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Integration for clinical application > Lecture 5- Mens urology > Flashcards

Lecture 5- Mens urology Flashcards

1
Q

foreskin problems

A

phimosis

paraphimosis

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2
Q

Phimosis

A
  • When prepuce cannot be fully retracted in adult
  • Incidence 1% in non circumcised pop.
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3
Q

Physiology phimosis

A

Normal non-retractability up to adolescence

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4
Q

Causes of phimosis

A
  • Poor hygiene (build-up of smegma)
  • STDs
  • Penile cancer
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5
Q

Symptoms of phimosis

A
  • Pain on intercourse, splitting/bleeding
  • Balanitis (inflamed glans)
  • Posthitis (inflamed foreskin/prepuce)
  • Balanitis xerotica obliterans (BXO)
  • Urinary retention
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6
Q

phimosis beware

A
  • In adulthood may be associated with other pathologies
  • Beware of the elderly with phimosis and balanitis
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7
Q

best treatment for phimosis

A
  • Circumcision best treatment
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8
Q

balanitis

A

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.

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9
Q

BXO- balanitis xerotica obliterans

A

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.

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10
Q

Paraphimosis

A

Painful constriction of the glans by the retracted prepuces proximal to the corona

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11
Q

Commonest causes of paraphimosis

A
  • Phimosis
  • Catheterisation esp in elderly (when you retract the foreskin and don’t put it back)
  • Penile cancer
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12
Q

Treatment of paraphimosis

A
  • Needs reduction
    • Achieved manually
    • Occasionally dorsal slit may be necessary
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13
Q

what type of cancer is penile cancer

A

squamous cell carcinoma (SCC)

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14
Q

Penile cancer- squamous cell carcinoma (SCC)

A

rare cancer

  • Untreated = most die within 2 years, with treatment = 5 years
    • Important not to miss
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15
Q

Risk factors for penile cancer

A
  • Phimosis
    • Hygiene(smegma)
    • HPV 16 and 18
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16
Q

causes of scrotal pain

A
  • Testicular torsion- Emergency
  • Epididymitis /orchitis/epididymo-orchitis
    • UTI
    • STI
    • Mumps
  • Torsion of hydatid of Morgagni (embryological remnant)
  • Trauma
  • Ureteric calculi (rarely)
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17
Q

diagnosis of acute scrotal pain

A
  • 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?
  • Opportunistic presentations
    • e.g. lumps, pain etc
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18
Q

Painless scrotal lump- not tender

A
  • Testis tumour
  • Epididymal cyst
  • Hydrocele
  • Reducible inguino-scrotal hernia
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19
Q

Painless/acheing at the end of the day- non-tender

A

Varicocele

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20
Q

Acute presentation with scrotal lump – painful

A
  • Epididymitis
  • Epididymo-orchitis
  • Strangulated inguino-scrota hernia- emergency

​​

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21
Q

Testicular torsion

A
  • 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
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22
Q

Epididymo-orchitis

A

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.

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23
Q

Epididymo-orchitis History

A
  • 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
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24
Q

Epididymo-orchitis examination

A
  • 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
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25
Q

Epididymo-orchitis investigations

A
  • Bloods
    • FCS/ U&Es/ cultures
  • Urine
    • MSU
    • Radiology
      • Scrotal USS
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26
Q

Treatment of epididymo-orchitis

A
  • Epididymo-orchitis- antibiotics
  • Abscess- surgical drainage and Abx
  • Fournier’s gangrene- emergency debridement and Abx
27
Q

Fournier’s gangrene

A

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.

28
Q

testicular tumours history

A
  • Usually painless
  • Germ cell tumours (seminoma/teratoma) usually in men aged <45 years
    • Risk – history of undescended testis)
  • Older men – could be lymphoma
29
Q

testicuar tumour examination

A
30
Q

testicular tumours referral

A
  • 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
31
Q

Hydrocele (adult)

A
  • 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
32
Q

Epididymal cysts

A
  • Painless
  • Examination
    • Separate from testis
    • Can get above mass
    • transilluminates
33
Q

Hydroceles vs varicoceles

A

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.

