Reproductive Flashcards
What is testicular torsion?
Sudden twisting of spermatic cord within the scrotum
Why is testicular torsion an emergency?
Risk of ischaemia and infarction of the testis
Irreversible damage after 6-12hrs of torsion
How does testicular torsion present?
Sudden onset unilateral testicular pain May radiate to lower abdo Swollen and tender testicle Nausea and vomiting Abnormal position of testicle: - Abnormal transverse lie - Scrotal elevation - Possible undescended testes (predisposes to testicular torsion)
When is testicular torsion most common?
Neonatal period (first 30 days of life) Puberty
What signs may / may not be elicited in testicular torsion?
Absent cremasteric reflex
Prehn sign negative
What is Phren sign? What does it suggest?
A positive Prehn sign is the relief of pain during elevation of the testes and suggests epididymitis rather than torsion
What investigations are done for testicular torsion?
Clinical diagnosis
Can US or radionuclide image scrotum if atypical features
What may an US show in testicular torsion?
Twisting of spermatic cord = whirlpool sign
Reduced / absent blood flow to / from the affected testis
Heterogenous appearance of testicular parenchyma indicates testicular necrosis
What may a radionuclide image show in testicular torsion? How does this compare to epididymitis?
Areas that do not absorb radionuclide as a result of decreased blood flow to affected testis = cold spots
Asymmetric blood flow
(Epididymytis would shot hot spots due to increased blood flow in inflammation)
What is the management of testicular torsion?
Surgical emergency - within 4-6 hrs
Bilateral orchidoplexy - cord and testis untwisted and both testicles fixed to the scrotum
Analgesics
Antiemetics
NBM
If testis not visible, orchidectomy - prosthetsis can be inserted at time of surgery or later date
What is the epididymis?
The tube located at the back of the testis that stores and carries sperm
Inflammation = epididymitis
+/- inflamed testes (epididymo-orchitis)
How does epididymis present?
Gradual onset (few days / weeks) Painful swelling \+/- urethral discharge Fever Dysura Urinary frequency
What may an examination show in epididymis?
Very tender
Positive Phren sign
Positive cremasteric reflex
What may bloods and urine show in epididymis?
Raised inflammatory markers
Possible pyuria
What is the tumour marker for testicular cancer?
Alpha fetoprotein (AFP)
How may testicular cancer present?
Slow progression (weeks to months) Usually painless testicular mass - may feel dull ache / heavy sensation
What may an examination show in testicular cancer?
Palpation of solid mass
Possible manifestations of metastatic disease eg LN, chest pain, GI symptoms
Possible ipsilateral lower limb swelling = venous engorgement due to obstruction
What can lead to insidious onset of unilateral scrotal pain in boys aged 3-5?
Torsion of testicular appendage (hydatid of Morgagni)
Describe what happens in torsion of testicular appendage (hydatid of Morgagni)
The hydatid of Morgagni (appendix of testes) is an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Müllerian duct)
This has the potential to rate
Causing symptoms that resemble acute testicular torsion
How does infarction of the hydatid of Morgani appear through the skin?
“blue dot” sign
What is prostatitis? What are the subtypes?
Inflammation of the prostate gland
Infectious (5%)
- acute vs chronic bacterial
Noninfectious (95%)
- chronic pelvic pain syndrome (CPPS)
What is the most common cause of acute and chronic bacterial prostatitis?
E coli
What are some risk factors for acute and chronic bacterial prostatitis?
Other genitourinary tract infections eg urethritis, cystitis, epididymitis
Genitourinary tract interventions:
- Indwelling catheter
- Transurethral surgery
- Prostate biopsy
Voiding dysfunction and bladder outlet obstruction
How does acute bacterial prostatitis present?
Spiking fever, chills, malaise
Acute dysuria, freq, urgency, cloudy urine
SEVERE perineal and pelvic pain, worse with defecation
Tender, boggy swollen prostate
How does chronic bacterial prostatitis present?
Commonly no systemic fever, sometimes low grade present
Chronic bladder irritation:
- Dysuria, freq, urgency
ED
Possibly bloody semen
Mild genitourinary pain worse on ejaculation
Prostate may be often normal, may be enlarged and tender
How does CPPS present?
Systemic symptoms absent - no fever ED Painful ejaculation Bloody semen May have symptoms of bladder irritation Moderate genitourinary pain: - Lower abdo, perineum, scrotum or penis Prostate usually normal but may be slightly tender
How is prostatitis diagnosed?
Bacterial - urinalysis and culture
CPPS - diagnosis of exclusion
What is the treatment of bacterial prostatitis?
