Lecture 5- Mens urology Flashcards
foreskin problems
phimosis
paraphimosis
Phimosis
- When prepuce cannot be fully retracted in adult
- Incidence 1% in non circumcised pop.
Physiology phimosis
Normal non-retractability up to adolescence
Causes of phimosis
- Poor hygiene (build-up of smegma)
- STDs
- Penile cancer
Symptoms of phimosis
- Pain on intercourse, splitting/bleeding
- Balanitis (inflamed glans)
- Posthitis (inflamed foreskin/prepuce)
- Balanitis xerotica obliterans (BXO)
- Urinary retention
phimosis beware
- In adulthood may be associated with other pathologies
- Beware of the elderly with phimosis and balanitis
best treatment for phimosis
- Circumcision best treatment
balanitis
Balanitis is the inflammation of the glans penis and posthitis is the inflammation of the foreskin (prepuce).
The term balanoposthitis refers to inflammation of both glans penis and prepuce.
BXO- balanitis xerotica obliterans
is a chronic, often progressive disease, which can lead to phimosis and urethral stenosis, affecting both urinary and sexual function. Steroid creams are usually the first-line treatment but have a limited role and surgical intervention is frequently necessary.
Paraphimosis
Painful constriction of the glans by the retracted prepuces proximal to the corona
Commonest causes of paraphimosis
- Phimosis
- Catheterisation esp in elderly (when you retract the foreskin and don’t put it back)
- Penile cancer
Treatment of paraphimosis
- Needs reduction
- Achieved manually
- Occasionally dorsal slit may be necessary
what type of cancer is penile cancer
squamous cell carcinoma (SCC)
Penile cancer- squamous cell carcinoma (SCC)
rare cancer
- Untreated = most die within 2 years, with treatment = 5 years
- Important not to miss
Risk factors for penile cancer
- Phimosis
- Hygiene(smegma)
- HPV 16 and 18
causes of scrotal pain
- Testicular torsion- Emergency
- Epididymitis /orchitis/epididymo-orchitis
- UTI
- STI
- Mumps
- Torsion of hydatid of Morgagni (embryological remnant)
- Trauma
- Ureteric calculi (rarely)
diagnosis of acute scrotal pain
- History
- Is it painful?
- How quickly has it improved?
- Exam
- Can I get above it
- If not likely it’s a hernia
- Is it in the body of the testis
- If yes, this could be a testicular tumour
- Is it separate to the testis?
- Does it fluctuate and transilluminate?
- Can I get above it
- Opportunistic presentations
- e.g. lumps, pain etc
Painless scrotal lump- not tender
- Testis tumour
- Epididymal cyst
- Hydrocele
- Reducible inguino-scrotal hernia
Painless/acheing at the end of the day- non-tender
Varicocele
Acute presentation with scrotal lump – painful
- Epididymitis
- Epididymo-orchitis
- Strangulated inguino-scrota hernia- emergency
Testicular torsion
- History
- Younger patient <30
- Sudden onset e.g. woke from sleep
- Unilateral pain, may be nauseated/ vomit
- No LUTS
- Examination
- Testis very tender
- Lying high in scrotum with horizontal lie
- Treatment
- Needs emergency scrotal exploration
- Do not waste time with US
Epididymo-orchitis
an inflammation of the epididymis and/or testicle (testis). It is usually due to infection, most commonly from a urine infection or a sexually transmitted infection. A course of antibiotic medicine will usually clear the infection. Full recovery is usual.
Epididymo-orchitis History
- Age
- 20-40/50- STI e.g. chlamydia
- 40/50+ - UTI esp E.coli
- Gradual onset
- Unilateral
- Often recent history of
- UTI
- Unprotected sex
- Catheter
- Check for mumps history (usually bilateral symptoms)- may present like this before glands in neck
Epididymo-orchitis examination
- Pyrexial, can be septic
- Scrotum erythematous
- Testis/epididymis enlarged, tender
- Fluctuant areas may represent abscess
- May have reactive hydrocele
- Rarely- necrotic area of scrotal skin (Fournier’s gangrene- high mortality rate 50%) – emergency – usually diabetic
Epididymo-orchitis investigations
- Bloods
- FCS/ U&Es/ cultures
- Urine
- MSU
- Radiology
- Scrotal USS
Treatment of epididymo-orchitis
- Epididymo-orchitis- antibiotics
- Abscess- surgical drainage and Abx
- Fournier’s gangrene- emergency debridement and Abx
Fournier’s gangrene
is a sometimes life-threatening form of necrotizing fasciitis that affects the genital, perineal, or perianal regions of the body. Necrotizing fasciitis is a serious condition that kills soft tissues, often quickly, including muscles, nerves, and blood vessels.
