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Clinical Medicine II > Male GU disorders > Flashcards

Male GU disorders Flashcards

1
Q

most cases of epididymitis are ? and can be divided into what ?

A

INFECTIOUS
can divide epididymitis into:
1. STD: usually M<40, C trachomatis, N gonorrhea
2. Non STD: usually older M, G- rod

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2
Q

Sx of epipdidymitis may follow

A
  • acute physical strain
  • trauma
  • sexual acitivty
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3
Q

ROS and PE of pt with epididymitis might reveal

A

Pain that develops in scrotum and radiates to flanks or along spermatic cord

  • usually fever and swelling of epididymis present
  • Prostate may be tender
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4
Q

What are typical lab findings of epididymitis

A

LEFT shift (elevated neutrophils)

  • Urethral Gram stain: n gonorrhea or white cells w/o visible organisms (chlamydia)
  • UA: pyuria, bacteriuria and varying hematuria
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5
Q

Imaging for epididymitis …helpful?

A

scrotal US may be helpful to confirm dx

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6
Q

Ddx for epididymitis includes

A 
Tumor (but these are generally painless)
Testiculor torsion (most important to r/o, usually seen in young M)
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7
Q

What is phrens sign suggestive of?

A

EPIDIDYMITIS… testicular torsion has neg phrens sign meaning, pain does not improve with elevation of scrotum

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8
Q

what is tx for epididymitis

A

bed rest with scrotal elevation
*if STD suspected:
ROCEPHIN 250 mg IM (3rd gen ceph DOC to cover N gonorrhea) &
DOXYCYCLINE or ZITHROMAX to cover chlamydia

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9
Q

tx for N. gonorr

A

Rocephin 250 mg IM (Cefriaxone) or Cefixime 400 mg oral

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10
Q

Tx for chlamydia

A

*macrolide or tetraycycline ie

Azithromycin (zithromax) 1 gm po or Doxycycline 100mg BID

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11
Q

what should you always do when treating for gonorr

A

treat for his friend chlamydia

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12
Q

IF STD is not the suspected cause of the epididymitis, what should you do?

A

empiric tx towards suspected pathogen - Levofloxacin 500-750 mg po qd x 10d
&NSAIDS may help the pain and inflammation

*Note: most likely pathogens are G- rod (e coli, proteus, klebsiella)

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13
Q

Prognosis for tx of epididymitis?

A

if prompt, good

delayed –> may result in orchitis, abscess or infertility

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14
Q

What are some important considerations for gonorrheal (GC) urethritis

A

GC is most common of STD
most prevalent in 15-29 yo
incubates 2-8 d
characterized by yellow dc and urethral pain

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15
Q

what are the common clinical findings for GC urethritis in men

A

burning pain w/ urination

clear to yellow urethral dc

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16
Q

what are common clinical finding for GC urethritis in women?

A

less severe or asymp sx compared to Males
generally complain of dysuria, freq, urgency and vaginal dx
*chandelier sign on pelvic exam

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17
Q

T/F.. GC is only in the genitals

A

False.. can be found in eyes, throat, anus or blood

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18
Q

How do you dx urethritis

A

Men: culture, Gram stain, tests for other likely STD in addition to GC (ie chlamydia, trich, garnerella, candida)
Women: dx from culture, hx, presentation (gram is of no use)

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19
Q

ddx for urethritis

A

in addition to NC, chlamydia, Trichomonas, gardnerella, candida

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20
Q

What are some general considerations for Chlamydia causing urethritis

A
  • chlamydia generally causes insidious, silent and latents states of infection
  • 5-21 d incubation
  • spread via sexual contact and can enter lymph
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21
Q

s/sx of urethritis (chlamydia) M and F

A

M: clear to white dc, LAD or asymp
*chlamydia may spread from urethra to epididymis or prostate

Female: s/sx of pelvic inflammatory disease (PID), cervicitis, salpingitis or asymp

