Surgery - Urology Flashcards
1
Q
What is the pathophysiology of renal stones, what are they made of?
A
- Can be renal stones or ureteric stones
- 80% are calcium (calcium oxolate, calcium phosphate, mixed oxolate and phosphate)
- The rest are struvite (staghorn calculi), urate (radiolucent) and cystine
Stones usually impact in narrowed points
- Pelviureteric Junction
- Crossing pelvic brin where iliac vessels travel across ureter
- Vesicoureteric Junction
Causes
- Urate stones = High purine (lots of red meat diet or myeloproliferative disease)
- Cystine stones = homocystinuria
- Oversaturation of urine basically causes the majority of them
2
Q
How do renal tract calculi present?
A
- Sudden onset severe pain radiating from flank to pelvis
- Nausea and vomiting
- Haematuria (typically microscopic)
3
Q
How would you investigate for renal tract calculi?
A
- Urine dip for haematuria and infection (send urine culture too)
- Routine bloods
- U&es for kidney function
- Urate and calcium levels too
- Gold standard = Non contrast CT of Renal tract (CTKUB)
- AXR sometimes however not all stones are radio-opaque
- USKUB for hydronephrosis if u&es deranged
4
Q
How would you manage renal tract calculi?
A
- Fluid resus as they are usually dehydrated
- If lower ureter or <5mm diameter = usually pass on their own with sufficient analgesia
- Opiate analgesia and NSAIDs per rectum are most effective
- >5mm stone or infected stone requires hospital admission
-
Obstructive nephropathy or significant infection = retrograde stent insertion or nephrostomy
- These are temporary measures
- You need to relieve the obstruction immediately to avoid kidney damage
- For stones that do not pass spontaneously
-
Extracorporeal Shock Wave lithotripsy
- For smaller ie <2cm stones
-
Percutaneous nephrolithotomy
- For renal stones only
- Preferred for large stones eg. staghorn calculi
- Flexible uretero-renosocpy
-
Extracorporeal Shock Wave lithotripsy
Recurrent stones
- Tell patients to stay hydrated
- Oxolate = avoid high purine foods and high oxolate foods (nuts, rhubarb, sesame)
- Calcium = check pth to exclude primary hyperparathyroidism, avoid excess salt
- Urate = avoid high purine foods (red meat, shellfish), give purine lowering meds (allopurinol)
- Cystine = genetic testing
5
Q
What are bladder stones?
A
- Form from urine stasis in the bladder so commonly seen in chronic urinary retention
- Also occur secondary to infections like schistosomiasis
- Present with LUTS
- Manage with cystoscopy or fragment them with lithotripsy
- Chronic irritation from bladder stones can cause SCC
6
Q
What is pyelonephritis?
A
- Inflammation of the kidney parenchyma and renal pelvis
- Uncomplicated = normal urinary tract in a non-immunocompromised host
- Complicated is the opposite
- Common organisms
- EColi, Klebsiella, Proteus, Enterococcus faecalis (catheter), S Aureus (catheters), Pseudomonas (catheters), Staph saprophyticus (commensal)
7
Q
What are some risk factors of pyelonephritis? (think about individual risk factors)
A
- Things that reduce antegrade flow of urine
- Neuropathic bladder from spinal cord injury
- Obstructed urinary tract eg bph
- Things that promote retrograde ascent of bacteria
- Female (short urethra)
- Indwelling catheter etc
- Structural abnormalities like vesico-ureteric reflux
- Factors causing infection/immunocompromise
- DM, corticosteroids, HIV
- Factors causing bacterial colonisation
- Renal calculi, sex, oestrogen depletion (menopause)
8
Q
How does pyelonephritis present?
A
- Triad = fever, unilateral loin pain, N&V
- Perhaps also Lower UTI symptoms = dysuria, freq, urgency
- Haematuria
- o/e pyrexial, features of sepsis
- unilateral or bilateral costovertebral angle tenderness +/- suprapubic tenderness
9
Q
How would you investigate and manage pyelonephritis?
A
- Urinalysis (nitrites and leucocytes) and send urine cultures
- Urinary bhcg for women
- Routine bloods
-
Renal Ultrasound scan (USKUB) to rule out obstruction
- Pyonephrosis would be an emergency
- If obstruction is suspected do a non contrast CTKUB
Management
- A-e resus
- Empirical antibiotics and iv fluids
- Analgesia and anti-emetics
10
Q
What kind of cancer is a renal cell carcinoma and what are some risk factors?
A
- It is an adenocarcinoma of the renal cortex
Risk factors = smoking, industrial exposure to lead/aromatic hydrocarbons/cadmium, dialysis, HTN, obesity, polycystic kidney disease, horseshoe kidneys
11
Q
How would RCC present?
A
- Haematuria
- Flank pain or flank mass
- Left sided masses also present with left varicocele sometimes due to compression of left testicular vein as it joins left renal vein
- Lethargy, weight loss etc
- Paraneoplastic syndromes = polycythaemia (erythropoietin), hypercalcaemia (pth), HTN (renin)
12
Q
How would you investigate and manage RCC?
