undescended testes?
palpable/impalpable / maldescended/ectopic
what is a maldescended testes?
testes that lies somewhere along the normal path of descent – most common
what is an ectopic testes?
Lies outside the normal path of decent often lying in the thigh, perineum, opposite side of the scrotum
when are undescended testes usually diagnosed?
During the newborn baby check the scrotum is checked to see if the testes are palpable
what are palpable undescended testes?
Most common type of undescended testes are palpable ones usually within the upper portion of the scrotum or the inguinal canal during the exam the testicle can be felt and looked down into the scrotum (retractile)
are retractable test is considered normal?
Yes they do not require surgical intervention
what should you be careful of in retractable testes?
they are of a high risk of progression to an ascending testicle meaning that they require recurrent checks
what is the management of undescended testes?
Mainly resolve spontaneously within six months of corrected gestation age this is more common in premature babies, if the testes are palpable and require surgery then orchid a plexi is performed if they are impalpable laparoscopy is used to identify the testes and bring it down into the scrotum if it’s viable
what test is recommended in children with undescended testes?
Karyotyping
what are the different types of impalpable testes?
abdominal (40%) vessels and vast and blindly in the deep inguinal ring (30%) vessels and bass ending blindly within the inguinal link (20%) testes existing within the inguinal canal (10%)
what does an blind ended underfunded testicle mean?
Testes is no longer existent and most likely this is been caused by intrauterine testicular torsion
what complications can occur if you do not treat and undescended testes?
Infertility/torsion/testicular cancer – doesn’t increase the risk that the testes can never be examined
What is an epididymal cyst?
A fluctuating swelling that is separate from the body of the testis
what are the symptoms of an epididymal cyst?
Palpable lump within the epididymis/ difficult to transilluminate/ may be painful or painless/ vary greatly in size
how do you diagnose an epididymal cyst?
ultrasound
what is the management of epididymal cysts?
management depends on the size and severity of symptoms treatment options are conservative and surgical excision
what is a sebaceous cyst?
hall cysts usually containing a white/yellowish substance
what is the presentation of a sebaceous cyst?
Palpable lump within the scrotal skin/ tethered to the skin and is separate to the underlying testis/lamp feels rubbery/non-transit innumerable/often multiple cysts/not painful
what does a painful sebaceous cyst indicate?
Infection
what is the management of a sebaceous cyst?
Conservative unless they are very large or infected then surgery
What are risk factors for incontinence?
Older age/female/oestrogen deficiency (postmenopausal)/anatomical disorders (fistula)/childbirth and pregnancy/abdominal, pelvic, perineal and prostate surgery/ diabetes and smoking/obesity/urinary tract infection/poor mobility/neurological disorders (MS, Parkinson’s, spinal-cord injury)
a patient presents with: in voluntary leakage of urine on exertion also when coughing/sneezing or laughing what is the diagnosis?
stress incontinence
patient presents with: in voluntary leakage of urine accompanied by/immediately preceded by feelings of urgency what is the diagnosis?
Urge urinary incontinence
a patient presents with symptoms of urgency (which may cause urination), nocturia and frequency what type of incontinence is this?
Overactive bladder syndrome
what is overflow incontinence?
in voluntary leakage of urine when the bladder is abnormally distended with large volumes of urine
what questions are important to ask in incontinence histories?
What is the timing of the incontinence (continuous or at specific times such as increased intra-abdominal pressure) are their associated symptoms of El UTS do they use incontinence pads and if so how many do they use per day or night what is their obstetric history are they postmenopausal are there any symptoms of bowel and sexual dysfunction (indicates neurological cause) past medical history of uro- gynaecological, neurological
what is the pathophysiology of stress urinary incontinence?
Hypermobility of the bladder as well as pelvic floor dysfunction which can occur with or without urethral sphincter dysfunction
what is the management of stress urinary incontinence?
Conservative measures (weight loss, exercise, smoking cessation) pelvic floor physiotherapy and training surgery (tape procedures or artificial urinary sphincter implant – mainly used in men post prostatectomy)
what is the pathophysiology of urge urinary incontinence?
overactive detrusor muscle
how do you manage urge urinary incontinence/overactive bladder syndrome?
conservative measures (reduced alcohol caffeine
anti-muscarinic medication ocybutanin ,
B3 adrenoceptor agonist (mirabregron)
neuro modulation/Botox injection into bladder
scystoplasty or urinary diversion
which type of incontinence does prolapse usually cause?
Stress although oftentimes pictures are mixed
how do you manage overflow incontinence?
treat any causes of bladder outflow obstruction / long-term catheter/intermittent self catheterisation
what are the causes of overflow incontinence?