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22
Q

what is the most reliable way to dx chlamydia urethritis

A

culture- but too long and expensive

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23
Q

Instead of culture (too long/expensive) what are the 3 alternatives for dx chlamydial urethritis

A
  1. immunofluorescence assay
  2. enzyme linked assay
  3. DNA probe (95% sensitive and specific, relatively quick, less costly)
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24
Q

of the 3 alternatives for dx chlamydia urethritis (immmunofluorescence assay, enzyme assay, DNA probe) which seems best

A

DNA probe - 95% sensitive and specific, relatively quick and cheap

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25
Q

ddx for chlamydial urethritis

A

bc chlamydia is a STD, all other STD are ddx!! GC, gardnerella, candida, trich

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26
Q

What is the recommended tx for Urethritis due to chlamydia

A

zithromax 1 g po (uncomplicated) or erythromycin
OR Doxycycline 100 mg bid X 7-10 d

*also want to empirically co-treat GC: Rocephin 250 mg IM

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27
Q

What is the prognosis for chlamydia infections

A

if left untreated of infection is chronic, FEMALES have PROBABILITY of INFERTILITY

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28
Q

what are the 5 major types of urinary stones

A 
Calcium Phosphate
Calcium Oxalate
Struvite
Uric Acid (radiolucent)
Cystine
*all radiopaque except uric acid with Ca being most common
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29
Q

What might labs reveal in urinary stone disease and what are presenting sx in a patient with stones

A

hematuria

PAIN, severe, pt moving around/unable to sit

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30
Q

Define impotence and what is ED usually due to

A

impotence: inability to maintain erection sufficient for sexual intercourse
* most ED is organic not psychogenic etiology

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31
Q

Loss of libido may indicate

A

androgen deficiency

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32
Q

What are the various etiologies of ED

A

neurogenic, psychogenic, ARTERIAL/VENOUS
*important to determine if nocturnal or early morning erection are occurring (STAMP test), if not, problem is probably organic

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33
Q

What information should be obtained in a pt with ED

A
  • If pt is on medications (esp antihypertensive Beta blockers or diuretics) that can be cause of ED
  • find out if nocturnal or morning erections are occurring
  • hyperlipidemia, HTN, DM, renal failure, neurologic dz, thyroid and adrenal disorders, hx trauma/surgery to pelvic area
34
Q

What clinical hx is important to obtain from pt with ED?

A 
if the pt has:
Hyperlipidemia
HTN
DM
Renal Failure
Neuro dz
Thyroid/adrenal disorders
Hx trauma or surgery to pelvic area
35
Q

On PE, what should be assessed in pt presenting with ED

A 
secondary sex characteristics**
Neurologic, vascular function
Genitalia - scarring?
Scrotal Content (Orchiectomy?)
*PROSTATE EXAM is essential in work-up
36
Q

What are some dx studies to order in pt with ED?

A 
CBC
UA
Glu (DM)
Lipids (hyperlipidemia)
Testosterone (androgen def, libido)
Prolactin (pituitary adenoma)
*if testosterone, FSH, LH or prolactin are abn then REFER to ENDOCRINOLOGIST
37
Q

What are tx options for ED

A

vascular reconstruction
prostheses
medical and vacuum constriction devices
meds

38
Q

What does ED med tx consist of

A

Testosterone injection (200 mg IM q 3wk)
Prostaglandin injections into penis
Prostaglandin urethral suppository
Viagra (sildanefil), Cialis, Levitra

39
Q

What is the risk with Viagra like medications and nitrates

A

can be fatal

is this bc reflex tachycardia?

40
Q

What is the prognosis for men with ED

A

depending on extent of dz, ORGANIC ED is generally TREATABLE

41
Q

What percent of married couples are affected by infertility and what warrants clinical evaluation?

