GU: reproductive Flashcards
Gynecomastia
- basic patho– hormones?
- etiologies
- MC in
- cm
- dx
- tx
- *increase estrogen or decreased androgens
- *MC in–> infants due to maternal estrogen circulation, puberty (10-14 YO), older males
ETIOLOGIES
- idiopathic
- MEDS–>spironolactone, Thiazides
- other dz and CA that secrete hormones
CM
- palpable mass of tissue
- at lest 0.5 cm in diameter and centrally located (usually under nipple)
- symmetrical
- tender to palp
DX
- clinical
- mammo if suspected CA
TX
- supportive–>stop drugs
- Tamoxifen–>selective estrogen receptor modifier that is an estrogen antagonist in breast (used in breast CA)
- surgery if refractory to medical tx
Urethral Strictures
- what is it/patho
- etiologies— mcc
- mc in who
- CM
- dx
- tx
- complications?
- narrowing of lumen of urethra
- occurs from infection, injury, or surgical manipulation that makes a scar that reduces the caliber of urtethra
- MCC=infection (STI or UTI), trauma, FB,
- MC in M > W bc they have longer urethra
CM
- chronic obstructive voiding s/s–>weak urinary stream and incomplete bladder emptying
- recurrent UTIs
- urinary spraying
- dysuria
DX
-cystourethroscopy or retrograde urethrogram or voiding cystourethrogram or ultrasound urethrogram
TX
- ENDOSCOPIC: dilation or surgical reconstruction
- prophylactic ABX recc prior to surgery
COMPLICATIONS
-urinary fistula
Urethral injury
- MC in who
- MCC and other etiologies
- CM
- PE–hallmark findings?
- Dx –TOC
- TX
- MC in men
- MCC is blunt force trauma (80%)–anterior urethral injury–straddle type falls or direct blows
- posterior urethral injuries or pelvic fx or MVA
- physical or sexual assault
CM
- gross hematuria****
- diff urinating
- urinary retention
- lower abd pain
PE
- blood at urtrheal meatus, swelling or ecchymosis of the scrotum, penis or perineum OR high riding prostate
- TRIAD/HALLMARK–>blood at meatus, inability to void, distended bladder
- *NEVER NEVER NVEVER CATH A PT WHO HAS BLOOD AT URETHRAL MEATUS**
DX
- retrograde urethrogram=TOC—always done first if we see blood at urethreal meatus
- UA=hematuria
TX
- non-operative: catheter placement and monitor for healing–MILD
- surgical: indicated in severe injuries–may involve temporary suprapubic catheter placement prior to surgery–SERIOUS
Hypospadias
- what is it
- MCC
- patho
- CM/PE
- TX
- congenital anomaly=ventral placement of urethral opening***, penile curvature, abnm foreskin development
- ->opening can be within glans, shaft, scrotum or perineum
- MCC=failure of the urogenital folds to fuse during development
PATHO:
- failure of urogenital folds to fuse during development
- assoc with additional genitourinary malformations
CM + PE *incr risk of UTIs, ED *deflection of urinary stream PE *ventral placement of urethra *abnormal foreskin with incomplete closure around the glans (dorsal hooded prepuce) *abnormal penile curvature (chordee)
TX
- should NOT be circumcised in neonatal periods–>foreskin may be used to repair defect!!
- surgical: arthroplasty–penile straightening–>only done in HEALTHY FULL TERM infants MC b/w 6mo-1 yr
EPISPADIAS
- what is it
- often assoc with?