Obstruction of urinary tract/ detrusor failure
what examination should be performed on women presenting with incontinence?
vaginal examination checking for prolapse pelvic floor strength (asking the patient to squeeze pelvic floor/cough)
what examination should be performed in a male presenting with incontinence?
DRE you may find an enlarged prostate
what investigations should be performed in a patient with incontinence?
urinalysis, cystoscopy, in patients with overflow incontinence residual urine test should be performed - urodynamic testing is usually not performed as it is very uncomfortable and invasive
defined erectile dysfunction?
the recurrent inability to achieve or maintain an erections for satisfactory amount of time to allow for sexual intercourse
what is a key feature of erectile dysfunction caused by organic causes?
usually has a more gradual onset with no significant loss of libido
what questions are important to ask in a history of erectile dysfunction?
Is it getting worse/are you able to achieve and direction and for how long/are you able to achieve penetrative sex/is there a morning erection/is a loss of libido/ what have they already tried/ onset description
what past medical history is significant in erectile dysfunction?
Diabetes/hypertension/vascular disease/neurological conditions/pelvic surgery
what psychosocial causes are there for erectile dysfunction
relationship status/relationship difficulties/anxieties and depressions/any past traumatic sexual experiences
what endocrine causes are there for erectile dysfunction?
diabetes hyper- or hypothyroidism hyperprolactinaemia hypogonadism
what neurogenic causes are therefore erectile dysfunction?
Spinal-cord pathology (Bifuda, compression) Multiple Sclerosis Parkinson’s disease
what vascular causes are there for erectile dysfunction?
Hyperlipidaemia peripheral vascular disease hypertension
what drugs can cause erectile dysfunction?
Antidepressants Parkinson’s medication antiandrogen antihypertensives
what blood tests should you perform in a patient with erectile dysfunction?
testosterone luteinising hormone FSH prolactin sex hormone binding globulin thyroid function glucose levels
what examinations should you perform in erectile dysfunction?
Cardiovascular neurological abdominal DRE genital (deformity testicular atrophy)
what investigations (apart from blood tests) would you perform in erectile dysfunction?
Nocturnal penile tumescence testing/MRI/Doppler ultrasound for vascular - all of these tests are not routinely used
what drugs can be given to help erectile dysfunction?
phosphodiesterase inhibitors intra urethral prostaglandins inter cavernosum injection therapy testosterone replacement therapy in hypogonadism
what management should be given for psychogenic erectile dysfunction?
psychosexual therapy
apart from drugs what other management can be given to organic erectile dysfunction?
vacuum erecting device penile prosthesis
how do phosphodiesterase inhibitors work in erectile dysfunction?
Block the breakdown of CGAMP made by phosphodiesterase causing vasodilation- still requires sexual stimulation
what is periones disease?
a benign condition that becomes more common with age characterised by the curvature of the penis/holes by the development of fibrotic tissue on the tunica albunginea
what is the pathophysiology of periones disease?
initial inflammation characterised by increasing deformity of the penis and painful erections/ followed by quiescent phase during which the deformity stabilises/ thought to be caused by minor trauma over time causing microvascular damage in genetically predisposed males
what is periones disease associated with?
diabetes hypertension high cholesterol dupatrons contracture and plantar fasciitis
what’s is the presentation of periones disease?
significant curvature to the penis noticeable when erect/ penile shortening penile pain erectile dysfunction difficulty having penetrative intercourse can have palpable fibrous plaques along the shaft at the deviation/ penis can have hourglass appearance due to plaques
what is the management of periones disease?
oral pentoxifylline verapamil injections surgery only performed on stable plaques and can include the insertion of a penile prosthesis
what is phymosis?
tight foreskin which is unable to attract over the glans
what is the presentation of phymosis?
usually asymptomatic/may notice balooning of the foreskin on urination/may cause pain and irritation during sexual intercourse/ men may develop infections of the foreskin and glans - balanoprosthisis
what are some key features to ask for in a history of phymosis?
are you able to retract the foreskin (v severe) / checked for diabetes previous neurological surgery or if they have had any steroid cream use in the past
what is balantis xerotica obliterans?
chronic inflammatory condition which is the male equivalent of light and sclerosis and it can cause phymosis
what awesome features that you may find on examination of balantis xerotica obliterans?
grey white discolouration of the foreskin
what are some complications of balantis xerotica obliterans?
urethral stenosis penile cancer phimosis
how do you treat balantis xerotica obliterans?
steroids topically often circumcision as required
a teenager of 14 years old presents with phimosis, it isn’t causing too many problems apart from some balooning on urination, what is the management?
nothing as it is not severe and phimosis is often physiological in childhood and almost always becomes retractable by the age of 16
what is the management of phimosis?
circumcision
what is the pathophysiology of urethral strictures disease?
sub epithelial fibrosis within the corpus spongiosum causing the narrowing of the urethra
what can cause a urethral structure disease?
trauma (straddle injuries) catheterisation (catheterisation) inflammatory urethritis
what are symptoms of urethral strictures disease?
