Men's Health - Urology

Question 1

What is phimosis?

Answer 1

Prepuce (foreskin) cannot be fully retracted in adults.

1% incidence in non-circumcised individuals.

Question 2

What are the consequences of phimosis?

Answer 2

Poor hygiene - increased STDs

Pain on intercourse, splitting / bleeding

Balanitis (inflamed glans)

Posthitis (inflamed foreskin / prepuce)

Balanitis Xerotica Obliterans (scar tissue around the foreskin)

Urinary retention

Penile cancer

Question 3

What is paraphiosis?

Answer 3

The painful constriction of the glans penis by the retracted prepuce proximal to the corona.

Question 4

What are the commonest causes of paraphimosis?

Answer 4

Phimosis

Catheterisation (esp. elderly)

Penile cancer

Question 5

What is the difference between phimosis and paraphimosis?

Answer 5

Phimosis:

• In adulthood may be associated with other pathologies
• Beware the elderly man with phimosis and balanitis
• Circumcision is probably the best treatment

Paraphimosis:
-Needs reduction:
Usually achieved manually
Occasionally dorsal slit may be necessary

Question 6

Decide the risk factors and incidence of penile cancer

Answer 6

Around 350 new cases per year.
20%<50yrs old

Risk factors:
Phimosis - hygiene / smegma
HPV 16 and 18

Untreated, most de in under 2 years and almost all in under 5 years.

Question 7

Why would people get circumcised?

Answer 7

Paediatric:
Religious
Pecurrentl balanitis / UTIs

Adults:
Recurrent balanitis 
Phimosis
Recurrent paraphimosis
Balanitis erotica obliterans
Penile cancer

Question 8

What are causes of acute scrotal pain?

Answer 8

Testicular torsion

Epidymitis / orchitis / Epididymo-orchitis:

• UTI
• STI
• Mumps

Torsion of hydatid of Morgagni

Trauma

Ureteric calculi (rarely)

Question 9

Describe a typical history and examination of testicular torsion

Answer 9

Usually younger patient (under 30)

SUDDEN onset e.g. woke from sleep

Unilateral pain: may be nauseated / vomit often no LUTS

Testis is very tender

Lying high in scrotum with horizontal lie

If suspect torsion - emergency scrotal exploration

Question 10

Describe a typical history of a patient with epididymo-orchitis

Answer 10

20-40/50 (especially chlamydia)
40/50+ (especially E. Coli)

Gradual onset

Usually unilateral

Often recent history of:
UTI
Unprotected intercourse
Catheter / Urethral instrumentation 
Check for mumps history

Question 11

Describe a typical examination of a patient with epididymo-orchitis

Answer 11

May be pyrexial; can be septic

Scrotum erythmatous

Testis / epididymis enlarged, tender

Fluctuate areas may represent abscess

May have reactive hydrocoele

rarely - necrotic area of scrotal skin (Fournier’s Gangrene) - 50% mortality.

Question 12

What are the typical investigations and treatments of epididymo-orchitis?

Answer 12

Bloods - FBC, U&E, Cultures of septic

Urine - MSU for MC&S

Radiology - Scrotal USS if suspect abscess

Treatment:
Epididymo-orchitis = antibiotics

Abscess = Surgical drainage and antibiotics

Fournier’s gangrene = Emergency debridement and antibiotics

Question 13

What key questions do you ask when they present with / you examine a scrotal lump

Answer 13

Painful?
How quickly has appeared?

Can I get above it? - no = hernia
Is it in the body of the testes? - yes = testicular tumour
Is it separate to the testes?
Does it fluctuate / transilluminate?

Question 14

DIfferential diagnosis of painless scrotal lump

Answer 14

Testis tumour
Epididymal cyst
Hydrocele
Reducible inguino-coral hernia

Painless and also aching at the end of the day:
Varicocele

Question 15

DIfferential diagnosis of acute presentation of painful an tender scrotal lump

Answer 15

Epididymitis
Epididymo orchitis
Strangulated inguinoscrotal hernia (emergency)

Question 16

Describe the typical history of testicular tumour

Answer 16

Usually painless

Germ cell tumours (seminoma / teratoma) usually in men aged <45yrs

Risk = history of undescended testicles

Older men (could be lymphoma)

On examination: Body of testis is abnormal; can ‘get above’

Refer via 2 week wait to urology who will:
Arrange urgent USS of scrotum
Check testis tumour markers

Question 17

Describe the typical history and examination of a hydrocoele

Answer 17

Slow or sudden onset

Uni/bilateral scrotal swelling

Imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis.

