Male repro - Surgery Flashcards
What is acute epididymitis?
Etiology:
-less than 35: sexually transmitted (chlamydia, gonorrhea), no pyuria;
-older than 35: bladder outlet obstruction (coliform bacterium - e. coli), pyuria
Presentation: unilateral, posterior testicular pain, epididymal edema, pain improved with testicular elevation (Prehn sign), dysuria, frequency (w/ coliform infection)
Dx: NAAT for chlamydia and gonorrhea, urinalysis/culture
Tx: ceftriaxone and doxycycline
What is Fournier Gangrene?
Life threatening necrotizing fasciitis that affects perineal, scrotal, and lower abdominal skin
Presentation: rapid-onset swelling, tenderness, crepitus of affected region, systemic symptoms (eg hypotension, high fever, leukocytosis, acidemia, renal insufficiency, and coagulopathy)
RF: poorly controlled DM and obesity
Dx: surgical exploration
Tx: debridement
What is Peyronie disease?
Acquired disorder due to repetitive blunt trauma to penis during sex w/ subsequent aberrant wound healing
Etiology: formation of fibrous plaques (due to transforming growth factor 1 upregulation) in tunica albuginea, which reduces tissue elasticity and expansion during erections
Presentation: penile pain, curvature, dorsal nodules or plaques
Dx: clinical, U/S sometimes necessary
Tx: resolves spontaneously over 1-2 years, NSAIDs for pain (active or aggressive PD), pentoxifylline to reduce fibrosis and/or intralesional injections of collagenase; surgery in refractory cases
What is benign prostatic hyperplasia?
RF: age greater than 50
Causes slow voiding, postvoid dribbling, hesitancy, urgency, or nocturia;
Affected part: central portion of prostate (transitional zone)
Exam: symmetrically enlarged and smooth prostate, can have elevated PSA
Complications: bladder outlet obstruction w/ acute urinary retention
Mgmt of acute retention: bladder decompression w/ urethral or suprapubic catheterization
Definitive tx:
-alpha blockers (terazosin, tamsulosin) - provide rapid relief of sxs by relaxing bladder neck and prostatic smooth muscle (1st line)
-5alpha reductase inhibitors (finasteride)- can be used in additioin to alpha blockers for pts w/ persistent sxs or as an alt tx for those who do not tolerate alpha blockers (hypotension); they act by reducing prostate size and have a much slower onset of action
-possible surgery
What is prostate adenocarcinoma?
RF: age greater than 40 (age is greatest risk factor), African American, family history
Affected part: usually peripheral zone of prostate but can be anywhere
Presentation: systemic symptoms (fatigue, weight loss), bone pain (due to metastases) and/or lower urinary tract symptoms
Exam: asymmetrically enlarged, nodular and firm prostate, markedly elevated PSA
Dx: transrectal biopsy
What is acute bacterial prostatitis?
Etiology: colonic pathogens (e. coli -75%, proteus) that contaminate urethra and enter prostate via intraprostatic urinary reflux
Presentation: fever, dysuria, leukocytosis, tender, swollen prostate, difficulty voiding or acute urinary retention (w. renal insufficiency), severe tenderness on prostate exam
Chronic - Sxs: recurrent UTI that transiently improves w/ short courses of abx, pain w/ ejaculation; prostate exam is often normal; RF: DM, smoking, urinary tract procedure
Tx: Suprapubic catheter is required for decompression; prolonged treatment (6 weeks) with FQ (levofloxacin) or TMP-SMX, both agents have excellent coverage against enteric pathogens and achieve high prostatic tissue levels
What is testicular cancer?
Epidemiology: age 15-35
RF: family history, cryptorchidism
Types: Germ cell tumors (95%) - seminomatous or nonseminomatous (embryonal carcinoma, yolk sac, choriocarcinoma, teratoma, mixed);
sex cord-stromal tumors - sertoli cell, leydig cell
Presentation: unilateral, painless testicular nodule or swelling; dull lower abdominal ache, metastatic symptoms (eg dyspnea, neck mass, low back pain)
Metastatic disease - retroperitoneal lymphadenopathy, lumbar back pain due to compression from lymph nodes, lung mets (nodules) leading to cough or dyspnea
Dx: exam - firm, ovoid mass or unilateral swelling;
scrotal ultrasound (solid, hypoechoic lesions (seminoma) or lesions with cystic areas + calcifications (nonseminomatous)),
tumor markers (AFP, bHCG), staging imaging (CT scan, CXR)
Radical orchiectomy confirms the dx histologically and provides definitive tx
Chemo
[Scrotal orchiectomy, transscrotal biopsy, and FNA are assoc. w/ worsened outcomes and increased chance of recurrence b/c incision through scrotal wall promotes spread of tumor through local lymphatic system.]
What is testicular torsion?
Epi: most common in adolescents
Due to insufficient fixation of the testis to the tunica vaginalis, which can lead to testicular hypermobility, twisting of the spermatic cord, ischemia, and necrosis
Presentation: sudden severe testicular, inguinal, abdominal pain often after physical activity or mild testicular trauma; nausea/vomiting, horizontal testicular lie w/ elevated testicle; absent cremasteric reflex, swollen, erythematous scrotum; boys awaken at night due to pain, some reports of prior episodes that resolved w/o intervention (intermittent torsion)
Pain does not resolve with elevation of the testicle
Imaging: no blood flow on doppler ultrasound
U/S: reactive hydrocele; heterogeneous echotexture indicates testicular necrosis
Mgmt: surgical detorsion and fixation w/ exploration of the contralateral side; manual detorsion (if immediate surgery is not available)
What is a varicocele?
Tortuous dilation of pampiniform plexus surrounding spermatic cord and testis
Presentation: soft scrotal mass (“bag of worms”): decreases in supine position, increases w/ standing/valsalva maneuvers; subfertilty, testicular atrophy
U/S findings: retrograde venous flow, tortuous, anechoic tubules adjacent to testes, dilation of pampiniform plexus veins
Assoc. w/ increased risk for infertility (due to increased scrotal temp), for pts with testicular atrophy or changes in semen analysis, surgical venous ligation can improve fertility
Tx: gonadal vein ligation (boys and young men w/ testicular atrophy); scrotal support and NSAIDs (older men who do not desire additional children)
What is a nonseminomatous/mixed germ cell tumor?
Mediastinal mass, common in young males
Locally invasive
Labs: beta hcg and AFP are elevated, also diagnostic
Dx: confirmed with biopsy
What is the differential diagnosis for an anterior mediastinal mass?
Thymoma
Teratoma (and other germ cell tumors)
Thyroid neoplasm
Terrible lymphoma
Complications of varicocele.
Assoc. w/ increased risk for infertility and testicular atrophy, which may be due to slightly increased scrotal temperature.
Tx: surgical venous ligation can improve fertility
Cryptorchidism.
An undescended testis
Spontaneous descent is rare after 6mo, and orchiopexy is optimally performed before 1y old to avoid complications.
Uncorrected cryptorchidism: increases risk of infertility, testicular torsion, and testicular malignancy
Risk of testicular germ cell tumor remains elevated post-orchiopexy compared to general population
Lower urinary tract symptoms
Urinary frequency, nocturia, hesitancy
Pts should be evaluated w/ a U/A to evaluate for hematuria and infection.
PSA should also be obtained in symptomatic pts to assess risk for prostate cancer unless predicted life expectancy is less than 10y
What is IV urography (IV pyelography)?
Used to evalute ureteral obstrution (eg kidney stones) or anatomic variants (horseshoe kidney)
Can also be used in conjuction w/ other modalities in the evaluation of renal cell or transitional cell carcinoma
