Male conditions - GU

Question 1

Hydrocele

Answer 1

• Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis, the layer that directly surrounds the testis and spermatic cord
• Varied sizes
• Bigger hydroceles are more painful/disabling
• Surgical excision if very symptomatic
• Infants - associated with hernia, need repair
• definitive is surgical excision
• often reoccur

Question 2

Varicocele

Answer 2

• Dilatation of the pampiniform plexus of spermatic veins
• Present in 15 to 20 percent of post-pubertal males, L or bilat - if unilateral R, worry about Inferior vena cava obstruction
• Asymptomatic OR
• Dull, aching, left scrotal pain, typically noticeable when standing and relieved by recumbency
• Testicular atrophy due to increased temperature environment
• Decreased fertility
• Exam: Dilation of the scrotal venous complex with valsalva in standing position
• Resolves when supine
• Treatment in boys with testicular growth issues
• Refer to urology to discuss options: usually surgical, have lots of assoc. risks

Question 3

Cryptorchidism

Answer 3

-Undescended testes
-Common 2-4 % of full-term and 30% of premies
-Short-term endogenous testosterone after birth decreases incidence to 1% by 3 months.
-After 6 months, spontaneous descent rare
Risks
-Infertility and malignancy
-Fertility impaired 33% after unilateral, 66% bilateral
-Cancer risk 5-10 times greater than normal
-Histologic changes as early as 6 months
Cause
-Mostly unknown
-Occurs isolated or associated with other abnormalities (hypothalamic-pituitary-gonadal axis)
-Bilateral cryptorchidism in an otherwise normal newborn male may be a fully virilized FEMALE with congenital adrenal hyperplasia (CAH), which is potentially fatal if missed
Find the testes
-Infants 2-6 months - LH, FSH, and testosterone levels help determine if the testes are present
-After 6 months, HCG stimulation tests will confirm presence or absence of functional abdominal testes
-US, CT, MRI may detect testes in the inguinal region, but unreliable for abdominal

Question 4

Cryptorchidism - Exam and Tx

Answer 4

• Exam - confounded by the cremasteric reflex
• Place fingers across the abdominal ring and upper portion of the inguinal canal to prevent ascent first
• Examining while in squatting position may be helpful
• Retractile testes - recheck annually - some ascend…
• Management - refer to ped urology at 3-6 months

Treatment

• Surgical orchidopexy at 6-12 months by experienced surgeon, if descent has not occurred
• Getting the testes to a low-temp environment reduces risks, but
• Some of the testes are abnormal, which led to their failure to descend
• Hormonal treatment with HCG has a success rate of <20% - alternative to surgery

Question 5

Testicular Torsion

Answer 5

• Torsion (twisting) of the spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle
• Urological emergency
• Early diagnosis and treatment are vital to saving the testicle and preserving future fertility, can result in necrosis of testicle
• Any age, but peaks in neonates and adolescents
• Higher incidence in males (17%) with bell clapper deformity - testicle located horizontally not up and down

Question 6

Testicular Torsion - History / management

Answer 6

History
-Sudden onset of severe unilateral scrotal pain, then swelling
-Pain may lessen as the necrosis becomes more complete
-Spontaneous, with activity, or related to trauma
-Nausea and vomiting
-Recurrent torsion/detorsion possible - REFER
-Neonatal torsion - can present hard, nontender, fixed
Exam
-Swollen, tender
-High riding - shortening of structures
-Abnormal transverse lie
-Absent cremasteric reflex, negative Prehn sign

Management

• Clinical diagnosis - Emergency Urology Consult
• Detorsion and orchiopexy (bilateral)
• Ultrasound good, but do not delay treatment!!!

Question 7

Phimosis

Answer 7

• Inability to fully retract the foreskin
• Physiologic - almost all newborns have phimosis
• 90% are retractable by age 3
• 1% still unretractable by age 17
• Pathologic - associated with scarring, usually from infection
• Symptoms include skin irritation, dysuria, bleeding, and occasionally enuresis or urinary retention
• If severe, the distal foreskin often appears swollen and erythematous with cracked fissures
• Pain and discomfort during sexual activity or when they attempt to retract the foreskin
• Physical examination usually reveals white cicatricial scarring at the preputial ring