On examination:
Testis not palpable separately
Can usually ‘get above’
Transilluinates

Question 18

Describe a typical history and examination of epididymal cyst

Answer 18

Usually painless

On examination:
Separates from testis
Can ‘get above’ mass
Transilluminates

Question 19

Describe the typical history and examination of a varicocele

Answer 19

Dull ache at the end of the day

Lt>Rt

May be associated with reduced fertility

Examination:
Bag of worms
NOT tender
Maybe a palpable abdominal / renal mass

Question 20

How do you treat a testicular tumour?

Answer 20

Inguinal orchoidectomy

Inguianal to reflect the lymph node drainage and stop accidental spread

Question 21

How do you treat a varicocele?

Answer 21

Reassure

Radiological embolisation
-Symptomatic
Infertility
If present in adolescent and growth of testis affected

Question 22

What is urinary retention?

Answer 22

Inability to pass urine, rather than the inability to make urine.

Common in males and rare in females.

Question 23

What are some causes of urinary retention?

Answer 23

Prostatic enlargement - BPH, cancer

Phimosis, urethral stricture, meatal stenosis

Constipation

UTI

Drugs -anticholinergics

Over-distention - too much fluids at party

Following surgery

Neurological

Question 24

What are the different types of urinary retention?

Answer 24

Acute

Chronic

Acute on chronic

Question 25

What is acute urinary retention and how do you treat it?

Answer 25

Painful
Pain relieved by drainage (catheter)
Residual volume <1000ml
No kidney insult

Trial without catheter after addressing exacerbating factor os usually successful

Question 26

What is chronic urinary retention and how do you treat it?

Answer 26

Painful / less painful
-May just notice abdominal swelling
-Residual volume >300ml
May have kidney insult

Treat by teaching them to self catheterise

Question 27

What is acute on chronic urinary retention and how do you treat it?

Answer 27

Painful

• Residual volume >1000ml
• Usually have kidney insult

Trial without catheter (not usually successful)

Long-term catheter or surgical intervention

Question 28

If an older man presents with nocturnal enuresis (bed wetting) what is wrong?

Answer 28

They have chronic retention with overflow incontinence until proven otherwise

Question 29

What do you have to determine from the history of LUTS?

Answer 29

Voiding or Storage

Voiding:
Hesitancy
Poor flow
Post micturition dribbling

Storage:
Frequency
Urgency
Nocturia

Question 30

Other than the prostate, what other things could be causing storage LUTS?

Answer 30

Irritating e.g. bladder infection / inflammation, bladder stone, bladder cancer

Overactive bladder -idiopathic or neuropathic (CVA, Parkinson’s, MS)

Low compliance of bladder (scarred) e.g. TB / Schistosomiasis / pelvic radiotherapy

Polyuria (making too much urine)

• Global e.g. uncontrolled diabetes
• Noctural e.g. venous stasis, sleep apnoea

Question 31

What could cause LUT voiding symptoms?

Answer 31

Bladder outflow obstruction:

Physical:
Urethra (phimosis, stricture)
Prostate (benign, malignant, bladder neck)
Dynamic:
Prostate
Bladder neck 
Neurological:
Lack of coordination between bladder and urunary sphincter (UMNL)

Reduced contractility:

Physical
Neurological (LMNL)

Question 32

What does spraying of urine suggest?

Answer 32

A stricture (fibrous band of scar tissue)

Question 33

What do you check for in examination and investigations?

Answer 33

DRE - bladder palpable? Neurological?

Dipstick - UTI, blood

Consider PSA -counsel before requesting, It is not a surrogate for DRE, If UTI, treat first and if palpably benign prostate, wait 4-6 weeks

Question 34

What lifestyle things can you do to minimise LUT symptoms?

Answer 34

Reduce caffeine

Avoid fizzy drinks

No more than 2.5L/day

Question 35

How do Alpha blockers work?

Answer 35

Act by relaxing smooth muscle within the prostate and the bladder neck -Rapid symptom release

E.g. Tamsulosin

Question 36

How do 5a-Reductase Inhibitors work?

Answer 36

Act by ‘shrinking’ the prostate by means of androgen deprivation

Slower symptom relief than alpha blockers
Slows progression
Reduces the risk of retention

E.g. Finasteride, Dutasteride

Question 37

What are the standard indications for surgery of LUTS? What surgery is normally done?

Answer 37

Indications:
Failed lifestyle and medical management
Urinary retention needing intervention

Standard:
Transurethral resection of prostate (TURP) - monopolar/ laser/ bipolar