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Penile & Urethral DOs Flashcards

- Balanitis & Balanoposthitis - Penile CA - Phimosis & Paraphimosis - Penile Constriction Tourniquet - Hypospadias & Epispadias - Simple Acute Cystitis in Men - Urethritis - Penile Fracture - Urethral Injury - Urethral Stricture

1
Q

What is the Coronal Sulcus?

A

rim of the glans penis

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2
Q

What is Balanitis & Balanoposthitis? How do they differ?

A

Balanitis = Inflammation/Infx of Glans penis
Balanoposthitis = Glans + Foreskin

MCC: poor hygiene in an uncircumcised male -> Candida (MALE YEASTY)

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3
Q

MCC of Balanitis & Balanoposthitis?

A

Poor hygiene in an uncircumcised male -> Candida (MALE YEASTY)

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4
Q

Which dermatologic conditions can cause Balanitis & Balanoposthitis?

A
  • Lichen Sclerosis (chronic progressive inflammation and skin thinning -> SCC risk)
  • Lichen Planus
  • Psoriasis
  • Eczema (irritants, condoms), Allx Rxn

Lichen Sclerosis used to be called “balanitis xerotica obliterans (BXO)”

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5
Q

Balanitis & Balanoposthitis may be the 1st sign of undiagnosed _____

A

DM

Immunocompromised states such as DM are HIGH Risk Factors

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6
Q

Dx?
Pt presents with glans/foreskin -> red, burning, itchy, +/- red papules “Satellite lesions”, +/- cottage cheese like discharge

A

Balanitis or Balanoposthitis

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7
Q

Candida Balanitis Tx

A
  • Twice daily bathing with SALINE SOLUTION (with foreskin retracted)
  • Clotrimazole cream (1% BID x7 days)

Refractory -> Stop Clotrimazole and start Fluconazole PO or Nystatin Cream

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8
Q

What is Lichen Sclerosus?

“balanitis xerotica obliterans (BXO)”

A
  • chronic atrophic dermatitis
  • white atrophic plaques on glans/foreskin that get bigger over time -> turn into a large sclerotic mass w/adhesions, Phimosis, Meatal Stenosis
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9
Q

Lichen Sclerosus Tx:
- Mild?
- Mod/Severe (Phimosis, Meatal Stenosis)?

“balanitis xerotica obliterans (BXO)”

A
  • Mild -> Topical Steroids (Clobetasol) q night
  • MOD/SEVERE -> CIRCUMCISION
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10
Q

SS progression of HSV

A

Prodromal (tingling, burning, itching) -> PAINFUL RED VESICLES/ULCERS -> CRUSTING

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11
Q

Balanitis/Balanoposthitis -> HSV Dx

A

1. PCR of Lesion sample
2. Antibody tests (HSV-1/2, IgM, IgG)

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12
Q

Balanitis/Balanoposthitis -> HSV Tx

A

Acyclovir, Valacyclovir, Famciclovir

dosing differs (initial vs subsequent episodes)

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13
Q

Primary Syphilis ET & SS

A
  • ET: STI Spirochete (Treponema Pallidum)
  • SS: SINGLE CHANCRE -> FIRM, PAINLESS, +/- LAD 2-6wk after exposure
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14
Q

Primary Syphilis Dx
- Screen?
- Confirm?

A
  • SCREEN -> NON-Treponemal Test (RPR, VDRL)
  • CONFIRM -> TREPONEMAL Test (TP-EIA)
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15
Q

Primary Syphilis Tx

A
  • PCN G Benzathine (just 1x)
  • PCN Allx -> Doxy
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16
Q

HPV ___ & ___ = Genital warts

A

6 & 11

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17
Q

HPV “Genital Warts”
- SS?
- WU?