34
Q

varcicocele

A
  • 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
35
Q

treatmnt of testicular tumour

A

inguinal orchidectomy

36
Q

treatment for epidiymal cysts

A

reassure

excise if large

37
Q

treatment for adult hydrocele

A

if normal testis on US

  • reassure
  • surical removal if large/symptomatic
38
Q

treatment for varicocele

A
  • reassure
  • radiological emebolisation
    • symptomatic
    • infertility (slow motility of sperm)
    • if present in adolescent and growth of testis affected
39
Q

inguinal-scrotal hernia treatment

A

surgery- emergency if strangulated

40
Q

define urinary retention

A
  • Inability to pass urine, rather than inability to make urine
  • Common in males, rare in females
41
Q

causes od urinary retention

A
  • Causes
    • Prostatic enlargement- BPH or cancer
    • Phimosis/urethral strictures/meatal stenosis
    • Constipation
    • UTI
    • Drugs
      • Anticholinergic actions
    • Over distention
    • Following surgery
    • Neurological
42
Q

types of UR

A

acute

chronic

acut on chroninc

43
Q

Acute urinary retention

A

treatment- trial without catheter after addressing exacerbating factor

  • Painful relieved by drainage (catheter)
  • Residual volume <1000 ml
  • No kidney insult
44
Q

Chronic

A

(treatment- learn self catheterise)

​

  • Painless
  • May just notice abdominal sweeling
  • Residual volume >3000ml
  • May have kidney insult
45
Q

acute on chronic UR

A

treatment- TWOC not usually successful. Long-term cath. or surgical intervention

  • Painful
    • Residual volume >1000ml
    • Usually have kidney insult
46
Q

older men with nocturnal enuresis (bed wetting) have

A

chronic retention with overflow incontinence until proven otherwise

47
Q

LUTS

A

(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.

48
Q
  • From the history, determine if LUTS are predominantl:
A

Voiding (suggestive of bladder outflow obstruction)

  • Hesitancy
  • Poor flow
  • Post micturition dribbling

Storage

  • Nocturia
  • Urgency
  • Frequency
49
Q

Causes other than the prostate that can cause storage LUTS

A
50
Q

What could be causing voiding symptoms?

A
  • bladder outflow obstruction (BOO)
    • physical
    • dynamic
    • neurological
51
Q

physical BOO

A
  • urethra
    • phimosis
    • stricture
  • prostate
    • bening
    • malignant
    • bladder neck
52
Q

dynamic BOO

A
  • prostate
  • bladder neck
53
Q

neurological BOO

A

lack of coordination between bladder and urinary sphincter

  • UMN
54
Q

reduced contractiltiy of the bladder can also cause BOO

A

physical

neurological

  • LMN lesion
55
Q

spraying of urine suggests

A

urethral stricture

56
Q

LUTS assessment (primary care)

A

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
57
Q
A
58
Q

LUTS assessment (secondary care)

A

In secondary care usually get men to do a flow rate before considering surgery

59
Q

Management of BPH

A
  • Reduce caffeine intake
  • Avoid fizzy drinks
  • No need to drink more than 2.5 l a day
  • Sudafed exacerbations
60
Q

treatment of BPH

A
  • alpha blockers
  • 5-alpha reductase inhibitors (5ARIs)
61
Q

Alpha blockers

A

Act by relaxing smooth muscle within the prostate and the bladder neck- rapid symptom relief e.g. Tamsulosin

62
Q

5alpha reductase inhibitors (5ARIs)

A
  • 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
63
Q

Surgery for BPH

A
  • Indications
    • Failed lifestyle and medical management
    • Urinary retention needing intervention
  • Standard
    • Transurethral resection of prostate (TURP)
      • Monopolar/laser/bipolar

Integration for clinical application (13 decks)

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