Session 3: Men's Health - Urology Flashcards
What is phimosis?
When the prepuce (foreskin) cannot be fully retracted over the glans in adults.
Is phimosis common?
Phimosis can be physiological and then it is common in young ages.
50% at 1 year
10% at 3 years
1% at 17 years.
Complications/effects of phimosis.
Poor hygiene
Increased risk of STDs
Balanitis
Pain on intercourse where foreskin might split or bleed
Posthitis
Balanitis Xerotic Obliterans (BXO)
Paraphimosis
Urinary retention
Penile cancer
What is balanitis?
Inflamed glans
What is posthitis?
Inflamed foreskin
What is paraphimosis?
Painful constriction of the glans penis by the retracted prepuce proximal to the corona.
This means that the foreskin cannot be protracted after once being retracted.
Commonest causes of paraphimosis.
Phimosis
Catheterisation especially in elderly
Penile cancer
Best treatment of phimosis.
Circumcision
Treatment of paraphimosis.
Needs reduction and this is usually achieved manually.
However a dorsal slit might be necessary.
Most common type of penile.
Squamous cell carcinoma.
Epidemiology of penile cancer.
Very rare with around 350 new cases per year in the UK.
Risk factors of penile cancer.
Phimosis
Hygiene
Smegma
HPV 16&18
Prognosis of penile cancer.
If untreated most patients die within 2 years.
Almost all will die within 5 years.
Causes of circumcision in paediatrics.
Religious reasons
Recurrent balanitis and UTIs.
Causes of circumcision in adults.
Recurrent balanitis
Phimosis
Recurrent paraphimosis
Balanitis Xerotica Obliterans
Penile cancer
Causes of acute scrotal pain.
Testicular torsion (Most important to rule out)
Epididymitis
Orchitis
Epididymo-orchitis
Torsion of hydatid of Morgagni
Trauma
Ureteri calculi
Common presentation/history of testicular torsion.
Usually younger patient (<30 years)
Sudden onset which can commonly wake them up from sleep
Unilateral pain and may be associated with nausea
What would be found on examination on testicular torsion?
Testis is very tender
The testis is lying high in the scrotum and with a horisontal lie.
If you suspect testicular torsion, the patient needs emergency scrotal exploration.
Do not waste time with USS etc..
Common presentation of epididymo-orchitis.
Age around 20-40 years with an STI
Or 40/50+ with UTI.
It has a gradual onset compared to testicular torsions acute onset.
There is often a recent history of UTIs, unprotected intercourse, catheterisation or mumps.
Examination findings of epididymo-orchitis.
May be pyrexial and even septic
Scrotum erythematous
Can have enlarged and tender tesis/epididymis
Can have abscess
May have reactive hydrocoele.
What is a rare but serious complications of epididymo-orchitis?
Fournier’s gangrene.
What is Fournier’s gangrene?
Necrotic area of scrotal skin with a high mortality rate of around 50%.
Investigations of epididymo-orchitis.
Bloods like FBC, U&Es, cultures
Urine dipstick
Radiology if suspect abscess
Treatment of epididymo-orchitis.
Antibiotics (anaerobic)
If abscess then surgical drainage and antibiotics
If Fournier’s gangrene then emergency debridement and antibiotics.
Key history from scrotal lumps.
Is it painful?
How quickly did it appear?
Key examinations.
Can you get above it?
Is it in the body of the testis?
Is it separate to the testis?
Does it fluctuate and transilluminate?
If you can’t get above the lump, what is it likely to be?
A hernia
If it is in the body of the testis, what is it likely to be?
A testicular tumour
Give examples of painless non-tender lumps.
Testis tumour
Epididymal cyst
Hydrocoele
Reducible inguino-scrotal hernia
Likely diagnosis if the lump is painless during the day but get’s achy at the end of the day.
Varicocoele
Give examples of painful/tender scrotal lumps.
Epididymitis
Epididymo-orchitis
Strangulated inguino-scrotal hernia
General history of testicular tumour.
Usually painless
Germ cell tumours such as seminomas or teratomas are usually in men aged <45 years.
If in older men could be a lymphoma
Common risk factor of testicular tumours.
Cryptorchidism
Findings on examination of testicular cancer.
Body of testis is abnormal
Can get above
Investigations of testicular cancer.
Urgent USS of scrotum
Tumour markes such as aFP, hCG, LDH
Clinical presentation of hydrocoele.
Slow/sudden onset
Can be either unilateral or bilateral.
Cause of hydrocoele.
Imbalance of fluid production and resorption between tunic albuginea and tunica vaginalis.
Findings on examination of testis in hydrocoele.
Testis not palpable seperately
Can usually get above the testis
Transilluminates
Clinical presentation of epididymal cyst.
Usually painless
Findings on examination of epididymal cysts.
