Men's Health - Urology Flashcards
What is phimosis?
Prepuce (foreskin) cannot be fully retracted in adults.
1% incidence in non-circumcised individuals.
What are the consequences of phimosis?
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
What is paraphiosis?
The painful constriction of the glans penis by the retracted prepuce proximal to the corona.
What are the commonest causes of paraphimosis?
Phimosis
Catheterisation (esp. elderly)
Penile cancer
What is the difference between phimosis and paraphimosis?
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
Decide the risk factors and incidence of penile cancer
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.
Why would people get circumcised?
Paediatric:
Religious
Pecurrentl balanitis / UTIs
Adults: Recurrent balanitis Phimosis Recurrent paraphimosis Balanitis erotica obliterans Penile cancer
What are causes of acute scrotal pain?
Testicular torsion
Epidymitis / orchitis / Epididymo-orchitis:
- UTI
- STI
- Mumps
Torsion of hydatid of Morgagni
Trauma
Ureteric calculi (rarely)
Describe a typical history and examination of testicular torsion
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
Describe a typical history of a patient with epididymo-orchitis
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
Describe a typical examination of a patient with epididymo-orchitis
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.
What are the typical investigations and treatments of epididymo-orchitis?
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
What key questions do you ask when they present with / you examine a scrotal lump
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?
DIfferential diagnosis of painless scrotal lump
Testis tumour
Epididymal cyst
Hydrocele
Reducible inguino-coral hernia
Painless and also aching at the end of the day:
Varicocele
DIfferential diagnosis of acute presentation of painful an tender scrotal lump
Epididymitis
Epididymo orchitis
Strangulated inguinoscrotal hernia (emergency)
Describe the typical history of testicular tumour
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
Describe the typical history and examination of a hydrocoele
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
Describe a typical history and examination of epididymal cyst
Usually painless
On examination:
Separates from testis
Can ‘get above’ mass
Transilluminates
Describe the typical history and examination of a varicocele
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
How do you treat a testicular tumour?
Inguinal orchoidectomy
Inguianal to reflect the lymph node drainage and stop accidental spread
How do you treat a varicocele?
Reassure
Radiological embolisation
-Symptomatic
Infertility
If present in adolescent and growth of testis affected
What is urinary retention?
Inability to pass urine, rather than the inability to make urine.
Common in males and rare in females.
What are some causes of urinary retention?
Prostatic enlargement - BPH, cancer
Phimosis, urethral stricture, meatal stenosis
Constipation
UTI
Drugs -anticholinergics
Over-distention - too much fluids at party
Following surgery
Neurological
What are the different types of urinary retention?
Acute
Chronic
Acute on chronic
What is acute urinary retention and how do you treat it?
Painful
Pain relieved by drainage (catheter)
Residual volume <1000ml
No kidney insult
Trial without catheter after addressing exacerbating factor os usually successful
What is chronic urinary retention and how do you treat it?
Painful / less painful
-May just notice abdominal swelling
-Residual volume >300ml
May have kidney insult
Treat by teaching them to self catheterise
What is acute on chronic urinary retention and how do you treat it?
Painful
- Residual volume >1000ml
- Usually have kidney insult
Trial without catheter (not usually successful)
Long-term catheter or surgical intervention
If an older man presents with nocturnal enuresis (bed wetting) what is wrong?
They have chronic retention with overflow incontinence until proven otherwise
What do you have to determine from the history of LUTS?
Voiding or Storage
Voiding:
Hesitancy
Poor flow
Post micturition dribbling
Storage:
Frequency
Urgency
Nocturia
Other than the prostate, what other things could be causing storage LUTS?
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
What could cause LUT voiding symptoms?
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)
What does spraying of urine suggest?
A stricture (fibrous band of scar tissue)
What do you check for in examination and investigations?
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
What lifestyle things can you do to minimise LUT symptoms?
Reduce caffeine
Avoid fizzy drinks
No more than 2.5L/day
How do Alpha blockers work?
Act by relaxing smooth muscle within the prostate and the bladder neck -Rapid symptom release
E.g. Tamsulosin
How do 5a-Reductase Inhibitors work?
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
What are the standard indications for surgery of LUTS? What surgery is normally done?
Indications:
Failed lifestyle and medical management
Urinary retention needing intervention
Standard:
Transurethral resection of prostate (TURP) - monopolar/ laser/ bipolar
