Session 3 Flashcards
Define Phimosis
•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
paraphimosis
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
symptoms and presentation of penile cancer (rare, but important diagnosis)
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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Common causes of acute scrotal pain?
- Testicular torsion • Epididymitis / Orchitis / Epididymo-orchitis – Urinary tract infection (UTI) – Sexually transmitted infection (STI) – Mumps
- Torsion of hydatid of Morgagni
- Trauma • Ureteric calculi (rarely)
common causes of scrotal lumps testicular tumour, hydrocele, epididymal cyst, varicocele, hernia
testicular tumour, hydrocele, epididymal cyst, varicocele, hernia
learn common causes of LUTS, be aware of the assessment of patient with LUTS
- 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
common presentation, principles of assessment and management of BPH (Benign Prostatic Hypertrophy) •
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key trends in Men’s Health
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rates of mental health problems in men and patterns of health-seeking behaviour unique to men
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common causes of Erectile Dysfunction
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positive predictive value) in the context of screening for testicular cancer
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Circumcision
Key Indications
• Paediatric – Religious – Recurrent balanitis/UTIs • Adult – Recurrent balanitis – Phimosis – Recurrent paraphimosis – Balanitis xerotica obliterans – Penile Cancer
Testicular torsion history and examination
- Testicular torsion • Epididymitis / Orchitis / Epididymo-orchitis – Urinary tract infection (UTI) – Sexually transmitted infection (STI) – Mumps
- Torsion of hydatid of Morgagni
- Trauma • Ureteric calculi (rarely)
Epididymo-orchitis
• 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
Scrotal lumps history and examination
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?
How does pain with a scrotal lump hint at a diagnosis?
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
Testicular tumour
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!
Hydrocele (adult)
• 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
Epididymal cyst
•Usually painless
On examination •Separate from testis •Can‘get above’ mass •Transilluminates
Varicocele
• 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
Treatment for scrotal lump causes?
• 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)
Define urinary retention
• Inability to pass urine, rather than inability to make urine • Common in males, rare in females
Causes of urinary retention
• 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
Urinary Retention – Types and Treatment Strategies
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What do older men with bed wetting have unless proven otherwise?
Older men with nocturnal enuresis (bed wetting) have chronic retention with overflow incontinence until proven otherwise
What could be causing voiding symptoms?
• 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
Male LUTS
Assessment (Primary Care)
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
Management of BPH (Primary Care)
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
Management of BPH (Secondary Care)
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
