Penile/ Urethral Disorders

Question 1

• Etiology: E.coli is the most common; pseudomonas, klebsiella, enterobacter
• often clinical dx; ascending > descending; Female> male
• PE: fever, CVAT, +/- N/V, LUTS
• DX: UA with micro, gram stain
• c&s: pyruia, WBC casts, CBC, CT imaging

Answer 1

pyelonephritis

Question 2

what would pylonephritis look like on CT?

Answer 2

dilation
delayed nephrogram
fat stranding
renal abscess
emphysematous pyelo

Question 3

treatment of pylonephritis?

Answer 3

Mild

• 14d course FQ
• if abx nomogram with > 10% FQ resistance, add 1x dose of long acting abx such as IV/IM ceftriaxone

Severe

• admission
• pan culture
• extended spectrum abx (ceftriazone, FQ,)
• amp/gent, zosyn, penem if high risk MDR
• once afebrile x 24-48h, transition to PO

Question 4

• Etio: E.coli most common
• chronic bacterial prostatitis= most common for recurrent UTI in males
• tx: uncomplicated: 3-5d course; complicated 7-10 day course avoid nitrofurantoin 2/t poor tissue penetration outside of bladder

Answer 4

Cystitis

Question 5

• most common presentation of STI in sexually active males
• non-infectious

infectious (GU or NGU)

• Neisseria gonorrhea (think purulent discharge)
• chlamydia trachomatis- most common NGU organism (usually more dysruia)
• trichomonas vaginalis- flagellated protozoan (50% asymptomic)
• mycoplasma/ ureaplasma
• HSV, adenovirus (ulcers)
• bacterial

can lead to infertility, pain, PID, strictures

Answer 5

Urethritis

Question 6

Diagnosis of urethritis?

Answer 6

Urethral swab gram stain

• > 2WBC/ hpf on urethral swab gram stain
• qtip swab discharge of the first 2cm of urethra

Urine microscopy/PCR

Co-infections are common

• all patients require GC/glamydia testing (NAAT urine)
• trichomonas vaginalis- flagellated protozoan
• mycoplasma/ureaplasma
• HSV 1 (most oral herpes) HSV 2 (most GU herpes)

Question 7

treatment of urethritis?

Answer 7

Gonorrhea/chlamydia- most common

• chlamydia-doxycyline 100mg BID x 7 ds vs azithromycin 1g PO x1
• gonorhhea- ceftriaxone 250mg IM x1
• if 1+ always treat for both

Trichomonas vaginalis- flagellated protozoan

• metronidazole 2gm PO x 1 or 500mg PO bid x7 days

Mycoplasma/ureaplasma

• Doxyclycline PO bid x14d vs azithromycin 1g PO 1 vs FQ

HSV1 (most oral herpes) HSV 2 (most GU herpes)

• acyclovir life long flares- suppressive/ recurrent tx

Question 8

• most common GU CA, 4th leading cause of death in males
• presentation: painless intermittent gross hematuria vs asymptomatic microscopic hematuria ( >3RBC/ hpf on 1 UA)
• +/- irritative voiding sx: urinary frequency/ urgency, dysuria
• pain from obstruction
• renal insufficiency from upper tract obstruction
• weight loss, fatigue, anorexia FTT occurs late in disease state

Answer 8

Bladder CA

Question 9

Urothelial CA risk factors

Answer 9

• Age
• male sex
• tobacco history
• degree of microhematuria
• persistance of microhematuria
• history of gross hematuria

Question 10

diagnostics for bladder carcinoma

Answer 10

• Upper tract imaging (RBUS, CTU, MRU)
• cystoscopy
• culture
• cytology

Question 11

• intercourse or masturbation injury
• describes the traumatic rupture of the tunica albuginea of an erect penis, when the engorged penile are forced to pop under the pressure of a blunt sexual trauma
• Pain, pop and rapid detumescence
• bruising “eggplant deformity”
• no blood at the meatus
• voided clear urine w/o difficulty

Answer 11

Penile fracture

Question 12

Penile Fracture (trauma) TX

Answer 12

• Urgent/emergent urology referral- most often present through ED
• observation (prolonged pain, epic swelling and bruising, significant incidence ED, curvature- 20-30%
• Surgery (emergent exploration in some cases, within 24-48 hours is best)