L UTS voiding symptoms urinary retention multiple UTIs difficulty passing catheter and hitting resistance/obstruction distal to the prostate
what is the management of urethral strictures disease?
sequential urethral dilation in theatre/ optical urethrotomy
what is the ongoing management of urethral strictures disease?
Following initial operation patients taught how to intermittently self-dilate prevent future recurrence
what is paraphimosis?
the foreskin is retracted behind the glands and cannot be replaced to its original position resulting in a tight ring of tissue around the corona - it is a medical emergency that is not to be mistaken with phimosis
why is paraphimosis a medical emergency?
It leads to venous occlusion congestive oedema and eventually will compromise the blood supply to the glans and foreskin causing ischaemia
what is the presentation of paraphimosis?
foreskin retracted behind the corona of the glans penile oedema possible discolouration and necrosis cracks in the skin can be painful
what is a common cause for paraphimosis?
catheterisation patients
what is the management of paraphimosis?
lies again and applying ice with then manually replacing the foreskin surgical interventions are rarely needed follow-up by urologist is required as circumcision may be needed as long-term management
what is fourniers gangrene?
necrotising fascitis of the genitalia and perineum - is a urological emergancy
what pathogens usually cause fourniers gangrene?
usually caused by both aerobic and anaerobic organisms – E. coli Klebsiella or enterococcus/colostrum
what is the presentation of fourniers gangrene?
an acutely unwell patient with septic symptoms erythematous tender area along the genitalia or penny blistering of the skin practice caused by gas forming from the organisms blue or black skin as necrosis occurs
what are risk factors for developing fourniers gangrene?
diabetes catheterisation immunocompromised postsurgical perineal and perianal infections steroid therapy
what is the management of fourniers gangrene?
sepsis six do a group group and save stop broad-spectrum antibiotics keep patient nil by mouth as requires prompt surgery inform ITU
what is priapism?
The presence of an unwanted erections more than four hours in the absence of sexual stimulation
what is in low flow priapism?
Caused by ischaemia: venous occlusion resulting in a rigid painful erection
how do you manage low flow priapism?
aspiration of intra-cavernosal blood (blood will be acidotic with low O2 high CO2 and high lactate) must be done by urologist
what is high flow priapism?
is arterial caused by dysfunctional arterial flow resulting in a semi rigid painless erection / associated with a history of trauma which then results in the formation of AV fistula
what is the management of high flow priapism?
can be managed conservatively but if intervention is required then embolise the supplying artery
what happens if aspiration of intracavernosal blood does not solve low-flow priapism?
immediate escalation intra cavernosal injection of alpha-1 adrenergic agonist ( phenothrin) failing that surgery
what can you do if a patient presents a low flow priapism and you are waiting for urologist to arrive?
as patient exercise walking up and down the stairs and called the area with ice
what is the most common cause for recurrent priapism?
sickle-cell anaemia
what is the presentation of recurrent priapism?
self-limiting but painful erection however it can turn into low flow priapism
how do you manage a sickle-cell caused priapism?
hyper hydration hyper oxygenation and haematological optimisation with analgesia
Why do bladder stones form?
to urinary stasis either from obstruction or any other method of failure of the bladder
what properties of bladder stones usually made of?
calcium
what is the presentation of bladder stones?
Pain / L UTS/ haematuria/ UTI/ asymptomatic and found incidentally
what is the diagnosis of bladder stones?
Ultrasound scan or x-ray normal contrast / flexible cystoscopy may be part of Ix or on way to confirm / treat
how do you treat bladder stones?
cystolotholapaxy - stone crusher in bladder / lazer or open surgery
What is the most common cause of penetrative bladder trauma?
iatrogenic - most commonly from the section of bladder tumour or in operation
what is the most common cause of blunt bladder trauma
high risk of injury in pelvic fractures and seatbelt injuries in road crashes
what is the presentation of bladder trauma?
peritonism / abdominal distension ideas and your ES haematuria blood at urethral meatus perianal/scrotal bruising a high riding prostate
how do you diagnose bladder trauma?
CT with contrast or cysto gram
what is absolutely contraindicated in bladder trauma?
catheterisation this should only be done by neurologists or senior clinicians
what is the management of an extra peritoneal bladder injury?
catheterisation for 2/3 weeks
what is the management of an inter peritoneal bladder trauma?
open surgical repair
what part of the penis gets injured in a penile fracture?
tunica albunginea
what is the presentation of a penile fracture?
feeling of a snap or pop whilst the penis is erect/ immediate de tumescence/ eggplant appearance due to swelling discolouration and deformity
what is the management of a penile fracture?
urgent neurological review and surgical repair
