GU Flashcards
Epispadias
Embryonic malformation due to malposition of the genital tubercle that causes incomplete urethral tubularization on the DORSAL penis when associated with bladder exstrophy, although in attenuated form
Epispadias Treatment
Young patients: Operative closure
With urethroplasty and reconstruction of genitalia if indicated
In patients with long-term indwelling catheters: Insertion of a suprapubic indwelling catheter (reconstructive treatment is usually not necessary)
Complication of Epispadias
Males: ED and infertility
Females: Frequent and painful urination, recurrent UTIs
Hypospadias
Common congenital malformation with incorrect position of the external urethral meatus due to failure of urethral folds and foreskin to fuse on VENTRAL penis
Signs and symptoms of Hypospadias
Abnormal foreskins (dorsal hood)
Ventral penile curvature
Two meatal openings
Proximal hypospadias are assoc. With bifid scrotum and penoscrotal transposition
Assoc. With:
-Inguinal hernias
-Cryptorchidism
-Chordee (abnormal ventral curvature)
Hypospadias Treatment
Mild cases do NOT necessarily require surgery
Significant displacement or symptomatic micturition warrants surgical repair
Reconstruction of urethra, penis, scrotum at 6 months of age: urethroplasty and arthroplasty
Severe Cases: Require two-stage repair with correction of penile curvature first followed by urethroplasty at least 6 months later
Complications of Hypospadias
Urethral Fistula, Meatal stenosis( Narrowing of ventral meatus causes thin urinary stream and straining with urination ), Urethral diverticulum( Distinct outpouching of the urethral mucosa that most frequently leads to dribbling, dysuria, and dyspareunia), UTIs
CIRCUMCISION CONTRAINDICATED
Phimosis
Tight foreskin that cannot be completely retracted over the glans penis mostly congenital but can be caused by trauma (circumsicion), or post-infectious complication following balanoposthitis
Signs and Symptoms of Phimosis
Relative: Difficulty in retracting the foreskin
Full: Inability to retract the foreskin
Painful erection and/or dyspareunia
Phimosis Treatment
Conservative: Reassurance, topical corticosteroid, stretching exercise
Surgical: Vertical incision (of constricting bands), or circumcision if conservative management fails
Phimosis Complication
Foreskin tear with possible hemorrhage, paraphimosis
Paraphimosis
Retracted foreskin in an uncircumcised male that cannot be returned to its original position
UROLOGICAL EMERGENCY
Paraphimosis Treatment
Conservative: Manual reduction with adequate pain control (topical anesthesia)
Surgical: Dorsal slit reduction surgery (incision of the constricting band) if manual reduction fails or penile ischemia occurs
Circumcision is LAST RESORT
Paraphimosis Complications
Penile Necorsis
Peyronie’s Disease
Fibroproliferative disorder that affects the tunica albuginea of the penis, causing abnormal curvature
Pathophysiology of Peyronie’s Disease
Repeated penile microtrauma during sexual course or athletic activity followed by abnormal wound healing: Fibrous plaque formation
Peyronie’s Disease Classification
Active phase: Acute or inflammatory phase; Characterized by progressive penile deformity and painful erection
Stable phase: Chronic phase, Characterized by lack of progression of penile deformity and pain
Signs and Symptoms of Peyronie’s Disease Classification
Penile pain, penile nodules/indurations on affected area, ED and can be associated with psychological conditions (anxiety, depression)
Peyronie’s Disease Treatment
Active phase: oral NSAIDs or oral pentoxifylline for 3 months
-No symptomatic improvement:
Intralesional collagenase injections
-Symptomatic improvement: Observative
or continuation of oral pentoxifylline for
another 6 months
Stable phase: Depends
-Observation: For patients with mild penile
curvature (<30 angle) and no ED
- Intralesional Collagenase injections:
Patients with penile curvature (>30
angle) and/or ED
- Surgical repair: patients unresponsive to
treatment, with severe penile deformity,
and/or with extensive calcifications
Erectile Dysfunction
Condition characterized by a persistent or recurrent inability to acquire or maintain an erection of sufficient rigidity or duration for sexual intercourse due to substances/medications, organic, and/or psychogenic causes
ED Acronym for Etiology
P.sycological E.ndocrine N.eurogenic I.nsuffecient blood flow, S.ubstance use
ED Dx
International Index of ED (IIEF), PMHx, Psychosocial Hx, Hypogonadism, abnormal pulses, CREMASTERIC REFLEX, anal tone, lower extremity sensation
Endocrine lab analysis: Testosterone (L), SHBG (H), Prolactin (H), LH (L), FSH (L)
Nocturnal penile tumescence measurement
Phallograohy: night time measurement
-Absence or nocturnal erections suggests and organic etiology (neurogenic, vascular)
-Normal test suggests a psychogenic cause
ED Treatment
(first-line therapy)
Oral tadalafil, sildenafil, vardenafil
MOA: Inhibition of the phosphodiesterase type 5 enzyme and increase in cGMP results in prolonged smooth muscle relaxation -> increased intracaernosal NO-induced vasodilation and blood flow in the corpora cavernosa -> increase in penis size during erection
Most effective in ED d.t cardiovascular
Contraindicated in pt’s taking nitrates d/t high risk of profound hypotension
Tx: second line cont.
Penile Posthesis: Surgical implantationof an inflatable implant (two hollow cylinders) into the corpora cavernosa, and a saline reservoir and pump into scrotum
Indications:
LAST RESORT
Peyronie disease
Testosterone replacement if low serum levels (hypogonadism)
Psychotherapy, education, exercise, and couples counseling for patients with psychogenic factors contributing to ED
Hydrocele
Painless accumulation of fluid in a sac around one or both testicles which derives from the tunica vaginalis, a tissue covering the testes
Signs and Symptoms 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
Normal spermatic cord and inguinal ring present
Hydrocele diagnostic
U/S: hypoechoic fluid
MUST be differentiated from an inguinal hernia
Treatment for Hydrocele
Congenital hydrocele usually resolves spontaneously in 6 months of birth
Surgery if it does not resolves by age 1, excessive discomfort, underlying pathology, testicle is not palpable or concern for infertility
Hydrolectomy
Performed to correct a hydrocele and prevent its recurrence. Indicated for the reduction of large/thick walled hydroceles. Involves incision and complete/partial resection of the hydrocele sac (tunica vaginalis)
Percutaneous aspiration
Aspirate fluid from hydrocele combined with instillation of sclerosing promoter into sac
Spermatocele
Painless and freely moveable cystic mass containing sperm, most are <1cm in size; occur superior, posterior and SEPARATE from the testicle
Spermatocele Dx
Scrotal U/S
Treatment of spermatocele
IF painful can surgically remove
