male GU Flashcards

Question

Priapism classifications

Answer 1

Classifications: 1) low-flow (veno-occlusive): Most common. Painful and tender penis; little intracorporal blood; “compartment syndrome” with metabolic changes and increased pressures leading to local hypoxia and acidosis by corporal blood gases. 2) high flow (inc arterial inflow without inc venous outflow resistance) non-tender penis Pathophysiology: Nitrous oxide imbalance leads to penile vasculopathy and anoxia and oxidative stress Diagnosis: Color Doppler US, assessment of corporal blood gases

Answer 2

consider any hard swelling testicular cancer until proven otherwise (esp young) swelling may be due to trauma, inflammatory conditions, neoplasms, etc

Answer 3

i. Tumors—e.g. adenocarcinoma ii. Abscess (may be tender) - tend to drain spontaneously iii. Hematocele- blood-filled swelling usu. 2° to trauma, may be initially tender. does not transilluminate iv Hydrocele- non-tender, serous fluid filled mass. Fluid between tunical layers acute – most common hydrocele occurs between 2-5 y/o, usu. the result of inflammation of epididymis or testis chronic – middle age men, from inflammation, injury usually aren't painful and typically require no treatment. Transilluminates; scrotal US to confirm

Answer 4

Due to gravity’s downward pull on venous valves as a result of upright posture, valve incompetence, leads to dilatation of pampiform plexus “bag or worms” appearance, located along spermatic cord (80% on left) worsens with valsalva maneuver and with standing Non-tender, may have “dragging” sensation Development of a new varicocele or worsening of an old one in an older man: a. On L: may be a tumor or other mass occluding the L renal or testicular vs. b. On R: occlusion of the vena cava possible.

Answer 5

firm, cutaneous nodules

Answer 6

from CHF, nephrotic syndrome, ascites, parasites, filariasis, tumor cells blocking lymphatics etc.

Answer 7

Large scrotal mass, compressible may hear bowel sounds cannot palpate above the swelling. Risk of bowel strangulation

Answer 8

Emergency--assume until proven otherwise! Needs to be de-torsed <6hrs! Severe scrotal pain after an episode of trauma or during intensive exercise; or spontaneous in sleep. Common age range 10-25 yo Most boys who develop torsion have the variant “bell clapper” anatomy (testicle freely rotates)

Answer 9

Sudden, acute onset unilateral, constant pain, poss N&V Swollen, tender, erythematous scrotum: difficult to discern structures Affected testicle higher, epididymis may be anterior; reactive hydrocele possible Pain may radiate to the abdomen “acute abdomen” Elevation of the scrotum does not relieve pain (negative Prehn’s sign) Cremasteric reflex absent

Answer 10

iii. Torsion of testicular appendix (vestigial structure upper pole of testis) in boys 7-14 yr SSX subacute onset of pain in upper pole of testis Cremasteric reflex present “blue dot” sign—discoloration seen under skin iv. Testicular tumor: painless unless large or hemorrhage is present v. Testicular trauma: clear history of event swelling, hematocele or hydrocele may develop vi. Mumps orchitis (paramyxovirus) 20% of post puberty boys, onset 1-2 weeks after parotitis unilateral or bilateral scrotal pain, erythema and swelling Abdominal pain, N&V may result in testicular atrophy

Answer 11

Small, painless cyst on the superior, posterior pole of the testicle (on vas deferens), may follow epididymitis. Benign. Contains dead spermatozoa Diagnosis-- ultrasound or aspiration.

Answer 12

-Infectious: result of an ascending LUT infection In children and men over 35 – UTI most common cause from coliform bacilli Teens to age 35 – STIs most common cause (GC or Chlamydia) --NON-INFECTIOUS VERSION: urine reflux/chemical irritation into ejaculatory ductsfrom heavy lifting or local trauma

Answer 13

Painful, swollen epididymis; pain may radiate along spermatic cord to abdomen Hydrocele may develop Overlying skin may look like peau d’orange; skin is movable (fixed suggests abscess) May be febrile. Discharge (if ascending infection), urinary frequency, dysuria may be present PE: exquisitely tender, swollen epididymis Scrotum often indurated, erythematous elevating the testicle eases pain (positive Prehn’s sign) no change in cremaster reflex Diagnosis: UA reveals pyuria Urine culture, NAAT (Nucleic Acid Amplification Test) testing for GC/chlamydia Scrotal ultrasound to rule out torsion in those <30

Answer 14

inflammation with no infection present Enlarged, thickened, non-tender epididymis occurs after repeated acute epididymitis may find incidentally on exam

Answer 15

Failure of the testicles to descend into the scrotum during infancy (most by 3-12mos) Categories: a. true cryptorchidism - testis remains in abd. cavity from mechanical obstruction or hormonal abnormality b. incomplete – testis in inguinal canal, obstructed by mechanical means c. ectopic testis - lies outside the usual course of descent d. hypermobile or retractile testis - may lie in the scrotum at times (e.g. hot bath) and then retract up into the inguinal canal hormonal function is usually normal

Answer 16

High risk of developing infertility or testicular cancer later in life (2.5-20x risk) PE- (gloved hand and warm room). Palpate for testicles If unpalpable, have patient squat or valsalva and repeat palpation This will distinguish retractile teste from undescended testicle Treated with orchiopexy

Answer 17

Most common solid cancer in males 15-34 yo Classification (germ cell tumors) a) Seminomas - 40% (arising in seminiferous tubules) b) Non-seminoma germ cell tumor (NSGCT): Embryonal: 24% Teratoma: 5% Mixed: 26% Choriocarcinoma: rare Yolk sac: rare