A
  • SS: FLESH-COLORED CAULIFLOWER LESIONS
  • WU: CLINICAL Dx, STI WU (bc high risk), +/- Bx (CA?)
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18
Q

HPV “Genital Warts” #1 Tx

A
  • IMIQUIMOD (ALDARA) CREAM - 3xWk before bed, wash in AM
  • If not better by 16wk -> Derm refer

+/- Cryotherapy, Trichloroacetic acid, Sx excision, Lazer

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19
Q

Circinate Balanitis ET

A
  • REACTIVE ARTHRITIS (REITER SYNDROME)
  • Infx ** (#1 CHLAMYDIA)** -> systemic SS -> Can’t Pee (Urethritis/Balanitis), Can’t See (Conjunctivitis), Can’t Bend at the knee (Arthritis)
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20
Q

Circinate Balanitits: Penile SS

A

PAINLESS, small red SHALLOW ULCERS on glans/foreskin

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21
Q

Circinate Balanitis Tx

A

Tx underlying ET (Chlamydia) +/- Topical Steroids

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22
Q

Complications of Balanitis/Balanoposthitis?

A
  • Scarring
  • Phimosis/Paraphimosis
  • Urethral Stricture
  • SCC
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23
Q

Balanitis/Balanoposthitis Tx if NO identifiable ET?

A
  • Saline solution bath 2xday
  • Empiric Yeasty (Candida Balanitis) Tx -> Clotrimazole 1% BIDx7days (Alt -> Fluconazole PO, Nystatin Cream)
  • if no improvement -> Hydrocortisone 1% BIDx7days
  • IF ALL ELSE FAILS -> Refer derm or urology for poss Bx
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24
Q

1 Risk for Penile Cancer

A

HPV 6, 16, 18

Others: older 60yo, Uncircumcized, HIV, Smoking, UTI, Injury, Urethral stricture, Inflammation

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25
Q

Majority of Penile CA =

26
Q

When to suspect penile CA

A
  • Painless, Palpable lump/ulcer +/- inguinal LAD
  • Presumable Infx/inflammation thats FAILING STEROID/ABX Tx
27
Q

Pt presents with penile painless, palpable lump/ulcer. They have been taking Steroids and ABX for over 1mo for a presumable infection that has not gone away. You should suspect what?

28
Q

Penile CA Dx

A
  • Lesion Bx (incisional or punch)
  • Inguinal lymph node eval -> CT, MRI, CT/PET, or Inguinal US +/- US FNA)
29
Q

Order a ____ for pt with sussy penis CA that also has bone pain, HIGH Ca, HIGH Alk Phosph

30
Q

Tx for EARLY STAGE Penile CA & PeIN (pre-malig lesion)

A

Organ sparing procedures
* Topical (5-FU, Imiquimod)
* Rad
* Mohs Sx
* Laser Ablation
* Partial excision

31
Q

Tx for LATER STAGE Penile CA

A
  • Partial/Total PENECTOMY (Reroute urethra to perineum)

+/- Inguinal lymph node dissection
+/- ADD Chemo/Rad

32
Q

Tx for Physiologic Phimosis

A
  1. REASSURANCE, self-resolve by 16yo
  2. If does not go away with age -> STEROIDS + STRETCH EXERCISES
  3. REFRACTORY -> CIRCUMCISION
33
Q

1 ET for Pathologic Phimosis

A

Lichen Sclerosus (BXO)

Any Trauma, Inflammation, Infx

34
Q

Tx for Pathological Phimosis

A
  • CIRCUMCISION (MC INDICATION FOR ADULT CIRCUMCISION)
  • Preputioplasty (Sx release scar tissue)
  • Preputial Balloon Dilation (widen the ring while saving the prepuce)
35
Q

1 ET for Paraphimosis

A

IATROGENIC Foreskin Manipulation (Urine Cath)

  • Injuries (self, sex, piercings, GU procedures)
  • Partial Phimosis
36
Q

Paraphimosis occurs when the foreskin is stuck behind the ___________

A

Coronal Sulcus

37
Q

Paraphimosis Tx: If NO signs of necrosis?