Question 8

Phimosis - Tx

Answer 8

• Steroid cream (0.05% betamethasone) bid for 4-6 weeks (success rate of 87%) + stretching exercises
• If concomitant balanitis or balanoposthitis - treat with appropriate antimicrobials
• Patients with diabetes mellitus should be advised on proper serum glucose control
• If unsuccessful, refer to urology

Question 9

Paraphimosis

Answer 9

• Foreskin in uncircumcised or partially circumcised penis retracted behind the glans penis
• Venous and lymphatic congestion causes swelling
• Unable to return forskin to normal position
• Must be reduced emergently - minimally invasive or invasive, to prevent necrosis of the glan penis

Question 10

Care of the Uncircumcised Penis

Answer 10

• No special care in newborn - no forcible retraction
• After 6 months, gentle retraction with bathing
• Older child - instruct in gentle retraction and cleaning
• Always return foreskin to normal position

Question 11

Hypospadias

Answer 11

• Proximal displacement of the urethral meatus
• Blind metal pit can be deceiving - take a closer look
• Take family history for congenital disorders
• Look for associated problems like cryptorchidism
• DO NOT CIRCUMCISE: because they need reconstruction, need foreskin to provide extra tissue for creating a channel for urine
• Refer to Urology

Question 12

Posterior Urethral Valves

Answer 12

• Obstructing membranous folds within the lumen of the posterior urethra
• Most common etiology of urinary tract obstruction in the newborn male
• Most common cause of chronic renal disease due to urinary tract obstruction in children
• Most detected on prenatal ultrasound
• May present in infancy with lung hypoplasia, failure to thrive, abdominal distension (bladder distension), poor urine stream, urosepsis
• Older boys - UTIs, enuresis, voiding dysfunction, bed wetting, weak stream
• Results in bladder dysfunction, VUR, and chronic kidney disease
• Diagnostic study of choice - VCUG -Void cystic urethra gram
• Refer to urology – do cystoscopy, to remove tissue/expand

Question 13

Acute epididymitis

Answer 13

• Inflammation of the epididymis causing pain and swelling, which is usually unilateral and develops over the course of a few days.
• In sexually active men (aged s age and clinical and sexual history.

Question 14

Acute epididymitis - hx and exam

Answer 14

• age duration
• tenderness
• hot, erythematous, swollen hemiscrotum
• frequent and painful micturition
• purulent urethral discharge
• with irritative voiding symptoms (urgency, frequency, dysuria, burning)

Question 15

Acute epididymitis - labs

Answer 15

• CBC: leukocytosis with a left shift common but not mandatory
• In nonsexually transmitted variety can have pyuria, bacteruria, hematuria.
• Obtain routine UA with culture.
• In sexually transmitted variety (usually Chlamydia) can see white cells (pyuria) without bacteria.

Question 16

Acute epididymitis - Tx

Answer 16

• bed rest and scrotal elevation (brief shorts/athletic supporter)
• Antibiotics: 10-21 days for STD (of doxycycline, one time dose of Rocephin at initiation of treatment). Treat partner if STD if possible.
• Non-STD: Cipro 250-500mg p.o. BID, Ofloxacin 200-400mg p.o. BID, Bactrim DS one p.o. BID = 21-28 days for non-STD

Question 17

Benign Prostatic Hyperplasia

Answer 17

• Multifactorial involving smooth muscle hyperplasia, prostatic enlargement, and bladder dysfunction, as well as input from the CNS.
• Presents with both storage symptoms (frequency, urgency, nocturia, and incontinence) and voiding symptoms (weak stream, dribbling, dysuria, straining).
• Physical examination may demonstrate prostate volume ≥30 g, nodules or tenderness suspicious of prostate cancer or prostatitis.
• Evaluation includes history and examination including an abdominal exam for a palpable bladder, a digital rectal exam, and a neurologic assessment.

Question 18

Benign Prostatic Hyperplasia - tests

Answer 18

• UA
• PSA
• If recurrent infections use CT or renal ultrasound may be helpful to rule out stones or other abnormalities of the urinary tract such as hydronephrosis.
• Cystometrograms/urodynamic profiles/post-void residuals—done by urology, helpful in diagnosing obstructive urinary issues such as detrusor muscle weakness.
• Perform at least a basic neuro exam when evaluation BPH and try to obtain a good history to r/o issues such as CA of the bladder—sometimes will have irritative voiding symptoms in addition to hematuria – back problems causing the issues? -Sensation and strength of legs
• Neurogenic bladder – think about this which is why you do the Neuro exam

Question 19

Benign Prostatic Hyperplasia - tx

Answer 19

• TURP-Transurethral Resection of the Prostate, “Roto-Rooter” – clean up prostate shave off pieces of prostate
• Turp-Transurethral incision of the Prostate – make inscision to widen the uretha
• Open Prostatectomy, when prostate is very large (over 100 gms), two approaches to prostate. Has the most complications.
• Needle ablation, electrovaporization, hyperthermia (i.e. microwaving the prostate), laser therapy.