Answer 18

SSX: painless testicular nodule, usually smooth enlargement, firm and nontender Increases in size over time, may get dull ache, sensation of heaviness/weight Mass does not transilluminate Often found on self exam

Answer 19

Work-up –Scrotal US, Pelvic CT increased alpha-fetoprotein, HCG, LDH (esp. LDH1) 5 yr. survival of seminoma is > 80% with treatment

Answer 20

Any condition that narrows the prostatic urethra

Answer 21

Chronicity of obstruction will lead to damage to the

Answer 22

Normal-- like thenar eminence/tip of nose Rubbery--BPH Boggy - congested (infrequent ejaculation, chronic infection) Indurated – nodules (infection, with or without stones) Hard – consider tumor in absence of WBC’s & infection 3. symmetry 4. presenceoftenderness 5. presence of urethral secretions after the exam (EPS)

Answer 23

Serum prostate-specific antigen (PSA) PSA: protein manufactured in prostate epithelial cells. . Three typical sources for damage are: cancer, bacterial infection, and prostate damage by infarction Normally a little PSA leaks from the prostate into the blood. If the prostate is enlarged thenthe leakage appears exaggerated.

Answer 24

DRE ( do blood draw before!) Ejaculation, Recent sexual activity BPH Cystitis Acute & Chronic prostatitis (falls when treated) Prostate biopsy Exercise involving perineal pressure

Answer 25

``` Finasteride (Proscar) Saw palmetto Radical prostatectomy Withdrawal of anti-androgen drugs Regular prostatic massage Green tea ```

Answer 26

Hyperplasia of prostatic stromal and epithelial cells in the transitional zone, resulting in the formation of large, fairly discrete nodules in the periurethral region. Lumen of prostatic urethra narrows leading to urine outflow obstruction Urine stasis in the bladder from residual urine leads to hypertrophy of detrusor muscle....Higher number of androgen receptors....malfunction of valves, etc

Answer 27

SSX: progressive urinary frequency, urgency, nocturia due to incomplete emptying and rapid refilling of bladder

Answer 28

Complications: UTI from urine stasis (cystitis, pyelonephritis) Urolithiasis from urine stasis Hydronephrosis and resulting impaired renal function Straining to urinate may cause rupture of veins, hematuria and vasovagal syncope, hemorrhoids, hernias Sudden urinary retention (catheterization needed!)

Answer 29

PE- DRE: enlarged, rubbery consistency Smooth, symmetric enlargement (typically), loss of median furrow (sulcus) Non-tender prostate Abdominal exam may reveal distended bladder

Answer 30

increased BUN, serum creatinine if obstruction backs up to kidneys UA and urine culture- to rule out causative or concomitant infection PSA: mod. increased (depending on size and degree of obstruction).. NOTE: PSA increased with DRE, so draw blood sample prior to PE

Answer 31

Procedures: Uroflowmetry: to check urine flow rate and post-void residual volume May consider transrectal U/S or prostate biopsy to help R/O cancer

Answer 32

Inflammation of the prostate which may be infectious or non-infectious (often poorly understood). Variable presentations of irritative and/or obstructive urinary sx and perineal pain.

Answer 33

Chronic (>3mos) genitourinary pain in the absence of bacteria (no infx) localized to prostate DRE: moderate tenderness, boggy, enlarged, soft prostate Lab: Post-massage urine culture and sensitivity, EPS culture, semen culture UA: May be incidental bacteriuria >10 leukocytes/HPF in EPS Studies ongoing using RT-PCR for occult infx

Answer 34

Significant WBCs found (>10-20/hpf) in the semen, expressed prostatic secretions (EPS) or voided bladder urine-3 (VB-3)

Answer 35

No specific CP/CPPS symptoms found but WBCs found in EPS or in prostate tissue bx

Answer 36

Lab: CBCshowsleukocytosiswithleftshift UA shows many WBC's (cloudy), bacteria, possible hematuria Culture of prostatic secretions (semen culture may be more accurate!) reveals increased bacteria Elevated CRP Transient increase in PSA (back to normal in~ 2 wks)

Answer 37

most common male cancer in men >50yrs ~220,000 new cases diagnosed/yr; 32,000 deaths Lifetime risk 1 in 6 white men; 1 in 5 black men >75% of CaP diagnosed in men over 65 More men die WITH prostate cancer that FROM it!! BUT there are aggressive, fast growing forms

Answer 38

Late: bladder outlet obstruction, ureteral obstruction, hematuria, pyuria metastasis to pelvis, ribs, vert. may create bone pain tumor enlargement may lead to cord compression and neuropathy unintended weight loss

Answer 39

Lab: Total PSA: 4-10 ng/ml likelihood of CaP is 25%; >10 ng/ml likelihood of CaP is >50% PSA Velocity: inc of >0.75 ng/ml/year or higher (based on 3 PSA measurements over 18-24 mos) when the PSA is 4-10 ng/ml is suspicious for CaP Free to total PSA ratio: <25% (reduced) in CaP Other markers being used: PCA3 mRNA in urine Advanced cancer-- CMP: inc BUN, creatinine (if bilateral utereral obstruction) Inc alk phos from bone mets, inc acid phos CBC: Anemia from mets

Answer 40

``` Transrectal US (TRUS) with biopsy Axial CT or MRI (for STAGING) ```