A

MANUAL REDUCTION
1. Pain control -> dorsal penile block, topical, procedural sedation
2. DECR Swelling -> Granulated sugar, Compression dressing, Manual circumferential compression
3. Manual reduction (pull it back on). If fails -> try puncture technique
4. DO NOT retract foreskin for 1 week

AVOID ICE for pain control bc it vasoconstricts = BAD

38
Q

Paraphimosis Tx: IF Manual Reduction FAILS or Signs of NECROSIS (Blue)

A

DORSAL SLIT PROCEDURE +/- Circumcision later on

cut constricting band and replace it

39
Q

Tx for Penile Constriction Tourniquet

A
  1. Superficial -> Dissolve the hair (Nair, Magic Shave, Veet)
  2. Use forceps to unwind it or cut the hair
40
Q

1 organism -> Simple Acute Cystitis (UTI) in Men

41
Q

Red flags for complicated UTI

A
  • Flank pain, CVA tenderness = PYELO
  • Pelvic/Perineal pain = Prostitis
  • Systemic SS = Pyelo, Prostitis, Sepsis -> DO PROSTATE EXAM
42
Q

You suspect a UTI in a mean who also presents with systemic ss. Next step?

A

Do a prostate exam

43
Q

1 Dx order for man with likely UTI

A

UA Culture

all men get a UA culture bc it gets complicated very fast

44
Q

1st line Tx options for Simple UTI in men

A

Bactrim, Macrobid, or Beta-lactams x7 days

45
Q

Tx for Simple UTI in men if SEVERE SS or possible prostate involvement

A

Ciprofloxacin x 5 days

46
Q

Men with persistent and/or recurrent cystitis should be WU for…

A
  • Predisposing factors (BPH, Other Urinary tract obstruction)
  • Chronic Prostatitis
47
Q

1 organism -> Urethritis

A

Neisseria Gonorrhea

48
Q

Discharge Consistency if…
- Gonorrhea ->
- Chlamydia ->

A
  • Gonorrhea -> Purulent
  • Chlamydia -> CLEAR
49
Q

Dx for urethritis

A

Clinical Dx
NAAT - STI specific

50
Q

Urethritis Tx

A

Presumptive Tx both GONORRHEA & CHLAMYDIA
* Gonorrhea -> CEFTRIAXONE 500mg IM x1
* Chlamydia -> DOXYCYLINE 100mg PO BID x7 days

51
Q

Suspect ______ infx if Urethritis is persistent/fails meds

A

Mycoplasma genitalium

52
Q

Tx for confirmed Mycoplasma genitalium Infx -> Urethritis

A

Moxifloxacin

53
Q

WU for Penile Frx and Urethral Injuries

A
  • Inital -> US
  • Retrograde Urethrogram (RUG)
54
Q

Penile fractures occur when the _______ layer of the penis thins during erection and then ruptures d/t direct trauma

A

Tunica Albuginea

55
Q

Order a _____ for poss Urethral Injury

A

RUG
Retrograde urethrogram

56
Q

Retrograde urethrogram for possible urethral injury is (+) for extravasation. What does this mean?

A

contrast is outside of the urethra = Urethral injury confirmed

Partial = some dye in the bladder
Complete = NO dye in the bladder!!!!

57
Q

Should you avoid cathing if there is urethral injury?

A

AVOID Urethral bladder caths. However, you MUST DO A SUPRAPUBIC CATH TO DRAIN THE BLADDER ASAP

58
Q

Urethral strictures are MC in which age group and by which mechanism?

A

Males 55yo+
Idiopathic, Iatrogenic, Trauma, Inflammation

59
Q

1 DDx?

55yo Male presents with weak stream, incomplete bladder emptying, urinary spraying, and says he “doesn’t cum like he used to”

A

Urethral Stricture

60
Q

Urethral Stricture WU
- order ___ to Screen
- order ____ to CONFIRM Dx

A
  • SCREEN = UROFLOWMETRY
  • Dx CONFIRM = (RUG) Retrograde Urethrogram

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