14 day course of:
Ciprofloxacin 500 mg PO BD or
Ofloxacin 200 mg PO BD twice daily first line
or if they are unsuitable trimethoprim 200 mg PO BD
Analgesics
Hydration
Review after 48hrs
Suprapubic catheterisation in cases of acute urinary retention and persistent fever
What is the treatment of CPPS?
Alpha blockers eg tamsulosin, doxazosin = improves urinary voiding by relaxing smooth muscles in prostate and bladder
5-alpha reductase inhibitors eg finasteride = reduce prostate size by blocking growth-inducing effect of androgen on the prostate
NSAIDs
Anti-inflammatory phytotherapeutic agents eg cernilton
Physio - prostatic and pelvic floor masage
Why is finasteride is not recommended in young patients?
5-alpha-reductase inhibitors reduce semen volume
What are some complications of prostatitis?
Prostatic abscess
Acute urinary retention
Pyelonephritis and sepsis
Epididymitis
What is balanittis?
Inflammation of the glans penis (head / tip of penis)
What is balanoposthitis?
Inflammation of the glans penis and the foreskin
What can cause balanitis and balanoposthitis?
Poor hygiene Contact irritants Drug reaction Bacterial infection Yeast
Rarely:
- Pemphigus
- Pemphigoid
- Lichen sclerosis
What is lichen sclerosis of the penis called?
Balanitis xerotica obliterans
How does balanitis and balanoposthitis present?
Pruritis, pain, edema of glans penis
Erythema and uclerated lesions of the glans or foreskin
Thick penile discharge or discharge from ulcerated lesions
Systemic symptoms may occur eg fever, arthralgias, malaise
How are balanitis and balanoposthitis diagnosed?
Usually clinical
KOH (potassium hydroxide preparation )to confirm fungal
Gram stain and culture for bacterial
What is the treatment of balanitis and balanoposthitis?
Conservative
- Daily retraction of foreskin and bathing with warm saline solution
- Avoid irritants
- Topical antifungal eg clotrimazole if yeast
- Topical bacitracin if bacterial
- Topical corticosteroid and aqueous cream for irritant or drug reaction
What are some complications of balanitis and balanoposthitis?
Postinflammatory phimosis
Urinary tract obstruction - requires bladder catheterisation
Recurrent UTIs
Penile cancer
What is phimosis?
Tight foreskin than cannot be completely retracted
When does phimosis occur?
Often normal in young children but may be pathological if it develops secondary to scarring
Pathological phimosis most commonly occurs as a complication of balanitis and balanoposthitis
What is the management of phimosis?
Topical steroids and stretching exercises
Surgery may be required:
- Vertical incision (incision of constricting bands) or circumcision
What is paraphimosis?
Condition in which the foreskin has retracted and cannot be returned to its original position
What can cause paraphimosis?
Phimosis
Sexual activity
Trauma
What is the management of paraphimosis?
Urological emergency
Pain control
Manual reduction
Some cases may need surgical intervention to prevent penile necrosis:
- Dorsal slit reduction surgery = incision of the constricting band
- Circumcision last resort
Define erectile dysfunction
Inability to achieve or sustain an erection sufficient in rigidity of duration for sexual intercourse which is present for a minimum of 6 months
List some vascular causes of ED
HTN DM CVD Hyperlipidemia Smoking
List some neurogenic causes of ED
Stroke Brain / spinal cord injury Dementia PD MS
List some endocrine causes of ED
Hypogonadism
Hyperprolactinemia
Thyroid disorders
List some medications than can cause ED
Anti HTN - beta blockers, thiazide diruetics
Antidepressants - SSRIs
Dopamine antagonists
How do dopamine antagonists cause ED?
Dopamine receptors blocked in tuberoinfundibulnar pathway, leading to an increase in prolactin secretion from the anterior pituitary
This leads to a decrease in GnRH secretion from the hypothalamus (negative feedback)
This leads to decreased LH secretion from the anterior pituitary which leads to decreased testosterone production from the Leydig cells
This leads to hypogonadotropic hypogonadism
List some iatrogenic causes of ED
Radical prostatectomy
Pelvic radiation
List some other causes of ED
Trauma
Alcohol abuse
Peyronie disease - scar tissue develops on the penis and causes curved, painful erections
Psychological - depression, anxiety, stress
What bloods are done for ED?
Testosterone levels SHBG (sex hormone binding globulin) Prolactin LH FSH TSH Fasting glucose / HbA1c Lipid profile
Other than bloods, what investigations can be done for ED?
Nocturnal penile tumescene measurement
Doppler US or arteriography to identify suspected arterial inflow or venous leaks after injection of a vasodilatory agent
What is a nocturnal penile tumescene measurement?
Measurement of spontaneous nightly erections (usually in a a sleep lab) to differentiate between organic and psychological causes of ED
Lack of nocturnal erections suggests organic cause of ED
What is the medical and psychological management of ED?