A

15-20% of couples

  • clinical eval indicated after 6 mth unprotected intercourse w/o successful conception
  • review eval in 3 mth bc spermatogenesis takes 74 days
42
Q

how long does spermatogenesis take (thus when should infertility evaluations be reviewed)

A

spermatogenesis is a 74 d process

THUS review couples infertility 3 mo post initial eval

43
Q

What should be included in the hx in a male troubled with infertility

A
  • prior insults - torsion, trauma, cryptorchism
  • Infection - MUMPS*, epididymitis, orchitis
  • environmental factors - heat, radiation, chemo
  • meds - anabolic steroids, cimetidine, spironolactone, phenytoin, sulfasalazine, nitrofurantoin
  • marijuana, ETOH
  • sexual habits, frequency, timing, lubricant use
  • libido loss, HA, visual disturbances ie bitemporal hemianopsia (may indicate pituitary tumor)
44
Q

libido loss, HA, bitemporal hemianopsia indicate…

A

potential pituitary tumor

45
Q

What might past med or surgical hx reveal in a male with infertility

A

thyroid or liver disease
DM
Pelivc or retroperitoneal surgery
Hernia repair

46
Q

What do we need to look for on PE in a male presenting with infertility

A

secondary sex characteristics (lack may suggest hypogonadism)

  • examine scrotal contents (testicle is normally 4.5x2.5 cm)
  • palpate vas deferens, epididymis, prostates
47
Q

labs to order for M infertility

A

SEMEN ANALYSIS after at least 72 hr abstinence
*analyze semen w/in 1 hr collection
*normal volume should be 1.5-5 mL
Normal: at least 50-60% motile cells and >60% normal morphology
*endocrine eval is low sperm count or suspicious hx
*FSH, LH, Testosterone, serum prolactin

48
Q

What might a scrotal ultrasound reveal in a male with infertility

A

varicocele

49
Q

how do you treat a M with infertility

A
  • educate on timing and technique
  • if hypogonadrotopic hypogonadism: treat w/ hcG
  • If Retrograde Ejaculation: Imipramine 25 mg TID
  • If varicocele or ductal obstruction: surgery
50
Q

what should you be aware of regarding testicular torsion

A
  • any age but usually age 10-20 yo

* results from fixation bw enveloping tunica vaginalis and posterior scrotal wall –> shuts off blood t

51
Q

Testicular Torsion usually involves hx of…

A

strenuous physical activity (but some happen when pt is asleep)

52
Q

What actually causes the torsion in testicular torsion?

A

Unilateral contraction of the cremaster muscle

53
Q

sx in pt with testicular torsion?

A

sudden onset SEVERE PAIN (lower abdomen, groin or testis) *pain can be constant or intermittent

54
Q

PE findings in a patient with testicular torsion may reveal

A

sudden onset severe pain

  • Palapation of cord may reveal twist or kink
  • cord may be shortened w/epididymis lateral or anterior (normally posterior/superior/lateral)
55
Q

What study must you do in pt suspected with testicular torsion

A

radionuclide study or DOPPLER ULTRASOUND bc need to see how much blood supply is cut off
*but no clinical or dx parameters to judge degree or duration of testicular ischemia

56
Q

testicular pain is considered…

A

torsion till proven otherwise!

If torsion r/o –> ddx: epididymitis, varicocele, hydrocele

57
Q

how do you treat testicular torsion

A

it is a SURGICAL EMERGENCY and demands IMMEDIATE referral for scrotal exploration

58
Q

what is the prognosis for pt with testicular torsion?