Question 13

• Trauma
• sx: dysuria/urgency, retention/pain, edema
• exam: blood at the meatus, +/- penile pain
• do not catherterize pt
• urgent Urology referral –> obtain RUG

Answer 13

Uretheral Injury

Question 14

• Persistent penile erection that continues hours beyond or is unrelated to, sexual stimulation & lasts > 4h
• urologic emergency–> emergent urology consult
• types: Ischemic (low flow, stuttering, nonischemic (high flow)

Answer 14

Priapism

Question 15

• Persistent erection w/ little or no cavernous blood flow
• abnormal cavernous blood gases (hypoxic, hypercarbic, and acidotic)
• the corpora cavernosa are rigid and tender. this type of priapism is an emergency
• etiologies: sickle cell, leukemia, medication (PDE5, testosterone, trazodone, cocaine, anti-psychotics)
• leads to fibrosis and ED
• longer time to detumescence–> increased risk of ED
• tx: corporal aspiration & irrigation, phenylephrine, shunt, if sickle cell- also hydrateion, O2, +/- pRBC

Answer 15

Ischemic (low flow) priapism

Question 16

• Recurrent form of ischemic priapism in which unwanted painful erection occur repeatedly with intervening periods of detumescence
• etio: most common= sickle cell disease with 75%-70 of these patients presenting before 20
• tx: aimed at prevention (low dose PDE5- I will reset circuit, hydroxyura, prevention of dehydation, infection in sickle cell patients

Answer 16

Stuttering priapism

Question 17

• Less common type
• nonsexual, persistent erection caused by unregulated cavernous arterial inflow
• cavernous blood gases are not hypoxic or acidotic (partially erect, non-tender)
• etio=antecedent trauma= most common. Also SCl or needle or injury to cavernosal artery
• does not require emergent treatment as is oxygenated blood and > 60% are self remitting
• TX: arterial embolization

Answer 17

Nonischemic (high flow) priapism

Question 18

• When the foreskin cannot be retracted behind the glans (normal finding in children < 5)
• may be congenital or acquired; acquired is much more common, caused by accumulation of smega beneath the foreskin due to poor hygiene; may also be secondary to BXO or balanoposthitis
• histology: Chronic inflammation, fibrosis (edema, vascular congestion)
• tx: circumcision/ dorsal slit, topical cortiocosteroid, manual stretching

Answer 18

Phimosis

Question 19

• foreskin is stuck in retracted position & unable to be pulled back- penile PAIN
• cause: most often iatrogenic, following urinary tract instrument (catheter )
• treatment: manually reduce, circumcision or dorsal slit

Answer 19

paraphimosis

Question 20

• inflammation of the glans penis
• or inflammation of the glans & foreskin
• DM (most common risk factor) also obesity, hygiene & broad spectrum ABX (leads to candida)
• Etio: Most common in uncircumcised population, candida, lichen sclerosus, contact dermatitis, other derm disorders, STIs fungal

Answer 20

Balanitis, Balanoposthitis

Question 21

signs and symptoms, PE and tx of balanitis?

Answer 21

signs and symptoms

• swelling, redness, blotchy, bleeding, pain, pruritis, odor

PE

• erythema, fissures, scaling, edema, discharge, smegama, phimosis, lesion

TX

• empiric topical corticosteroid, improved hygiene, topical or systemic antifungal
• refractory–> culture and refer to urology for possible circumcision

Question 22

• presents as white patch on the glans or prepuce that envelops or involves the urethral meatus; may be associated with induration (fibrosis) if it is long standing or recurrent balantis refractory to topical tx
• tx: variable response to laser, circumcision, steroids, antifungals, and retinoids (appropriate tx unknown)
• if urethral involvement - cystoscopy to r/o stricture
• bx if atypical or progressive

Answer 22

BXO (lichen sclerosus) balanitis

Question 23

• Penile plaques causing fibrosis & penile curvature
• pain initially +/- small degree/ progressing curvature (active phase)–> painless (letent phase)
• etio: unknown
• urology referral
• NSAIDs, plaque injections, surgery, prosthesis

Answer 23

Peyronie’s disease