- MCC
- CM (men and women)
- dx
- tx
Congenital anomaly=dorsal placement of urethral opening
-often assoc with bladder exstrophy–>protrusion of bladder wall thru a defect in abd wall
MCC=failure of midline penile fusion
CM
- males: opening of urethral meatus on dorsal top surface of penis, upward curvature of penis–absent dorsal foreskin
- females: clitoris with two tips (bifid), small, laterally displaced labia minora
- MALES MORE COMMON AND EASIER TO SEE*
DX
-prenatal US–>bladder exstrophy
TX
-surgical
Paraphimosis
- what is it
- patho
- etiologies— in general, for boys/infants, adolescents and adults
- cm
- pe
- tx
UROLOGIC EMERGENCY
- retracted foreksin that cant be returned to the normal position
- emergency bc it can lead to gangrene of penis
PATHO
- foreskin gets stuck behind the corona of the glans
- forms a tight band–>constricting penile tissues–>gangrene
ETIOLOGY
- forceful retraction of foreskin
- infants + young boys: physiologic or iatrogenic (caretaker)
- adolescents/adults: can occur after balanoposthitis (yeast infections ex) or penile inflammation (DM, or after sex)
CM
-severe pain and swelling around penis
PE: enlarged, painful glans with constricting band of foreskin behind the glans
TX
- manual reduction–restore original position of foreskin–> BUT FIRST reduce edema with cool compresses or pressure dressing
- pharm tx: granulated sugar, injection of hyaluronidase
- definitive=incisions (dorsal slit) or circumcision
Phimosis
- what is it
- etiologies
- tx
inability to retract foreskin over the glans
is NOT urologic emergency
ETIOLOGY: usually caused by scarring of foreskin after trauma, infection, inflammation
TX
- proper hygiene (wash that sucker out), stretching exercises
- 4-8 weeks topical corticos can increase retractility
- circumcisions for definitiive management
Priapism
- what is it
- types
- Etiologies–MC and others
- dz
- tx for each type (MOA and contras for any drugs)
Prolonged painful erections without sexual stimulation
GO TO ER IF YOUR ERECTION LASTS 4 HRS
TYPES
1. Ischemic (low flow)–>decr venous outflow may lead to a compartment syndrome–>increasing acidosis and hypoxia in cavernous tissue–>PAINFUL and RIGID erection—>MC TPYE***
- Nonischemic (high flow)–>incr arterial inflow due to a fistula b/w cavernosal artery and corpus cavernosum–>releated to perineal or penile trauma–>LESS PAINFUL and NOT FULLY RIGID vs ischemic
MC caused by
- idiopathic MCC (50%)
- sickle cell (10%)
- injection of ED agent for ED
- drugs: cocaine, marijuana
- etoh
- trauma (high flow)
- MEDS: PDE-5 inhibitors, trazadone, antipsychotics, anticonvulsants, alpha blockers
- neurologic: head trauma, meningitis, subarachnoid hemor, posop
DX
- PE and history
- cavernosal blood gas if over 4 hours–>
- ISCHEMIC: low flow–hypoglycemia, hypoxemia, hypercarbia and acidemia
- NON-ISCHEMIC: normal
- Doppler sono=will show high or normal blood flow in nonischemic and will show minimal or absent blood flow in ischemic
TX for ISCHEMIC (LOW-FLOW)
1. Intracavernosal Phenylephrine first line med
MOA: alpha-agonist cause contraction of the cavernous smooth muscle–>incrs venous outflow
CONTRA: cardiac or cerebrovascular hx
- Needle aspiration or corpus cavernosum and irrigation to remove blood ESP if over 4 hours with or without phenylephrine (with phenylephrine its called COMBO THERAPY** which is very effective)
- Terbutaline PO or SC–>constricts cavernosal artery, reducing arterial inflow—not as effective
- shunt surgery: refractory to medical tx and aspiration
TX FOR NONISCHEMIC (high flow)
- observation: most resolve within hours to days
- refractory: nonpermatent arterial embolization or surgical ligation
Penile CA
- mean age
- MC type and what its assoc with
- RF (4)
- CM
- dx
- tx–early and late dz
rare
-avg dx is 60 YO
MC type=squamous cell, commonly assoc with HPV 16, 6, 18
OTHER RISK FACTORS
- smoking
- lack of circumcision
- HIV
- bowens dz–>leukoplakia of the shaft of penis–assoc with HPV 16– some wil progress to squamous cell CA
CM
- mass or palpable lesion or ulcers on penile
- mc on the glans, coronal sulcus or prepuce
- RARE presentations: rash, bleeding and balantitis
dx
-biopsy
TX
early->limited excision
late–>penile amputation + lymph node dissection
Cryptorchidism -define -mc on what side -MC found where RF (4) -dx -CM -tx -complications
testcile that has not descened into the scrotum by 4 MO
- most eventually descend spontaneously by 3 MO— rarely after 4 MO
- MC right side
- 10% bilateral
MC found just outside the external ring (suprascrotal)
-can also be found: inguinal canal, or in abdomen
RF
- premmie (30%)
- full term (5%)
- low birth weight
- maternal obesity or DM
CM
- empty, small poorly rugated scrotum
- may have inguinal fullness (if in inguinal canal)
DX
- clinical/PE
- scrotal sono or MRI
TX
- orchiopexy–>bringing down the testes and attaching to scrotum as early at 4-6 MO–>ideally b4 1 year– HAS TO BE DONE BEFORE THEY ARE 2 YO
- Observation only done if under 6 MO–most descent by 3 MO
- hcg or gonadotropin release hormone–>HCG stimulates testosterone—rarely used
- orchiectomy if detected in puberty to reduce risk of testicular CA
COMPLICATIONS
- increased risk of testicular CA****
- reduce this risk by doing the orchipexy surgery early— earlier the better
- decr fertility
- testicular torsion
- if detected at puberty–>ORCHIECTOMY is indicated bc they are at such a rhigh risk of CA at this point
Hydrocele
- what is it
- MCC of?
