Session 3 Flashcards

1
Q

Define Phimosis

A

•Prepuce cannot be fully retracted in adult
•Incidence – 1% adult non-circumcised population
Physiological’phimosis
• ‘Normal’ non-retractability up to adolescence – 50% at 1 year – 10% at 3 years – 1% at 17 years
• Poor hygeine,  STDs • Pain on intercourse, splitting / bleeding • Balanitis (inflamed glans) • Posthitis (inflamed foreskin/prepuce) • Balanitis Xerotica Obliterans (BXO) • Paraphimosis • Urinary retention • Penile cancer

– In adulthood may be associated with other pathologies – Beware the elderly man with a phimosis and‘balanitis’ – Circumcision is probably the best treatment

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2
Q

paraphimosis

A

The painful constriction of the glans penis by the retracted prepuce proximal to the corona
Commonest Causes Phimosis Catheterisation (esp. Elderly) Penile cancer
– Needs reduction • This is usually achieved manually • Occasionally dorsal slit may be necessary

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3
Q

symptoms and presentation of penile cancer (rare, but important diagnosis)

A

Squamous cell carcinoma (SCC)
20% < 50 yrs old
• Risk factors – Phimosis – hygiene - smegma – HPV 16 & 18
• Untreated, most die < 2yrs, almost all < 5yrs
Important not to miss – GP may only see one in their lifetime
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4
Q

Common causes of acute scrotal pain?

A
  • Testicular torsion • Epididymitis / Orchitis / Epididymo-orchitis – Urinary tract infection (UTI) – Sexually transmitted infection (STI) – Mumps
  • Torsion of hydatid of Morgagni
  • Trauma • Ureteric calculi (rarely)
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5
Q

common causes of scrotal lumps testicular tumour, hydrocele, epididymal cyst, varicocele, hernia

A

testicular tumour, hydrocele, epididymal cyst, varicocele, hernia

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6
Q

learn common causes of LUTS, be aware of the assessment of patient with LUTS

A
  • LUTS are not disease specific! – Do not use the term ‘prostatism’ for male LUTS – it implies that urinary symptoms in men are always related to the prostate.
  • From the history, determine if LUTS are predominantly – Voiding (suggestive of bladder outflow obstruction) • Hesitancy • Poor flow • Post micturition dribbling – Storage • Frequency • Urgency • Nocturia
  • Irritative – e.g. Bladder infection/inflammation, bladder stone, bladder cancer • Overactive bladder – Idiopathic – Neuropathic • e.g. CVA, Parkinson’s, multiple sclerosis • Low compliance of bladder (Scarred) – e.g. after TB/Schistosomiasis/pelvic radiotherapy • Polyuria (making too much urine) – Global • e.g. uncontrolled diabetes – Nocturnal • e.g. venous stasis, sleep apnoea
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7
Q

common presentation, principles of assessment and management of BPH (Benign Prostatic Hypertrophy) •

A

8

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8
Q

key trends in Men’s Health

A

9

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9
Q

rates of mental health problems in men and patterns of health-seeking behaviour unique to men

A

10

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10
Q

common causes of Erectile Dysfunction

A

11

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11
Q

positive predictive value) in the context of screening for testicular cancer

A

12

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12
Q

Circumcision

Key Indications

A

• Paediatric – Religious – Recurrent balanitis/UTIs • Adult – Recurrent balanitis – Phimosis – Recurrent paraphimosis – Balanitis xerotica obliterans – Penile Cancer

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13
Q

Testicular torsion history and examination

A
  • Testicular torsion • Epididymitis / Orchitis / Epididymo-orchitis – Urinary tract infection (UTI) – Sexually transmitted infection (STI) – Mumps
  • Torsion of hydatid of Morgagni
  • Trauma • Ureteric calculi (rarely)
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14
Q

Epididymo-orchitis

A

• Age – 20-40/50 – STI (esp Chlamydia) – 40/50+ - UTI (esp. E. Coli) • Gradual onset • Usually unilateral • Often recent history of – UTI – Unprotected intercourse – Catheter/urethral instrumentation – Check for mumps history
Examination
• May be pyrexial; can be septic • Scrotum erythematous • Testis/epididymis enlarged, tender • Fluctuant areas may represent abscess • May have reactive hydrocoele
• Rarely – necrotic area of scrotal skin (Fournier’s Gangrene) – Fournier’s • High mortality rate (approx 50%)
Investigation • Bloods – FBC / U&E’s / Cultures if septic • Urine - MSU for MC&S • Radiology – Scrotal USS if suspect abscess or not settling
Treatment •Epididymo-orchitis – Antibiotics •Abscess – Surgical drainage and antibiotics •Fournier’s gangrene – Emergency debridement & antibiotics

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15
Q

Scrotal lumps history and examination

A

History •Is it painful? •How quickly has it appeared?
Examination •Can I get ‘above it’? – If not, it is likely to be a hernia •Is it in the body of the testis? – If yes, this could be a testicular tumour! •Is it separate to the testis? •Does it fluctuate and transilluminate?

