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YEAR 3 & 5 CORE CONDITIONS > Reproductive > Flashcards

Reproductive Flashcards

1
Q

What is testicular torsion?

A

Sudden twisting of spermatic cord within the scrotum

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2
Q

Why is testicular torsion an emergency?

A

Risk of ischaemia and infarction of the testis

Irreversible damage after 6-12hrs of torsion

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3
Q

How does testicular torsion present?

A 
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)
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4
Q

When is testicular torsion most common?

A 
Neonatal period (first 30 days of life)
Puberty
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5
Q

What signs may / may not be elicited in testicular torsion?

A

Absent cremasteric reflex

Prehn sign negative

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6
Q

What is Phren sign? What does it suggest?

A

A positive Prehn sign is the relief of pain during elevation of the testes and suggests epididymitis rather than torsion

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7
Q

What investigations are done for testicular torsion?

A

Clinical diagnosis

Can US or radionuclide image scrotum if atypical features

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8
Q

What may an US show in testicular torsion?

A

Twisting of spermatic cord = whirlpool sign
Reduced / absent blood flow to / from the affected testis
Heterogenous appearance of testicular parenchyma indicates testicular necrosis

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9
Q

What may a radionuclide image show in testicular torsion? How does this compare to epididymitis?

A

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)

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10
Q

What is the management of testicular torsion?

A

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

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11
Q

What is the epididymis?

A

The tube located at the back of the testis that stores and carries sperm

Inflammation = epididymitis

+/- inflamed testes (epididymo-orchitis)

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12
Q

How does epididymis present?

A 
Gradual onset (few days / weeks)
Painful swelling
\+/- urethral discharge
Fever
Dysura
Urinary frequency
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13
Q

What may an examination show in epididymis?

A

Very tender
Positive Phren sign
Positive cremasteric reflex

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14
Q

What may bloods and urine show in epididymis?

A

Raised inflammatory markers

Possible pyuria

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15
Q

What is the tumour marker for testicular cancer?

A

Alpha fetoprotein (AFP)

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16
Q

How may testicular cancer present?

A 
Slow progression (weeks to months)
Usually painless testicular mass - may feel dull ache / heavy sensation
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17
Q

What may an examination show in testicular cancer?

A

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

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18
Q

What can lead to insidious onset of unilateral scrotal pain in boys aged 3-5?

A

Torsion of testicular appendage (hydatid of Morgagni)

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19
Q

Describe what happens in torsion of testicular appendage (hydatid of Morgagni)

A

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

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20
Q

How does infarction of the hydatid of Morgani appear through the skin?

A

“blue dot” sign

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21
Q

What is prostatitis? What are the subtypes?

A

Inflammation of the prostate gland

Infectious (5%)
- acute vs chronic bacterial

Noninfectious (95%)
- chronic pelvic pain syndrome (CPPS)

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22
Q

What is the most common cause of acute and chronic bacterial prostatitis?

A

E coli

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23
Q

What are some risk factors for acute and chronic bacterial prostatitis?

A

Other genitourinary tract infections eg urethritis, cystitis, epididymitis

Genitourinary tract interventions:

  • Indwelling catheter
  • Transurethral surgery
  • Prostate biopsy

Voiding dysfunction and bladder outlet obstruction

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24
Q

How does acute bacterial prostatitis present?

A

Spiking fever, chills, malaise

Acute dysuria, freq, urgency, cloudy urine

SEVERE perineal and pelvic pain, worse with defecation

Tender, boggy swollen prostate

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25
Q

How does chronic bacterial prostatitis present?

A

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

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26
Q

How does CPPS present?

A 
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
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27
Q

How is prostatitis diagnosed?

A

Bacterial - urinalysis and culture

CPPS - diagnosis of exclusion

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28
Q

What is the treatment of bacterial prostatitis?

A

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

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29
Q

What is the treatment of CPPS?

A

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

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30
Q

Why is finasteride is not recommended in young patients?

A

5-alpha-reductase inhibitors reduce semen volume

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31
Q

What are some complications of prostatitis?

A

Prostatic abscess
Acute urinary retention
Pyelonephritis and sepsis
Epididymitis

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32
Q

What is balanittis?

A

Inflammation of the glans penis (head / tip of penis)

33
Q

What is balanoposthitis?

A

Inflammation of the glans penis and the foreskin

34
Q

What can cause balanitis and balanoposthitis?

A 
Poor hygiene
Contact irritants
Drug reaction
Bacterial infection
Yeast

Rarely:

  • Pemphigus
  • Pemphigoid
  • Lichen sclerosis
35
Q

What is lichen sclerosis of the penis called?

A

Balanitis xerotica obliterans

36
Q

How does balanitis and balanoposthitis present?

A

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

37
Q

How are balanitis and balanoposthitis diagnosed?

A

Usually clinical
KOH (potassium hydroxide preparation )to confirm fungal
Gram stain and culture for bacterial

38
Q

What is the treatment of balanitis and balanoposthitis?

A

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
39
Q

What are some complications of balanitis and balanoposthitis?