Separate from testis.
Can get above the mass
Transilluminates
Clinical presentation of varicoele.
Dull ache at the end of day.
May be associated with reduced fertility.
Left testicle more commonly affected than right.
Findings on examination of varicoele.
Bag of worms above testis.
Not tender
What is important to consider and examine in a varicocoele?
If there is any palpable abdominal/renal mass because varicocoeles can be secondary to renal disease.
Tx of testicular tumour.
Inguinal orchidectomy
Tx of epididymal cyst.
Reassurance but excision if large and symptomatic.
Tx of hydrocoele.
Reassure and excise if large/symptomatic
Tx of varicocoele.
Reassurance
Radiological embolisation if symptomatic, if infertile, if present in adolescent and growth of testis is affected.
Tx of inguino-scrotal hernia.
Surgery
Causes of urinary retention.
BPH and prostate cancer
Phimosis/urethral stricture or meatal stenosis
Constipation
UTI
Drugs
Over-distension
Following surgery
Neurological
What kind of drugs can lead to urinary retention?
Anti-cholinergics
Alpha-1 agonists
Why would anticholinergic cause urinary retention?
Anti-cholinergics inhibit the parasympathetic system.
The parasympathetic system is needed in order to void.
Why would alpha1-agonists cause urinary retention?
Because they act on alpha-1 receptors in the prostate and the IUS and constrict the IUS. This causes urinary retention.
Type of urinary retention.
Acute painful
Chronic painless/less painful
Acute on chronic which is painful
Features of acute painful UR.
Pain relieved by drainage
Residual volume less than 1000 ml
No kidney insult
Tx of acute painful UR.
Trial without catheter (TWOC) after addressing the exacerbating factors.
Features of chronic painless/less painful UR.
May just notice abdominal swelling
Residual volume >300 ml and may go up to extremely high numbers such as 5L.
May have kidney insult.
Tx of chronic painless/less painful UR.
Learn to self-catheterise.
Features of acute on chronic painful UR.
Residual volume >1000 ml
Usually have kidney insult.
Tx of acute on chronic painful UR.
Long-term catheter or surgical intervention as TWOC is usually not successful.
What is the clinical diagnosis of older men with nocturnal enuresis?
Chronic retention with overflow incontinence until proven otherwise.
What can LUTS in men be divided into?
Voiding problems
Storage problems
Give voiding symptoms
Hesistancy
Poor flow
Post-micturition dribbling
Give storage symptoms.
Frequency
Urgency
Nocturia
Give causes of storage LUTS.
Bladder infection/inflammation
Bladder stone
Bladder cancer
Overactive bladder that is idiopathic or neuropathic
Scarred bladder with low compliance.
Polyuria either global or nocturnal
Causes of overactive bladder
CVA
Parkinson’s
MS
Causes of low compliance of bladder
TB
Schistosomiasis
Pelvic radiotherapy
Causes of global polyuria.
Uncontrolled diabetes
Causes of nocturnal polyuria.
Venous stasis
Sleep apnoea
Causes of voiding LUTS.
Bladder outflow obstruction
Reduced contractility of bladder
Give examples of physical BOOs.
Urethra such as phimosis or strictures.
Prostate such as BPH or cancer
Give causes of reduced contractility.
Neurological such as lower motor neurone lesion.
Explain dynamic BOO.
Where there is increased sympathetic smooth muscular tone leading to constriction and possible stasis.
Assessment of LUTS in primary care.
IPSS (international prostate symptom score)
Examination of LUTS.
DRE
Palpable bladder?
Neurological if history suggest it
Investigations of LUTS.
Dipstick looking for UTI or blood.
Consider as PSA
Management of BPH in primary care.
Lifestyle interventions such as reduce caffeine intake, avoid fizzy drinks and don’t drink excessive amounts of fluid.
Medicinal management of BPH in primary care.
Alpha blockers
5alpha-reductase inhibitors
Explain the action of alpha-blockers.
Acts by relaxing the smooth muscle in the prostate and also the IUS.
This gives rapid symptom relief.
Explain the action of 5ARIs.
Shrinks the prostate by inhibiting 5alpha-reductase which is supposed to convert testosterone to dihydrotestosterone (DHT).
How does 5ARIs differ to alpha-blockers.
5ARIs have slower symptoms relief and also slows progression and reduces the risk of retention.
Give examples of alpha-blockers.
Tamsulosin
Give examples of 5ARIs
Finasteride
Dutasteride
Management of BPH in secondary care (if lifestyle and medication fails)
Flow rate done before considering surgery.
Surgery.
When is surgery done?
When lifestyle and medical management fails.
When there is urinary retention that needs intervention.
What surgical procedure is used in BPH?
TURP (Transurethral resection of prostate)
