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Integration for Clinical Application > Session 3: Men's Health - Urology > Flashcards

Session 3: Men's Health - Urology Flashcards

1
Q

What is phimosis?

A

When the prepuce (foreskin) cannot be fully retracted over the glans in adults.

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2
Q

Is phimosis common?

A

Phimosis can be physiological and then it is common in young ages.

50% at 1 year

10% at 3 years

1% at 17 years.

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3
Q

Complications/effects of phimosis.

A

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

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4
Q

What is balanitis?

A

Inflamed glans

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5
Q

What is posthitis?

A

Inflamed foreskin

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6
Q

What is paraphimosis?

A

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.

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7
Q

Commonest causes of paraphimosis.

A

Phimosis

Catheterisation especially in elderly

Penile cancer

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8
Q

Best treatment of phimosis.

A

Circumcision

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9
Q

Treatment of paraphimosis.

A

Needs reduction and this is usually achieved manually.

However a dorsal slit might be necessary.

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10
Q

Most common type of penile.

A

Squamous cell carcinoma.

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11
Q

Epidemiology of penile cancer.

A

Very rare with around 350 new cases per year in the UK.

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12
Q

Risk factors of penile cancer.

A

Phimosis

Hygiene

Smegma

HPV 16&18

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13
Q

Prognosis of penile cancer.

A

If untreated most patients die within 2 years.

Almost all will die within 5 years.

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14
Q

Causes of circumcision in paediatrics.

A

Religious reasons

Recurrent balanitis and UTIs.

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15
Q

Causes of circumcision in adults.

A

Recurrent balanitis

Phimosis

Recurrent paraphimosis

Balanitis Xerotica Obliterans

Penile cancer

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16
Q

Causes of acute scrotal pain.

A

Testicular torsion (Most important to rule out)

Epididymitis

Orchitis

Epididymo-orchitis

Torsion of hydatid of Morgagni

Trauma

Ureteri calculi

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17
Q

Common presentation/history of testicular torsion.

A

Usually younger patient (<30 years)

Sudden onset which can commonly wake them up from sleep

Unilateral pain and may be associated with nausea

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18
Q

What would be found on examination on testicular torsion?

A

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..

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19
Q

Common presentation of epididymo-orchitis.

A

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.

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20
Q

Examination findings of epididymo-orchitis.

A

May be pyrexial and even septic

Scrotum erythematous

Can have enlarged and tender tesis/epididymis

Can have abscess

May have reactive hydrocoele.

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21
Q

What is a rare but serious complications of epididymo-orchitis?

A

Fournier’s gangrene.

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22
Q

What is Fournier’s gangrene?

A

Necrotic area of scrotal skin with a high mortality rate of around 50%.

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23
Q

Investigations of epididymo-orchitis.

A

Bloods like FBC, U&Es, cultures

Urine dipstick

Radiology if suspect abscess

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24
Q

Treatment of epididymo-orchitis.

A

Antibiotics (anaerobic)

If abscess then surgical drainage and antibiotics

If Fournier’s gangrene then emergency debridement and antibiotics.

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25
Q

Key history from scrotal lumps.

A

Is it painful?

How quickly did it appear?

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26
Q

Key examinations.

A

Can you get above it?

Is it in the body of the testis?

Is it separate to the testis?

Does it fluctuate and transilluminate?

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27
Q

If you can’t get above the lump, what is it likely to be?

A

A hernia

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28
Q

If it is in the body of the testis, what is it likely to be?

A

A testicular tumour

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29
Q

Give examples of painless non-tender lumps.

A

Testis tumour

Epididymal cyst

Hydrocoele

Reducible inguino-scrotal hernia

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30
Q

Likely diagnosis if the lump is painless during the day but get’s achy at the end of the day.

A

Varicocoele

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31
Q

Give examples of painful/tender scrotal lumps.

A

Epididymitis

Epididymo-orchitis

Strangulated inguino-scrotal hernia

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32
Q

General history of testicular tumour.

A

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

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33
Q

Common risk factor of testicular tumours.

A

Cryptorchidism

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34
Q

Findings on examination of testicular cancer.

A

Body of testis is abnormal

Can get above

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35
Q

Investigations of testicular cancer.

A

Urgent USS of scrotum

Tumour markes such as aFP, hCG, LDH

36
Q

Clinical presentation of hydrocoele.

A

Slow/sudden onset

Can be either unilateral or bilateral.

37
Q

Cause of hydrocoele.

A

Imbalance of fluid production and resorption between tunic albuginea and tunica vaginalis.

38
Q

Findings on examination of testis in hydrocoele.

A

Testis not palpable seperately

Can usually get above the testis

Transilluminates

39
Q

Clinical presentation of epididymal cyst.

A

Usually painless

40
Q

Findings on examination of epididymal cysts.

A

Separate from testis.

Can get above the mass

Transilluminates

41
Q

Clinical presentation of varicoele.

A

Dull ache at the end of day.

May be associated with reduced fertility.

Left testicle more commonly affected than right.

42
Q

Findings on examination of varicoele.

A

Bag of worms above testis.

Not tender

43
Q

What is important to consider and examine in a varicocoele?

