Mens Health - Urology Flashcards
What is phimosis
•Prepuce cannot be fully retracted in adult •Incidence – 1% adult non-circumcised population
Physiological phimosis:
‘Normal’ non-retractability up to adolescence – 50% at 1 year
– 10% at 3 years
– 1% at 17 years
What are the sequel ae of phimosis
- Poor hygeine,STDs
- Pain on intercourse, splitting / bleeding
- Balanitis (inflamed glans)
- Posthitis (inflamed foreskin/prepuce)
- Balanitis Xerotica Obliterans (BXO)
- Paraphimosis
- Urinary retention
- Penile cancer
What is paraphimosis
The painful constriction of the glans penis by the retracted prepuce proximal to the corona Swollen and tender Commonest Causes Phimosis Catheterisation (esp. Elderly) Penile cancer
What are the treatments for phimosis and paraphimosis
• Phimosis
– In adulthood may be associated with other pathologies
– Beware the elderly man with a phimosis and‘balanitis’ – Circumcision is probably the best treatment
• Paraphimosis
– Needs reduction
• This is usually achieved manually
• Occasionally dorsal slit may be necessary
Describe penile cancer
People lump, red patch thats not going away - red flag
• c.350 new cases/yr/UK
• 20%<50yrsold
• Risk factors
– Phimosis – hygiene - smegma
– HPV 16 & 18
Malignant
• Untreated, most †< 2yrs, almost all < 5yrs
• Important not to miss – GP may only see one in their lifetime
What are the key indications for circumcision
• Paediatric – Religious – Recurrentbalanitis/UTIs • Adult – Recurrentbalanitis – Phimosis – Recurrentparaphimosis – Balanitis xerotica obliterans – Penile Cancer
What a re teh causes of acute scrotal pain
• Testicular torsion
• Epididymitis / Orchitis / Epididymo-orchitis
– Urinary tract infection (UTI)
– Sexually transmitted infection (STI)
– Mumps Both testicular swollen and tender. Mumps can cause sterility
• Torsion of hydatid of Morgagni - Embryologyical Remnant on top of testicle can twist in young boys.
• Trauma
• Ureteric calculi (rarely) - Small stone from kidney down ureter to vuj, gets stuck. Referred pain to testicle. Pain but no tenderness. Get a dipstick.
Describe teh history and examination of testicular torsion
Testicular Torsion - History
• Usually younger patient (<30 y)
• SUDDEN onset e.g. woke from sleep
• Unilateral pain; may be nauseated/vomit; often no LUTS
Testicular Torsion - Examination
• Testis is very tender
• Lying high in scrotum with horizontal lie
If you suspect testicular torsion, the patient needs emergency scrotal exploration Do not waste time getting investigations such as ultrasound
What is epididymo-orchitis
• Age – 20-40/50 – STI (esp Chlamydia) – 40/50+ - UTI (esp. E. Coli) • Gradual onset • Usually unilateral • Often recent history of – UTI – Unprotected intercourse – Catheter/urethral instrumentation – Check for mumps history
Describe teh examination findings for epididymis-orchitis
• May be pyrexial; can be septic • Scrotum erythematous • Testis/epididymis enlarged, tender • Fluctuant areas may represent abscess • May have reactive hydrocoele • Rarely – necrotic area of scrotal skin (Fournier’s Gangrene) – Fournier’s • High mortality rate (approx 50%) Common in diabetics. A drug that blogs reabsorption og glucose in pct - increased risk of Fournier bc gycosuris
Describe teh investigation ad treatment fo epididymo-orchitis
Epididymo-orchitis - Investigation • Bloods – FBC / U&E’s / Cultures if septic • Urine - MSU for MC&S • Radiology – Scrotal USS if suspect abscess or not settling
Treatment
•Epididymo-orchitis – Antibiotics
•Abscess – Surgical drainage and antibiotics
•Fournier’s gangrene – Emergency debridement & antibiotics
Describe the history and examination for scrotal lumps
History •Is it painful? •How quickly has it appeared? Examination •Can I get ‘above it’? – If not, it is likely to be a hernia •Is it in the body of the testis? – If yes, this could be a testicular tumour! •Is it separate to the testis? •Does it fluctuate and transilluminate?
Describe the presentation for different testicular lumps
Opportunistic presentations •Painless scrotal lump – Not tender – Testis tumour – Epididymal cyst – Hydrocele – Reducible inguino-scrotal hernia •Painless/Aching at end of day – Not tender – Varicocele Acute presentation with scrotal lump •Painful – Tender – Epididymitis – Epididymo-orchitis – Strangulated inguino-scrotal hernia - emergency
Desribe the history and examination of testicular tumours
History
•Usually painless
•Germ cell tumours (Seminoma/Teratoma) usually in men aged <45 yrs
– Risk – history of undescended testis. •Older men (Could be lymphoma)
On examination
•Body of testis is abnormal; can ‘get above’ Refer via 2 week wait to Urology
•Urology will
– Arrange urgent ultrasound of scrotum to confirm diagnosis
– Check testis tumour markers (aFP, hCG, LDH)
•The average GP may only see two in their lifetime!