Non-surg

• a-blockers, e.g. doxazosin, prazosin; inhibit smooth muscle contraction at urethral sphincter among multiple other effects. (Have been used for hypertension and psychiatric uses as well).
• 5a Reductase Inhibitors -Finasteride—blocks conversion of testosterone to dihydrotestosterone, reducing (hopefully) in time the size of the prostate gland. Marketed as Propecia by Merck for baldness.
• Requires at least 6 months of therapy for improvement, helpful in those patients with definitely enlarged prostates by exam and/or ultrasound. Approximately 50% of patients have some improvement. Use for pts where youre worried about side of effects of other drugs

Question 20

ACUTE BACTERIAL PROSTATITIS

Answer 20

• Patients have classically fever and irritative voiding symptoms, perineal or suprapubic pain, painful prostate upon rectal exam. Often prostate feels swollen and boggy.
• Usually patients have positive urine cultures
• Patients can sometimes have obstructive symptoms (trouble initiating stream, dribbling)

Question 21

ACUTE BACTERIAL PROSTATITIS - labs/tx

Answer 21

• Lab: leukocytosis and Left shift on CBC
• UA shows pyuria, bacteruria, varying hematuria.
• Hospitalization and parental antibiotics may be required, then discharge on oral antibiotics. A suprapubic tube might be required to avoid reinfecting the urinary tract via catheterization. In older patients there is risk of sepsis.

Question 22

CHRONIC BACTERIAL PROSTATITIS

Answer 22

-Symptoms and signs are variable, most have varying irritative voiding symptoms.
-May have low back and perineal/groin pain
Patients may have history of of UTI’s of unclear etiology.
-The physical exam can be normal
Commonly dx of exclusion
-Many men have no preceding acute symptoms
-gram negative rods most common, but also gram-positive Enterococcus
-Symptoms and signs are variable, most have varying irritative voiding symptoms.
-May have low back and perineal/groin pain
-Patients may have history of of UTI’s of unclear etiology.
-The physical exam can be normal
-The UA is usually normal, unless there is a cystitis present
-Commonly dx of exclusion
-Symptomatic treatment may be helpful, such as NSAIDs and sitz baths

Question 23

NONBACTERIAL PROSTATITIS/PROSTADYNIA

Answer 23

• The most common of prostatitis symptoms, of unknown cause. Diagnosis is one of exclusion.
• Presentation is identical to chronic bacterial prostatitis, but no history of UTI’s. irratative sxs
• Increased numbers of leukocytes in urine, but cultures are negative.
• In older men, if recurrent symptoms but negative cultures, consider bladder CA and patient probably merits cystoscopy.
• Prostadynia is similar to the above, but is a misnomer that applies to younger and middle-aged men—the prostate is normal. But have prostate pain. Dx of exclusion.
• Urinalysis and cultures normal although again may have leukocytes on prostatic secretions.
• Urodynamic testing may be helpful under the care of a urologist.
• May have a trial of a-blockers, e.g. terazosin, doxazosin.

Question 24

URETHRITIS

Answer 24

-Hard to distinguish from other entities in males, especially prostatitis, epididymitis, and cystitis.
-Remember males can get a simple urethritis like women, but it is rare. Mostly it implies a pathological process such as ureteral stones, other previously mentioned issues, or -In sexually active males always consider the possibilities of an STD. Chlamydia is most prevalent, but Gonorrhea is rising in incidence (and in resistance).
-Obviously these organisms may be covered if we are treating other urological problems depending on medications used.
If STD is suspected:
-Azithromycin (Zithromax) 1 Gm p.o. single dose OR -Doxycycline 100 mg p.o. BID x 7 days PLUS
-Ceftriaxone (Rocephin) 250 mg IM (preferred med to cover Gc) or Cefixime (Suprax) 400mg oral single dose
*Do not use flouroquinalones (Cipro, Levaquin, Floxin, Avelox) because of these medications’ resistance to Gc