A

If there is any palpable abdominal/renal mass because varicocoeles can be secondary to renal disease.

44
Q

Tx of testicular tumour.

A

Inguinal orchidectomy

45
Q

Tx of epididymal cyst.

A

Reassurance but excision if large and symptomatic.

46
Q

Tx of hydrocoele.

A

Reassure and excise if large/symptomatic

47
Q

Tx of varicocoele.

A

Reassurance

Radiological embolisation if symptomatic, if infertile, if present in adolescent and growth of testis is affected.

48
Q

Tx of inguino-scrotal hernia.

A

Surgery

49
Q

Causes of urinary retention.

A

BPH and prostate cancer

Phimosis/urethral stricture or meatal stenosis

Constipation

UTI

Drugs

Over-distension

Following surgery

Neurological

50
Q

What kind of drugs can lead to urinary retention?

A

Anti-cholinergics

Alpha-1 agonists

51
Q

Why would anticholinergic cause urinary retention?

A

Anti-cholinergics inhibit the parasympathetic system.

The parasympathetic system is needed in order to void.

52
Q

Why would alpha1-agonists cause urinary retention?

A

Because they act on alpha-1 receptors in the prostate and the IUS and constrict the IUS. This causes urinary retention.

53
Q

Type of urinary retention.

A

Acute painful

Chronic painless/less painful

Acute on chronic which is painful

54
Q

Features of acute painful UR.

A

Pain relieved by drainage

Residual volume less than 1000 ml

No kidney insult

55
Q

Tx of acute painful UR.

A

Trial without catheter (TWOC) after addressing the exacerbating factors.

56
Q

Features of chronic painless/less painful UR.

A

May just notice abdominal swelling

Residual volume >300 ml and may go up to extremely high numbers such as 5L.

May have kidney insult.

57
Q

Tx of chronic painless/less painful UR.

A

Learn to self-catheterise.

58
Q

Features of acute on chronic painful UR.

A

Residual volume >1000 ml

Usually have kidney insult.

59
Q

Tx of acute on chronic painful UR.

A

Long-term catheter or surgical intervention as TWOC is usually not successful.

60
Q

What is the clinical diagnosis of older men with nocturnal enuresis?

A

Chronic retention with overflow incontinence until proven otherwise.

61
Q

What can LUTS in men be divided into?

A

Voiding problems

Storage problems

62
Q

Give voiding symptoms

A

Hesistancy

Poor flow

Post-micturition dribbling

63
Q

Give storage symptoms.

A

Frequency

Urgency

Nocturia

64
Q

Give causes of storage LUTS.

A

Bladder infection/inflammation

Bladder stone

Bladder cancer

Overactive bladder that is idiopathic or neuropathic

Scarred bladder with low compliance.

Polyuria either global or nocturnal

65
Q

Causes of overactive bladder

A

CVA

Parkinson’s

MS

66
Q

Causes of low compliance of bladder

A

TB

Schistosomiasis

Pelvic radiotherapy

67
Q

Causes of global polyuria.

A

Uncontrolled diabetes

68
Q

Causes of nocturnal polyuria.

A

Venous stasis

Sleep apnoea

69
Q

Causes of voiding LUTS.

A

Bladder outflow obstruction

Reduced contractility of bladder

70
Q

Give examples of physical BOOs.

A

Urethra such as phimosis or strictures.

Prostate such as BPH or cancer

71
Q

Give causes of reduced contractility.

A

Neurological such as lower motor neurone lesion.

72
Q

Explain dynamic BOO.

A

Where there is increased sympathetic smooth muscular tone leading to constriction and possible stasis.

73
Q

Assessment of LUTS in primary care.

A

IPSS (international prostate symptom score)

74
Q

Examination of LUTS.

A

DRE

Palpable bladder?

Neurological if history suggest it

75
Q

Investigations of LUTS.

A

Dipstick looking for UTI or blood.

Consider as PSA

76
Q

Management of BPH in primary care.

A

Lifestyle interventions such as reduce caffeine intake, avoid fizzy drinks and don’t drink excessive amounts of fluid.

77
Q

Medicinal management of BPH in primary care.

A

Alpha blockers

5alpha-reductase inhibitors

78
Q

Explain the action of alpha-blockers.

A

Acts by relaxing the smooth muscle in the prostate and also the IUS.

This gives rapid symptom relief.

79
Q

Explain the action of 5ARIs.

A

Shrinks the prostate by inhibiting 5alpha-reductase which is supposed to convert testosterone to dihydrotestosterone (DHT).

80
Q

How does 5ARIs differ to alpha-blockers.

A

5ARIs have slower symptoms relief and also slows progression and reduces the risk of retention.

81
Q

Give examples of alpha-blockers.

A

Tamsulosin

82
Q

Give examples of 5ARIs

A

Finasteride

Dutasteride

83
Q

Management of BPH in secondary care (if lifestyle and medication fails)

A

Flow rate done before considering surgery.

Surgery.

84
Q

When is surgery done?

A

When lifestyle and medical management fails.

When there is urinary retention that needs intervention.

85
Q

What surgical procedure is used in BPH?

A

TURP (Transurethral resection of prostate)

86
Q
A

Integration for Clinical Application (11 decks)

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