A
Investigations
- Routine bloods
- Urinalysis and send for cytology
- USKUB as routine for haematuria
- CTCAP with iv contrast
- TNM staging of cancer from renal biopsy
Management
- Localised disease
- Partial nephrectomy for small, radical nephrectomy for large
- Unfit for surgery = Percutaneous radiofrequency ablation or lap/percutaneous cryotherapy
- Surveillance
- Mets disease
- Nephrectomy + Immunotherapy
- Biological agents like sunitinib or pazopanib
- Metastasectomy if disease is resectable
13
Q
What are renal cysts? How would you classify them?
A
- Fluid filled sacs in the kidney
- Cysts can be Simple or Complex and are classified using the Bosniak classification
14
Q
What are some risk factors of kidney cysts?
A
Risk factors = old age, smoking, htn, male gender, genetics (polycystic kidney disease, tuberous sclerosis, von hippel-lindau disease)
- ADPKD is a mutation of PKD1 and PKD2 genes resulting in multiple renal cysts forming. Also associated with berry aneurysm formation, mitral valve disease, liver cysts. Pt eventually develop end stage renal failure
15
Q
How do renal cysts present?
A
- Flank pain (if rupture of infection)
- Haematuria
- PKD = uncontrolled hypertension and a flank mass
16
Q
How would you investigate and manage renal cysts?
A
Investigations
- CT imaging with IV contrast
- Bosniak scoring for risk of malignancy
- Routine bloods like U&Es
Management
- Asymptomatic simple cysts you just leave
- Symptomatic simple cysts are manged with simple analgesia
- If significant impact to pt = needle aspiration or cyst deroofing
- Complex cysts = depends on their bosniak stage
- Continued surveillance or surgical intervention eg. nephrectomy
17
Q
Most of incontinence in Gynae…
How would you manage Stress and Urge incontinence?
A
- Lifestyle = weight loss, reduce caffeine, avoid excessive fluids, smoking cessation
Conservative
- Stress 1st line = pelvic floor muscle training for 3 months
- 2nd line = duloxetine (SNRI)
- Urge 1st line = bladder training for 6 weeks
- 2nd line = antimuscarinics like oxybutynin
- Mirabegron for older ladies
Surgical
- Stress = tension free vagina tape, open colposuspension, artificial urinary sphincter, intramural bulking agents
- Urge = botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion via ileal conduit
18
Q
What kind of cancer is bladder cancer? Risk factors?
A
- Transitional Cell Carcinomas 80-90%
- Squamous Cell Carcinomas, adenocarcinomas, sarcomas
Risk factors = smoking, old age, aromatic hydrocarbons (industrial dyes or rubbers), schistosomiasis infection (risk for SCC), previous pelvic radiation
19
Q
How does bladder cancer present?
A
- Painless haematuria
- Recurrent UTIs or LUTS
- Pelvic pain
20
Q
How would you investigate and manage bladder cancer?
A
Investigations
- TNM staging
- Urgent cystoscopy (flexible cystoscopy under LA)
- If suspicious lesion identified from initial cystoscopy then do a rigid cystoscopy under GA too
- Do a biopsy on rigid cystoscopy
- Also potentially do a Transurethral Resection of Bladder Tumour (TURBT) during rigid cystoscopy
- CT staging
- Urine cytology (not that sensitive though)
Management
- Non muscle invasive bladder cancer
- T1 = TURBT
- If higher risk, give adjuvant intravesicle therapy eg. Mitoycin C or BCG (Macille Calmette-Guerin)
- Radical Cystectomy can also be offered to high risk disease
- Regular surveillance via cytology and cystoscopy due to high risk of recurrence
- Muscle invasive bladder cancer
-
Radical cystectomy!!!
- Neoaduvant chemotherapy (cisplatin combo regimen)
- Need a urinary diversion following cystectomy through ileal conduit formation or bladder reconstruction
- Monitor b12 and folate annually as ileum is resected in urinary diversion procedures
- Regular follow up with CT imaging
-
Radical cystectomy!!!
- Metastatic or locally advanced cancer
- Chemotherapy
- MDT team, palliative team
21
Q
What is the first thing you would do if you had a scrotal lump?
A
1st line is ultrasound scan of scrotum
- No biopsy needed even to rule out testicular cancer as it can risk seeding cancer
- Do tumour markers = Lactate Dehydrogenase (LDH), Alpha-fetoprotein (AFP), B-hCG
22
Q
What are 5 extratesticular causes of a scrotal lump and 4 testicular causes?