Psychological
- Counselling
- Senate focus exercises for performance anxiety = focuses on sensual experiences of touch without goal of orgasm
Medical
- Phosphodiesterase 5 inhibitors 1st line
- Intracavernous injection therapy or prostaglandin E1 (alprostadil) 2nd line
- Testosterone replacement if needed
How do phosphodiesterase 5 inhibitors work? Examples?
Slidenafil (viagra), tadalafil, vardenafil
Inhibit PDE 5 enzyme that normally breaks down cyclic GMP, thus sustaining cyclic GMP levels and increasing intracavernosal NO induced vasodilation
What are some considerations for prescribing phosphodiesterase 5 inhibitors?
Contraindicated in patients taking nitrites due to profound hypotension
May cause orthostatos hypotension in those taking alpha-adrenergic antagonist eg for BPH, take 4 hrs apart
How do nitrites work? Examples
Increase the release of nitric oxide (NO) in vascular smooth muscle cells, which leads to smooth muscle relaxation and subsequent vasodilation
Eg nitroglycerin, sodium nitroprusside, isosorbide mononitrate
What is the mechanical management of ED?
Vacuum pump - hollow cylinder that is placed onto the penis with a penis ring (outflow obstruction of the existing erection)
The suctioning function of the vacuum pump leads to stiffening of the penis (the blood is literally sucked into the penis). As the erection regresses again after releasing the vacuum (detumescence), an elastic penis ring is usually fixed to the base of the penis. The ring prevents the return of blood via constriction and provides a durable, sufficient erection
What is the surgical management of ED?
Implantation of penile prosthesis
Last resort
What are the most common causes of urethritis?
Gonococcal urethritis - neisseria gonorrhoea
Nongonococcal:
- Chlamydia trachomatis
- Mycoplasma genitalium
- Trichomonas vaginalis
- HS1 and 2
- Adenovirus
How doe urethritis present?
Dysuria Burning or itching of urethral meatus Uthehral discharge - purulent, cloudy, blood tinged or clear Initial haematuria Asymptomatic (esp nongonococcal)
How is urethritis investigated?
Urine dip of first void urine
Urethral smear
Swab
NAAT
What are some risk factors for testicular cancer?
Cryptorchidism
Klinefelter syndrome
Down syndrome
Hypospadia
How are testicular tumours classified?
Germ cell (95%)
- Seminoma
- Non seminoma
Non germ cells (5%)
- Leydig
- Sertoli
- Secondary eg lymphoma
List some types of nonseminoma germ cell tumours of the testis
Embryonal carcinoma Teratoma Testicular choriocarcinoma Yolk sac tumour Mixed germ cell tumour (most common)
How does testicular cancer present?
Painless testicular nodule or swelling Negative transillumination test Dull lower abdo or scrotal discomfort (more common than acute scrotal pain) Metastatic disease: - Cough, SOB, chest pain - Lower back or bone pain
Gynaecomastia
Paraneoplastic hyperthyroidism
What can cause gynaecomastia in testicular cancer?
HCG overproduction or excess estrogen
Which is the most aggressive testicular tumour?
Testicular choriocarcinoma
Highly malignant
Early mets to lungs or brain
What are testicular cancer tumour markers?
Alpha fetoprotein (AFP)
HCG
LDH
What investigations are done for testicular tumours?
Tumour markers US CT abdo pelvis chest Cranial CT / MRI if mets suspected Histopathology following radical inguinal orchidectomy
Describe US findings of:
Seminoma
Nonseminoma
Microlithiasis
Seminoma:
- Hypoechoeic (more dense)
- Homogenous
- Sharp margins
Nonseminoma:
- Variable echogenicity
- Inhomogenous
- May be calcified or cystic
Microlithiasis:
- Disseminated calcification as a possible precursor of carcinoma = starry sky appearance
Why is it important that the testis are removed and sent to pathology when investigating a suspected testicular tumour, rather than performing a transscortal biopsy?
Do not perform a transcrotal biopsy because of the risk fo tumour seeding
Ddx of testicular swelling
Hydrocele
Varicoele
Spermatocele
Scrotal hernia
Describe a hydrocele vs varicoele
Hydrocele is a swelling caused by fluid around the testicle
- Fluctuant swelling
- +ve transillumination
Varicocele is a swelling caused by dilated or enlarged veins within the testicles
- “Bag of worms”
- Reduced when lying supine
- -ve transillumination
What is the management of testicular cancer?
Sperm cryopreservation before surgery
Radial inguinal orchiectomy
Radiation / chemo
What is the prognosis of testicular cancer?
Excellent - high cure rate and >95% 5 yr survival
Often curable in advanced and metastatic stages
Better prognosis in seminomas but both still good survival rates