A

depends on amt of ischemia

*early intervention = good outcome; delayed = incrementally morbid

59
Q

how frequently do varicoceles occur in men and what are varicoceles associated with

A

15% adult males have varicocele

  • important when associated with infertility
  • there are no genetic or environmental risk factor for varicoceles
60
Q

What are Clinical findings in a Male pt who has a varicocele

A

Abnormal scrotal exam
*varicocele may not show if pt supine; have pt valsalva or stand (veins of pampiniform plexus dilate, feel like bag of worms)

61
Q

In clinical exam, what MUST be determined in pt with varicocele

A

whether or not the varicocele reduces when the pt is supine

62
Q

Diagnostics for M pt with varicocele include

A
  • routine lab studies are not indicated
  • semen analysis maybe if infertility and varicocele
  • if varicocele DOES NOT REDUCE, then the gold standard is VENOGRAPHY
63
Q

If there is no reduction in varicocele when the pt patient lies supine, what should you do

A

gold standard: VENOGRAPHY to investigate venous anatomy

64
Q

ddx for varicocele and why is this difficult

A

varicocele, inguinal hernia (often difficult to distinguish bw these two)

65
Q

how do you treat a varicocele

A

surgery

or watch and wait + scrotal support

66
Q

what is the usual prognosis for pt with a varicocele

A

5-10% surgically repaired varicoceles are recurrent

*Surgical risks: hydrocele and damage to surrounding structure

67
Q

How do you differentiate bw a direct and indirect inguinal hernia

A

Direct: protrudes through Hesselbach’s triangle (through abdominal wall)
*boundaries: inguinal ligament, inferior epigastric vessels, lateral border of rectus abdominis m

Indirect: comes down inguinal canal and occurs lateral to inferior epigastric vessels (more common in men bc descent of testes)

68
Q

Indirect vs direct hernias: which tend to become incarcerated

A

INDIRECT often become incarcerated

*direct rarely incarcerate

69
Q

Ways to remember direct/indirect hernia

A

Direct goes DIRECTLY through wall/triangle

INdirect: down INguINal canal, lateral to INferior epigastric vessels more common IN meN

70
Q

What would you find clinically on a Male with a hernia

A

majority asymptomatic and detected inadvertently on PE or by pt

71
Q

if the hernia is incarcerated, pain…

A

may develop suddenly

*incarcerated = won’t be able to flatten the bulge bc intestine is trapped

72
Q

if the hernia is strangulated, the patient may become

A

TOXIC
*strangulated = intestine is so tightly trapped that it loses blood supply and dies.. can block digestion resulting in a Toxic pt

73
Q

Pt with incarcerated hernia would describe it as…? And what is their pain like

A

hx of hernia for extended period but can’t return hernia/bulge to normal position (won’t flatten)

*acute incarcerations = PAINFUL, pt may have N/V

74
Q

Incarcerated hernias are a leading cause of what? they are second to which condition

A

Incarcerated hernias are 2nd most common cause of BOWEL OBSTRUCTION
*second to POSTOP adhesions

75
Q

what PE findings are indicative of pt with a hernia

A 
abnormal swelling (consistency of swelling varies depending on contents)
*potential tachycardia and mild temp
76
Q

What might come of an undetected incarcerated or strangulated hernia

A

abscess, obstruction, perforation, peritonitis and septic shock

77
Q

What are diagnostics for a hernia?

A
  • CBC: elevated WBC with left shift (^neutrophil)
  • electrolyte abn and ^BUN: hydration & toxic state
  • acute abdominal series (AAS) should be obtained to r/o free air and obstruction
  • barium enema may be useful
78
Q

Ddx for hernias

A

could be confused with lymph nodes (but different locations!)

  • hydrocele could have similar presenting s/sx, but hydrocele = non tender and transilluminates
  • testicular torsion: may be confused with acute incarcerated hernia
79
Q

how do you treat a hernia

A

If hx indicates recent onset incarceration: reduce it

If questionable duration of incarceration: do NOT reduce it…. dead bowel should NOT be re-introduced into the abdomen

Hernias that are non-reducable or strangulated need SURGERY

Hydration and antibiotics pre-op

80
Q

What is the general prognosis for a pt with a hernia

A

good if emergent surgery

Clinical Medicine II (8 decks)

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