Describe hydrocoele in an adult history and examination
• Slow/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’ •Transilluminates
Describe epididymis cyst
•Usually painless
On examination
•Separate from testis •Can‘get above’ mass •Transilluminates
Descrbe hx And ex of varicocoele
Varicocele • Dull ache, at end of day • Lt > Rt • May be associated with reduced fertility (esp.if bilateral) On examination • “Bag of worms” above testis • NOT tender • ? Palpable abdominal/renal mass
Describe the treatment for various testicular conditions
• Testicular tumour
– Inguinal orchidectomy
• Epididymal cyst
– Reassure; Excise if large
• Adult hydrocele
– If normal testis on ultrasound
• Reassure; Surgical removal if large/symptomatic
• Varicocele – Reassure – Radiological embolisation • Symptomatic • Infertility (slow motility of sperm) •If present in adolescent and growth of testis affected
• Inguino-scrotal hernia
– Surgery (emergency if strangulated)
What is urinary retention
- Inability to pass urine, rather than inability to make urine
- Common in males, rare in females
What are the causes of urinary retention in men
• Prostatic enlargement – Benign prostatic hyperplasia (BPH) – Cancer • Phimosis/urethral stricture/meatal stenosis • Constipation • Urinary tract infection • Drugs – Anticholinergic actions • Over-distension – e.g. Too much fluids at party • Following surgery • Neurological Meatal stenosis
Desvbe thr types of urinary retention
• Acute – Painful • Pain relieved by drainage (catheter) • Residual volume <1000 ml • No kidney insult
• Chronic – Painless/less painful • May just notice abdominal swelling • Residual volume >300 ml (Largest 5L in my experience!) • May have kidney insult
- Acute on chronic – Painful
- Residual volume >1000 ml
- Usually have kidney insult
What are the treatment strategies for urinary retention
Ss
What is the case with older men with enuresis
Have chronic retention with overflow incontinece until proven otherwise
Describe the history of lots
LUTS are not disease specific!
– Do not use the term ‘prostatism’ for male LUTS – it implies that urinary
symptoms in men are always related to the prostate.
• From the history, determine if LUTS are predominantly – Voiding (suggestive of bladder outflow obstruction)
• Hesitancy
• Poor flow
• Post micturition dribbling
– Storage
• Frequency
• Urgency • Nocturia
What are causes of luts orther than the prostate
• Irritative
– e.g.Bladderinfection/inflammation,bladderstone,bladdercancer
• Overactive bladder – Idiopathic
– Neuropathic
• e.g.CVA,Parkinson’s,multiplesclerosis
• Low compliance of bladder (Scarred)
– e.g.afterTB/Schistosomiasis/pelvicradiotherapy
• Polyuria (making too much urine) – Global
• e.g.uncontrolleddiabetes – Nocturnal
• e.g. venous stasis, sleep apnoea
What could cause voiding symptoms
• Bladder Outflow Obstruction (BOO) – Physical • Urethra – Phimosis – Stricture • Prostate – Benign – Malignant – Bladder neck – Dynamic • Prostate • Bladder neck – Neurological • Lack of coordination between bladder and urinary sphincter – Upper motor neurone
• Reduced contractility – Physical
– Neurological
• Lower motor neurone lesion
Describe bladder outflow obstruction
More distal - more likely to hav spraying
Spraying of urine suggests a stricture)
Bladder outflow obstruction - Dynamic
•Sympathetic smooth muscular tone (mediated principally by α1 receptors)
Describe the examinationa and investigations for urinary rendition
Examination
• DRE
• Is the bladder palpable?
• Neurological if suggestive history
Investigations • 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
Describe management of BPh
- Reduce caffeine intake
- Avoid fizzy drinks
- No need to drink more than 2.5L day
Descrbe how alpha blockers act for BPh
Alpha blockers
Act by relaxing smooth muscle within the prostate and the bladder neck
Rapid symptom relief
What are 5aris
5ARIs
Act by ‘shrinking’ the prostate by means of androgen deprivation
Slower symptom relief than alpha blocker
Slows progression
Reduces the risk of retention
e.g. Finasteride or Dutasteride
Describe low rate
S
Describe surgery for bph
Surgical
• Indications
– Failed lifestyle and medical management – Urinary retention needing intervention
• Standard
– Transurethral resection of prostate (TURP)
• Monopolar/laser/bipolar