- MCC?
- types
- CM
- PE
- dx
- tx
serious fluid collection within the layer of the tunica vaginalis of scrotum
MCC of painless scrotal swelling
MCC=idiopathic
-can also be from inflammation
TYPES
- communication
* communicates with abdomen
* fluid from abdomen enters the scrotum via patent processes vaginalias that failed to close - NON-communiaction
- doesnt comm with abdomen
- fluid collected is from mesothelial lining of tunica vaginalis–NO connection to peritoneum
CM
- painless**** scrotal swelling
- pain and swelling gets worse throughout the day due to gravity
- dull or heavy sensation
- PE
- translucency or transilluminate behind the scrotum–>light WILL go through scrotum
- fluid usually located ANTERIOR or LATERAL to testies
- swelling worse with Valsalva if it is the communicating type–>bc it incrs peritoneal pressure which pushes the fluid down on the scrotum
DX
- testicular sono=initiall TOC ro r/o tumor or other causes
- *sono tells uf if its solid or liquid!!!
- *CA will NOT transilluminate
TX
-usually no tx bc resolves on own
-surgical excision may be needed if persists after 1 year old– often occur at brith but resolve within 12 MO
OR
in adults with communicating types to reduce risk of hernia
Varicocele
- what is it
- MC what?
- which side MC
- CM
- PE
- dx
- TX
- Associations–right side due to? and left side due to?
cystic testicular mass of varicose veins–>pampiniform plexus + internal spermatic vein
MC surgically correctable cause of male infertility bc of the incr temperature from the inreased venous blood flow inhibits spermatogenesis
MC on left side
CM
- asympto found in 10%
- usually painless but. may cause a dull ache or heavy sensation
- can cause testicular atrophy
PE
- mc on the left
- “bag of worms” scrotal mass —superior to the testicle
- dilation worsesn with patient is uprgith or with valsalva
- less apparent when pt is laying supine
DX
- clinical
- sono is TOC
TX
- observation
- surgery: in some cases for pain, infertility, or impaired testicular growth
Associations
- R sided may be due to abdominal malignancy—-RIGHT SIDE IS RARE
- L side in older men may be due to renal cell carcinoma
Epididymitis
- define
- MCC in males 14-35
- MCC in males over 35
- CM
- PE
- Dx –best initial test?
- Tx
epididymal pain and swelling
-seconary to infection or reflux of urine
- **MCC in males 14-35=chlamydia (MC) and gonorrhea
- **MCC in males over 35 is E. coli and other enteric bacteria
- *prepubital: viruses, bacterial (e. coli or mycoplasma)
CM
-gradual onset (hours to days) of localized testicular pain and swelling usually unilateral
-may be assoc with fever, chills, dysuria, urgency and frequency
(Irritative s/s=dysuria, urgency and frequency)
-NO NAUSEA/VOMITING ** (unlike testicular torsion)
PE
- scrotal swelling and tenderness
1. (+) Prehn sign= pain relieved with scrotal elevation—- always used– rarely accurate
2. (+) normal cremasteric reflex= elevation of testicles after stroking inner thigh
DX
- scrotal sono= best INITIAL test—will show us its the epipdydmis thats enlarged and show incrs testicular blood flow (can also r/o torsion)
- UA for infection–> (+) pyuria or bacteriuria
- CT/GC testing wth NAAT
TX
-scrotal elevation, NSAIDS, cool compress
- if under 35 YO treat GC/CT—>Doxycyline 100 mg BID x10 days + Ceftriaxone 250 mg IM x1 dose OR and azithromycin 1G x1 dose alternative to doxycycline
- if over 35 yo– treat empirically with fluoroquinolones (cipro, ofloacin, levofloxacin) bc we suspect its E. coli——- trimethoprim-sulfamethoxazole is alternative
- bacterial in kids= cephalexin or amoxicillin
Spermatocele/Epididymal Cysts
- define
- CM
- PE
- Dx
- Tx
scrotal mass (epididymal cyst) that contains sperm
- if less than 2 cm=epididymal cyst
- over cm=spermatocele
CM
- PAINLESS
- cystic testicular mass
PE
- soft, round mass at head of epididymis
- separate from testicles
- freely movable
- above testicles
- (+) transilluminates **
DX
-scrotal US
TX
-no tx unless it is bothersome—>surgical excision for chronic pain (rare)
Orchitis
- define
- etiologies–mc
- CM
- tx
inflammation of one or both testicles
MCC=MUMPS
CM
- scrotal pain
- swelling
- tenderness
PE
-scrotal erythema + tenderness
TX
-symptomatic: NSAIDs, bed rest, scrotal support, cool packs
Testicular Torsion
- define
- etiology
- mc in who
- cm
- pe
- dx–definitive? most mc used? mc specific?