A

Postinflammatory phimosis
Urinary tract obstruction - requires bladder catheterisation
Recurrent UTIs
Penile cancer

40
Q

What is phimosis?

A

Tight foreskin than cannot be completely retracted

41
Q

When does phimosis occur?

A

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

42
Q

What is the management of phimosis?

A

Topical steroids and stretching exercises

Surgery may be required:
- Vertical incision (incision of constricting bands) or circumcision

43
Q

What is paraphimosis?

A

Condition in which the foreskin has retracted and cannot be returned to its original position

44
Q

What can cause paraphimosis?

A

Phimosis
Sexual activity
Trauma

45
Q

What is the management of paraphimosis?

A

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
46
Q

Define erectile dysfunction

A

Inability to achieve or sustain an erection sufficient in rigidity of duration for sexual intercourse which is present for a minimum of 6 months

47
Q

List some vascular causes of ED

A 
HTN
DM
CVD
Hyperlipidemia
Smoking
48
Q

List some neurogenic causes of ED

A 
Stroke
Brain / spinal cord injury
Dementia
PD
MS
49
Q

List some endocrine causes of ED

A

Hypogonadism
Hyperprolactinemia
Thyroid disorders

50
Q

List some medications than can cause ED

A

Anti HTN - beta blockers, thiazide diruetics

Antidepressants - SSRIs

Dopamine antagonists

51
Q

How do dopamine antagonists cause ED?

A

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

52
Q

List some iatrogenic causes of ED

A

Radical prostatectomy

Pelvic radiation

53
Q

List some other causes of ED

A

Trauma
Alcohol abuse
Peyronie disease - scar tissue develops on the penis and causes curved, painful erections
Psychological - depression, anxiety, stress

54
Q

What bloods are done for ED?

A 
Testosterone levels
SHBG (sex hormone binding globulin)
Prolactin
LH
FSH
TSH
Fasting glucose / HbA1c
Lipid profile
55
Q

Other than bloods, what investigations can be done for ED?

A

Nocturnal penile tumescene measurement

Doppler US or arteriography to identify suspected arterial inflow or venous leaks after injection of a vasodilatory agent

56
Q

What is a nocturnal penile tumescene measurement?

A

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

57
Q

What is the medical and psychological management of ED?

A

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
58
Q

How do phosphodiesterase 5 inhibitors work? Examples?

A

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

59
Q

What are some considerations for prescribing phosphodiesterase 5 inhibitors?

A

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

60
Q

How do nitrites work? Examples

A

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

61
Q

What is the mechanical management of ED?

A

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

62
Q

What is the surgical management of ED?

A

Implantation of penile prosthesis

Last resort

63
Q

What are the most common causes of urethritis?

A

Gonococcal urethritis - neisseria gonorrhoea

Nongonococcal:

  • Chlamydia trachomatis
  • Mycoplasma genitalium
  • Trichomonas vaginalis
  • HS1 and 2
  • Adenovirus
64
Q

How doe urethritis present?

A 
Dysuria
Burning or itching of urethral meatus
Uthehral discharge - purulent, cloudy, blood tinged or clear
Initial haematuria
Asymptomatic (esp nongonococcal)
65
Q

How is urethritis investigated?

A

Urine dip of first void urine
Urethral smear

Swab
NAAT

66
Q

What are some risk factors for testicular cancer?

A

Cryptorchidism
Klinefelter syndrome
Down syndrome
Hypospadia

67
Q

How are testicular tumours classified?

A

Germ cell (95%)

  • Seminoma
  • Non seminoma

Non germ cells (5%)

  • Leydig
  • Sertoli
  • Secondary eg lymphoma
68
Q

List some types of nonseminoma germ cell tumours of the testis

A 
Embryonal carcinoma
Teratoma
Testicular choriocarcinoma
Yolk sac tumour
Mixed germ cell tumour (most common)
69
Q

How does testicular cancer present?

A 
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

70
Q

What can cause gynaecomastia in testicular cancer?

A

HCG overproduction or excess estrogen

71
Q

Which is the most aggressive testicular tumour?

A

Testicular choriocarcinoma

Highly malignant
Early mets to lungs or brain

72
Q

What are testicular cancer tumour markers?

A

Alpha fetoprotein (AFP)
HCG
LDH

73
Q

What investigations are done for testicular tumours?

A 
Tumour markers
US
CT abdo pelvis chest
Cranial CT / MRI if mets suspected
Histopathology following radical inguinal orchidectomy
74
Q

Describe US findings of:
Seminoma
Nonseminoma
Microlithiasis

A

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

75
Q

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?

A

Do not perform a transcrotal biopsy because of the risk fo tumour seeding

76
Q

Ddx of testicular swelling

A

Hydrocele
Varicoele
Spermatocele
Scrotal hernia

77
Q

Describe a hydrocele vs varicoele

A

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
78
Q

What is the management of testicular cancer?

A

Sperm cryopreservation before surgery
Radial inguinal orchiectomy
Radiation / chemo

79
Q

What is the prognosis of testicular cancer?

A

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

YEAR 3 & 5 CORE CONDITIONS (30 decks)

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