testicular tumours history
- Usually painless
- Germ cell tumours (seminoma/teratoma) usually in men aged <45 years
- Risk – history of undescended testis)
- Older men – could be lymphoma
testicuar tumour examination
testicular tumours referral
- Refer via 2 week wait to urology
- Urology will
- Arranged urgent US of scrotum to confirm diagnosis
- Check testis tumour markers (aFP, hCG, LDH)
- Average GP may only see two in their lifetime
- Urology will
Hydrocele (adult)
- Slow/sudden onset
- Uni/bilateral scrotal swelling = imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
- Examination
- Testis not palpable separately
- An get above
- Transilluminates
Epididymal cysts
- Painless
- Examination
- Separate from testis
- Can get above mass
- transilluminates
Hydroceles vs varicoceles
both are types of testicular lumps and swellings involving the male scrotum. However they differ because hydrocele is a swelling caused by fluid around the testicle, whereas varicocele is a swelling caused by dilated or enlarged veins within the testicles.
varcicocele
- Dull ache, at the end of the day
- More common in left than right
- May be associated with reduced fertility esp if bilateral
- Exam
- Bag of worms above testis
- Not tender
- Need to feel for palpable abdominal, renal mass
treatmnt of testicular tumour
inguinal orchidectomy
treatment for epidiymal cysts
reassure
excise if large
treatment for adult hydrocele
if normal testis on US
- reassure
- surical removal if large/symptomatic
treatment for varicocele
- reassure
- radiological emebolisation
- symptomatic
- infertility (slow motility of sperm)
- if present in adolescent and growth of testis affected
inguinal-scrotal hernia treatment
surgery- emergency if strangulated
define urinary retention
- Inability to pass urine, rather than inability to make urine
- Common in males, rare in females
causes od urinary retention
- Causes
- Prostatic enlargement- BPH or cancer
- Phimosis/urethral strictures/meatal stenosis
- Constipation
- UTI
- Drugs
- Anticholinergic actions
- Over distention
- Following surgery
- Neurological
types of UR
acute
chronic
acut on chroninc
Acute urinary retention
treatment- trial without catheter after addressing exacerbating factor
- Painful relieved by drainage (catheter)
- Residual volume <1000 ml
- No kidney insult
Chronic
(treatment- learn self catheterise)
- Painless
- May just notice abdominal sweeling
- Residual volume >3000ml
- May have kidney insult
acute on chronic UR
treatment- TWOC not usually successful. Long-term cath. or surgical intervention
- Painful
- Residual volume >1000ml
- Usually have kidney insult
older men with nocturnal enuresis (bed wetting) have
chronic retention with overflow incontinence until proven otherwise
LUTS
(lower urinary tract symptoms) are symptoms related to problems with your lower urinary tract: your bladder, your prostate and your urethra. LUTS are broadly grouped into symptoms to do with storing or passing urine. You might have symptoms linked mainly to one or the other, or a combination of both.
- From the history, determine if LUTS are predominantl:
Voiding (suggestive of bladder outflow obstruction)
- Hesitancy
- Poor flow
- Post micturition dribbling
Storage
- Nocturia
- Urgency
- Frequency
Causes other than the prostate that can cause storage LUTS
What could be causing voiding symptoms?
- bladder outflow obstruction (BOO)
- physical
- dynamic
- neurological
physical BOO
-
urethra
- phimosis
- stricture
- prostate
- bening
- malignant
- bladder neck
dynamic BOO
- prostate
- bladder neck
neurological BOO
lack of coordination between bladder and urinary sphincter
- UMN
reduced contractiltiy of the bladder can also cause BOO
physical
neurological
- LMN lesion
spraying of urine suggests
urethral stricture
LUTS assessment (primary care)
uses the international prostate symptom score (IPSS)
-
Examination
- DRE
- Is the bladder palpable
- Neurological if suggestive history
-
Investigations
- Dipstick
- UTI, blood
- Prostate specific antigen
- Counsel before requesting
- Not surrogate for DRE
- If UTI, treat first and if palpably benign prostate- wait 4-6 weeks
- Dipstick
LUTS assessment (secondary care)
In secondary care usually get men to do a flow rate before considering surgery
Management of BPH
- Reduce caffeine intake
- Avoid fizzy drinks
- No need to drink more than 2.5 l a day
- Sudafed exacerbations
treatment of BPH
- alpha blockers
- 5-alpha reductase inhibitors (5ARIs)
Alpha blockers
Act by relaxing smooth muscle within the prostate and the bladder neck- rapid symptom relief e.g. Tamsulosin
5alpha reductase inhibitors (5ARIs)
- Reducing conversion of testosterone to dihydrotestosterone (more potent)
- Shrinks prostate by means of androgen deprivation
- Slower relief thank alpha blockers
- Slows progression
- Reduces risk of retention
- E.g. Finasteride or dutasteride
Surgery for BPH
- Indications
- Failed lifestyle and medical management
- Urinary retention needing intervention
- Standard
- Transurethral resection of prostate (TURP)
- Monopolar/laser/bipolar
- Transurethral resection of prostate (TURP)