- tx–when can irreversible damage start to occur?
UROLOGIC EMERGENCY
-spermatic cord twists and cuts off testicular blood supply–>usually due to congential malformation where testes doesnt fix correctly to the tunica vaginalis leading to increased mobility of the testicles
MC in. males 10-20 and neonates
CM
- ABRUPT onset of scrotal, inguinal or lower abd pain (<6 hrs)
- if N/V present—- suspect torsion!!!!!*** unlike epididymitis
PE
-swollen, tender, retracted high riding testicles
-may lie horizontally
- (-) Prehn sign–>no relief with scrotal elevation
(-) cremasteric reflex on affected side–>no elevation of testicles after stroking the inner thigh
DX
- clinical dx—-IMMEDIATE SURGERY—do not go to imaging if hx and PE are suspicious of torsion
- testicular doppler sono–mc used–>decr or absent testicular flow
- emergency surgical exploration (definitive dx)— preff over sono if highly suspected
- radionuclide scan–>most specific but rarely used
TX
- urgent detorsion and orchiopexy within 6 hrs of pain onset
- irreversible damage likely if >12 hrs of ischemia
- manual detorsion should be done if surgical intervention not available
- orchiectomy if not salvageable
Testicular CA
- MC in who + avg age of dx
- RF
- types—mc type and which is worst prognosis
- cm
- pe
- dx—toc
- tx: for each one
- 5 yr survival rate?
MC in young men 15-35 YO
avg age is 32 YO
RF
- Cryptorchidism is MOST SIGNIFICANT (testes not descending) with 4-10x risk in BOTH testicles
- Whites, Klinefelters syndrome, hypospadias
most testicular CA arise from germinal cells— cells that produce sperm
-two types
1. Nonseminomas (66%)
-assoc with incr serum alpha-fetoprotein and beta-hcg and resistant to radiation
-two types
A) yolk sac–> MC in boys 10 y/o and younger
B) Choriocarcinoma (worst prognosis)
- Seminoms (33%) Better prognosis but less common
- simple (no alpha-fetoprotein)
- sensitive to radaition
- slower growing
- stepwise spread
OTHER TYES (3%) aka non-germinal cell tumors: -leydig cell tumors= may be benign-->secrete testosterone -seroli cell tumors= ^^^ Gonadoblastoma=testicular lymphoma
CM
- painless mass in testicle MC
- may have dull pain or testicular heaviness—acute pain in only 10%
- secondary hydrocele
- gyecomastia but rare
PE
-firm hard fixed mass that does not transilluminate
DX
- sonogram—initial TOC
- Seminoma=hypoechoic mass
- nonseminoma=nonhomogenous mass
- tumor markers–> alpha-fetoprotein and beta-hgc— if these are elevated=PROBLEM
- staging–>CT of abdomen, pelvis and chest
TX
-5 yr survival rate for all is 95%
- Seminoma stage 1 (limited to testes)–>radical orchiectomy and possible radiation
- Seminoma, stage 2–>debulking chemo followed by orchiectomy and radiation
- nonseminoma, stage 1–>NO RADIATION bc its resistant— we just do radical orchiectomy
Benign prostatic hyerplasia
- define
- leads to
- common in who
- CM–what can worsen
- dx
- tx–pharm (best initial) + surgical
- drugs: name/endings, MOA, indications, SE
- prostate hyperplasia
- often leading to bladder outlet obstruction
- common in older men— hyperplasia is part of the normal aging procress
CM
- irritative symptoms: incr frequency, urgency and nocturia
- OBSTRUCTIVE S/S–>hesitancy, weak or intermittent stream, incomplete emptying and dribbling
- Sympathomimetics (pseudoephedrine) and anticholinergics may worsen the s/s
DX
- DRE–>smooth uniformly enlarged, firm, nontender rubbery prostate
- Prostate Specific Antigen (PSA)–>correlated with risk of symptom progression (normal is under 4)
- U/A–>to look for hematuria (or other cause of symptoms)
- urine cytology–> if at risk for bladder CA
- biggest RF for bladder CA–>smoking**
MEDICAL TX
monitor if just mild s/s*
1. Alpha 1 blockers (-OSIN) (usually first line): Doxazosin, Tamsulosin, Terazosin
MOA: smooth muscle relaxation of prostate and baldder neck leading to decr urethral resistance, obstruction relief and incr urinary outflow
