Male conditions - GU Flashcards
Hydrocele
- 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
Varicocele
- 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
Cryptorchidism
-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
Cryptorchidism - Exam and Tx
- 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
Testicular Torsion
- 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
Testicular Torsion - History / management
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!!!
Phimosis
- 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
Phimosis - Tx
- 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
Paraphimosis
- 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
Care of the Uncircumcised Penis
- 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
Hypospadias
- 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
Posterior Urethral Valves
- 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
Acute epididymitis
- 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.
Acute epididymitis - hx and exam
- age duration
- tenderness
- hot, erythematous, swollen hemiscrotum
- frequent and painful micturition
- purulent urethral discharge
- with irritative voiding symptoms (urgency, frequency, dysuria, burning)
Acute epididymitis - labs
- 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.
Acute epididymitis - Tx
- 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
Benign Prostatic Hyperplasia
- 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.
Benign Prostatic Hyperplasia - tests
- 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
Benign Prostatic Hyperplasia - tx
- 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
ACUTE BACTERIAL PROSTATITIS
- 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)
ACUTE BACTERIAL PROSTATITIS - labs/tx
- 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.
CHRONIC BACTERIAL PROSTATITIS
-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
NONBACTERIAL PROSTATITIS/PROSTADYNIA
- 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.
URETHRITIS
-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
