S3: men's health Flashcards
Describe phimosis
Prepuce cannot be fully retracted in adult (physiological phimosis – normal non-retractability up to adolescence)
Sequelae: poor hygiene, pain on intercourse, balanitis (inflamed glans), posthitis (inflamed foreskin/prepuce), balanitis xerotica obliterans, paraphimosis, urinary retention, penile cancer
Describe paraphimosis
Painful constriction of the glans penis by the retracted prepuce proximal to the corona
Commonest causes: phimosis, catheterisation, penile cancer
Compare phimosis and paraphimosis treatments
Phimosis – may be associated with other pathologies, beware man with phimosis & balanitis
-circumcision is best treatment
Paraphimosis – needs reduction (achieved manually)
Describe penile cancer (SCC)
Risk factors: phimosis, HPV 16 & 18
Untreated, most dead in less than 2 years, almost all less than 5 years
Important not to miss – GP may only see one in their lifetime
List indications for circumcision
Paediatric: religious, recurrent balanitis/UTIs
Adult: recurrent balanitis, phimosis, recurrent paraphimosis, balanitis xerotica obliterans, penile cancer
List causes of acute scrotal pain
Testicular torsion Epididymitis/orchitis/epididymo-orchitis (UTI, STI, mumps) Torsion of hydatid of Morgagni Trauma Ureteric calculi (rarely)
Describe history and examination for testicular torsion
History – usually younger patient, sudden onset, unilateral pain, may be nauseated/vomit, often no LUTS
Examination – testis is very tender, lying high in scrotum with horizontal lie
If you suspect testicular torsion, the patient needs emergency scrotal exploration
Describe history for epididymo-orchitis
Age: 20-40/50: STI, 40/50+: UTI
Gradual onset
Usually unilateral
Often recent history of UTI, unprotected intercourse, catheter/urethral instrumentation, check for mumps history
Describe examination findings for epididymo-orchitis
May be pyrexial, can be septic
Scrotum erythematous
Testis/epididymis enlarged, tender
Rarely – necrotic area of scrotal skin (Fournier’s gangrene) -> high mortality rate
Describe investigations and treatment for epididymo-orchitis
Investigation: bloods, urine, radiology
Treatment:
1) Epididymo-orchitis – antibiotics
2) Abscess – surgical drainage and antibiotics
3) Fournier’s gangrene – emergency debridement & antibiotics
Describe different presentations for scrotal lumps
Painless, non-tender scrotal lump – testis tumour, epididymal cyst, hydrocele, reducible inguino-scrotal hernia
Painless/aching at end of day, non-tender – varicocele
Painful & tender – epididymitis, epididymo-orchitis, strangulated inguino-scrotal hernia (emergency)
Describe the history and examination of a testicular tumour
History – usually painless, history of undescended testis (germ cell tumours in men <45), older men (lymphoma)
Examination – body of testis is abnormal, can ‘get above’
Refer to urology -> arrange urgent ultrasound of scrotum & check testis tumour markers
Describe hydrocele
Slow/sudden onset
Uni/bilateral scrotal swelling -> imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
On examination: testis not palpable, can usually ‘get above’, transilluminates
Describe an epididymal cyst
Usually painless
On examination: separate from testis, can ‘get above’ mass, transilluminates
Describe varicocele
Dull ache, at end of the day (more common on left compared to right)
May be associated with reduced fertility
On examination: ‘bag of worms’ above testis, NOT tender
List causes of urinary retention
Prostatic enlargement – BPH & cancer Phimosis/urethral stricture/meatal stenosis Constipation UTI Drugs Over-distension Following surgery Neurological
Describe the different types of urinary retention and the treatment for each
Acute (painful) – pain is relieved by drainage, residual volume <1000ml, no kidney insult, trial without catheter after addressing exacerbating factor
Chronic (painless/less painful) – may just notice abdominal swelling, residual volume >300ml, may have kidney insult, learn to self catheterise
Acute on chronic (painful) – residual volume >1000ml, usually have kidney insult, long-term catheter or surgical intervention
Compare voiding and storage symptoms
Voiding – hesitancy, poor flow, post micturition dribbling
Storage – frequency, urgency, nocturia
List causes of storage LUTS
Irritative
Overactive bladder
Low compliance of bladder
Polyuria
List causes of voiding LUTS
Bladder outflow obstruction – physical, dynamic & neurological
Reduced contractility
Describe primary care assessment of male LUTS
International prostate symptom score
Examination – DRE, is the bladder palpable? Neurological if suggestive history
Investigations – dipstick, consider PSA
Outline primary care management of BPH
Lifestyle – reduce caffeine intake, avoid fizzy drinks, no need to drink more than 2.5L Alpha blockers (tamsulosin) – act by relaxing smooth muscle within the prostate and the bladder neck 5alpha-reducatase inhibitors (finasteride/dutasteride) – act by shrinking the prostate by means of androgen deprivation, slower symptom relief than alpha blocker
Outline secondary care management of BPH
Flow rate
Surgical intervention if: failed lifestyle & medical management, urinary retention needing intervention
Standard: transurethral resection of prostate (TURP)
List physical causes of erectile dysfunction
Atherosclerosis Smoking cigarettes Damage to key blood vessels due to cycling Diabetes Regular heavy drinking – can damage the nerves leading to the penis & reduce testosterone levels Spinal cord injury Prescribed medication Prostate gland surgery