-provides rapid s/s relief but NO effect in on clinical course of BPH
SE: dizziness and orthostatic hyPOtension (MC)
- 5-alpha reductase inhibitors: Finasteride and Dutasteride
MOA: androgen inhibitor–inhibs conversion of testosterone to dihydrotestosterone which supresses prostate growth which decrs size of prostate and decrs need for surgery
-doesnt provide immediate releif from s/s since it takes time for prostate to shrink
-SE: sexual dyfunction, decrs libido, breast tenderness and enlargement
SURGICAL TX
-if persistent, progressive or refractory to medical tx for 12-24 MO
-Transurethral resection of prostate (TURP)–removes excess prostate tissue
RISK of surgery–>sexual dysfunction and urinary incontinence
Prostatitis (acute)
- define
- etiologies–mc for <35, >35, kids
- CM
- pe
- dx
- tx for each age group
prostate gland inflammation secondary to infection (MC)
- ->etiologies
- men<35= GC/CT
- men >35=E coli
- children=mumps
- can progress to chronic (>3MO)
CM
- fevers
- chills
- perineal pain
- lower bac pain or abd pain
- Irritative s/s: incr frequency, urgency, nocturia
- obstructive s/s: hesitancy, weak or intermittent stream, incomplete emptying and dribbling
ACUTE PE findings
-exquisitely tender or hot prostate
“BOGGY” prostate
DX
- urinalysis and culture=WBC incr, bacteria, pyuria
- avoid prostatic massage (may cause bacteremia)
TX
1. Acute <35 yo= Ceftriaxone + Doxcycline OR ceftiaxone + azithromycin
- acute >35 yp=
OUTPATIENT: fluoroquinolones or trimethoprim-sulfamethoxazole x4-6 weeks***** (outpatient) (takes a long time bc little blood flow to prostate and so takes a while to heal)
*INPATIENT: IV fluoros with or without aminoglycoside OR Ampicillin with or w/o gentamicin
Chronic prostatitis
- mcc
- etiologies
- cm
- dx
- tx
-MCC E. coli
CM -usually presents as recurrent UTIs or intermittent dysfunction, malaise or arthralgia -incr freqeunecy, urgency and nocturia -obstructive s/s - PE -non-tender, boggy -its more mild than acute
DX
- UA: often normal—>so we need to do prostatic massage (IF and only if you know it is CHRONIC)
- massage will yield bacterial yield
TX
- fluoroquinolones or trimethoprim-sulfamethoxazole x 6-12 weeks****
- if refractory, TURP
- Alpha 1 blockers can help with chronic pain
Prostate CA
- mc type
- RF –which is strongest one?
- CM
- dx
- tx –local dz?
- adv dx tx
second MC CA in men
(FIRST is skin ca!!!)
MC type=adenocarcinoma–>slow growing tumor of prostate— most men die WITH prostate CA than FROM it
RF
- over 40 (strongest) and genetics
- black
- diet high in fat
CM
- most PT are asymptomatic and are dx either abnormal DRE or via workup after abnormal PSA or after invasion of bladder, urethral obstruction or bone involvement
- back or bone pain with METS to bone,
- weight loss
DX
- DRE: hard, indurated, nodular, enlarged, asymmetrical prostate
- PSA (prostate specific antigen): above 4 (but elevated PSA can be seen with otehr disorders– so this is not specific)
- *****if either of these are (+), then a biopsy is done
- ->transrectal US guided needle biopsy=Most accurate test
- ->if PSA over 10–>bone scan is usually done bc the MC site of METS is BONE*****
- ->Gleason grading system is used to determine aggressiveness or malignant potential (higher grader=more benefit from removing the prostate)
TX
-controversial since many cases are so slow growing and others mets
LOCAL DZ:
1. Observation/surveillance if low risk, clinically localized or life expectancy is <10 yrs
OR
2. definitive tx with external beam radiation, brachytherpay or radical prostatectomy
RISKS of prostatectomy= incontinence and ED!!!!
ADV DZ
- external beam radiation
- hormonal tx=androgen deprivation (GnRH agonists and/or Flutamide) so the prostate doesn’t grow and/or orchiectomy
- Chemotherapy if hormonal tx is ineffective