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16
Q

How does pain with a scrotal lump hint at a diagnosis?

A

Opportunistic presentations •Painless scrotal lump – Not tender – Testis tumour – Epididymal cyst – Hydrocele – Reducible inguino-scrotal hernia •Painless/Aching at end of day – Not tender – Varicocele
Acute presentation with scrotal lump •Painful – Tender – Epididymitis – Epididymo-orchitis – Strangulated inguino-scrotal hernia - emergency

17
Q

Testicular tumour

A

History •Usually painless •Germ cell tumours (Seminoma/Teratoma) usually in men aged <45 yrs – Risk – history of undescended testis. •Older men (Could be lymphoma)
On examination •Body of testis is abnormal; can ‘get above’
Refer via 2 week wait to Urology •Urology will – Arrange urgent ultrasound of scrotum to confirm diagnosis – Check testis tumour markers (aFP, hCG, LDH) •The average GP may only see two in their lifetime!

18
Q

Hydrocele (adult)

A

• Slow/sudden onset • Uni/bilateral scrotal swelling • = imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
On Examination •Testis not palpable separately •Can usually ‘get above’ •Transilluminates

19
Q

Epididymal cyst

A

•Usually painless

On examination •Separate from testis •Can‘get above’ mass •Transilluminates

20
Q

Varicocele

A

• Dull ache, at end of day • Lt > Rt • May be associated with reduced fertility (esp.if bilateral)
On examination • “Bag of worms” above testis • NOT tender • ? Palpable abdominal/renal mass

21
Q

Treatment for scrotal lump causes?

A

• Testicular tumour – Inguinal orchidectomy • Epididymal cyst – Reassure; Excise if large • Adult hydrocele – If normal testis on ultrasound • Reassure; Surgical removal if large/symptomatic • Varicocele – Reassure – Radiological embolisation • Symptomatic • Infertility (slow motility of sperm) • If present in adolescent and growth of testis affected • Inguino-scrotal hernia – Surgery (emergency if strangulated)

22
Q

Define urinary retention

A

• Inability to pass urine, rather than inability to make urine • Common in males, rare in females

23
Q

Causes of urinary retention

A

• Prostatic enlargement – Benign prostatic hyperplasia (BPH) – Cancer • Phimosis/urethral stricture/meatal stenosis • Constipation • Urinary tract infection • Drugs – Anticholinergic actions • Over-distension – e.g. Too much fluids at party • Following surgery • Neurological

24
Q

Urinary Retention – Types and Treatment Strategies

A

insert slide

25
Q

What do older men with bed wetting have unless proven otherwise?

A

Older men with nocturnal enuresis (bed wetting) have chronic retention with overflow incontinence until proven otherwise

26
Q

What could be causing voiding symptoms?

A

• Bladder Outflow Obstruction (BOO) – Physical • Urethra – Phimosis – Stricture • Prostate – Benign – Malignant – Bladder neck – Dynamic • Prostate • Bladder neck – Neurological • Lack of coordination between bladder and urinary sphincter – Upper motor neurone • Reduced contractility – Physical – Neurological • Lower motor neurone lesion

27
Q

Male LUTS

Assessment (Primary Care)

A

International Prostate Symptom Score (IPSS)
1. Incomplete Emptying 2. Frequency 3. Intermittency 4. Urgency 5. Weak Stream 6. Straining 7. Nocturia
8. If you were to spend …
Mild: 0-7 Moderate: 8-19 Severe: 20-35
Examination
• DRE • Is the bladder palpable? • Neurological if suggestive history
Investigations
• Dipstick - ? UTI, blood • Consider PSA – Counsel before requesting – It is not a surrogate for DRE – If UTI, treat first and if palpably benign prostate – wait 4-6 weeks

28
Q

Management of BPH (Primary Care)

A

Lifestyle
• Reduce caffeine intake • Avoid fizzy drinks • No need to drink more than 2.5L day
Alpha blockers
 Act by relaxing smooth muscle within the prostate and the bladder neck
 Rapid symptom relief
e.g Tamsulosin
5α-Reductase Inhibitors (5ARIs)
5ARIs
 Act by ‘shrinking’ the prostate by means of androgen deprivation
 Slower symptom relief than alpha blocker
 Slows progression
 Reduces the risk of retention
e.g. Finasteride or Dutasteride

29
Q

Management of BPH (Secondary Care)

A

Flow rate (before considering surgery in secondary
-Normal -Suggestive of Prostatic Obstruction -Suggestive of Urethral Stricture
Surgical
• Indications – Failed lifestyle and medical management – Urinary retention needing intervention
• Standard – Transurethral resection of prostate (TURP) • Monopolar/laser/bipolar add image