A
Extratesticular
- hydrocoele
- varicocoele
- epididymal cysts (spermatocoele)
- epididymitis
- inguinal hernia
Testicular
- testicular tumour
- testicular torsion
- benign lesions = leydig cell tumours, sertoli cell tumours, lipomas, fibromas
- Orchitis
23
Q
What is a hydrocoele? (brief)
A
- Peritoneal fluid between parietal and visceral layers of tunica vaginalis
-
Painless fluctuant swelling that transilluminates
- Large epididymal cysts also transilluminate
- Can grow large and cause discomfort when sitting/walking
- Can occur congenitally in neonates where they regress spontaneously
- Can occur in infants due to patent processus vaginalis and need ligation
- In older males need urgent US
24
Q
What is a varicocoele? (brief)
A
- Abnormal dilation of pampiniform venous plexus within spermatic cord
- Feels like a bag of worms, there is a dragging sensation, disappears when lying flat
- Typically on L side as spermatic vein drains into left renal vein (R drains into inferior vena cava)
- Can cause infertility and testicular atrophy by increasing scrotal temp
- Undergo semen analysis
- Management = embolization or lap/open ligation of spermatic veins
25
What is a spermatocoele? (brief)
* Benign fluid filled sacs arising from epididymis
* **Smooth fluctuant nodules** that are above and separate from tests and **transilluminate**
* Often there are multiple of them
* Typically do not need treatment
26
What is Acute urinary retention and what are some risk factors?
* New onset inability to pass urine (may be passing bits but still significant residual vol)
* Results in **pain** and discomfort
Risks
* Common in older male pt due to enlarged prostate eg. BPH, strictures or prostate cancer
* Uti
* Constipation
* Severe pain
* Meds like antimuscarinics, epidurals, spinal anaesthesia etc
* Neuro causes like peripheral neuropathy, iatrogenic nerve damage in pelvic surgery, UMN disease (MS, parkinsons), Bladder Sphincter Dysinergy
27
How does acute urinary retention present?
* Acute suprapubic **pain**
* Inability to micturate
* Associated symptoms suggesting the cause eg. UTI, worsening voiding LUTS
* O/E distended palpable bladder, suprapubic tenderness
* PR to check for constipation or prostate enlargement
28
How would you investigate and manage acute urinary retention?
Investigations
* **Post void bedside bladder scan** for retained urine vol
* Routine bloods
* **_U&Es_** for high or low pressure
* Urinalysis
* **_US KUB_** if high pressured retention to check for hydronephrosis
* High pressure retention = deranged renal function due to hydronephrosis
* Low pressure retention is in patients where upper renal tract is unaffected due to competency of urethral valves or detrusor muscles contractility reduction/failure
Management
* **_Immediate urethral catheterisation_**
* Measure vol drained post catheterisation
* **Monitor urine output over 24 hours** post catheterisation
* Monitor for **post-obstructive diuresis**
* High pressure urinary retention
* **_Keep catheter insitu_** until definitive management is arranged (eg TURP) as repeated high pressure episodes can cause AKI and renal scarring and CKD
* Otherwise can remove catheter in a **_TWOC 24-48 hours after_** insertion
* If pt voids successfully with minimal residual vol = twoc successful
* Multiple failed attempts warrant a **_long term catheter_**
* Treat underlying cause eg. tamsulosin for bph
* Check urinalysis for infection and give antibiotics etc
* Review meds
29
What is Chronic urinary retention and what are some risk factors?
* **Painless** inability to pass urine
* Typically long standing retention with **significant bladder distension**, resulting in **bladder desensitisation** (therefore minimal discomfort)
Risks
* Most common cause is BPH, urethral strictures, prostate cancer
* Women = pelvic prolapse, pelvic masses (fibroids)
* Neuro = peripheral neuropathies, UMN (MS, Parkinson’s)
30
How would chronic urinary retention present?
* **Painless** urinary retention
* Voiding LUTS eg. weak stream and hesitancy
* **Overflow incontinence** (worse at night when sphincter tone is reduced = **nocturnal enuresis**)
* **Palpable distended bladder** o/e with **minimal tenderness**
* PR exam for prostate enlargement
31
How would you investigate and manage chronic urinary retention?
Investigations
* **Post void bladder scan**
* Routine bloods
* **US KUB** for high pressure if **u&es** deranged
Management
* If _\>1L post void vol_ or _high pressure_ retention = **_Long Term Catheter_**
* Also monitor urine output for post obstructive diuresis
* High pressure don’t undergo a twoc due to risk of repeated renal injury, therefore these pt need LTCs
* An alternative to LTCs are **intermittent self catheterisation**
* Pt needs to be taught how to self catheterise at regular intervals eg. 4-6 hours so needs good dexterity and compliance
32
What is benign prostatic hyperplasia?
what are some risk factors?
* Non cancerous hyperplasia of prostate tissue
* Risk factors = old age, 1st degree fhx, African/Caribbean, obesity
33
How would BPH present?
* LUTS
* Voiding = hesitancy, weak stream, terminal dribbling, incomplete emptying
* Storage = urinary freq, nocturia, nocturnal enuresis, urge incontinence
* Haematuria, haematospermia
* DRE = smooth firm symmetrical prostate
34
How would you investigate and manage BPH?
Investigations
* International Prostate Symptom Score **(IPSS) questionnaire**
* Urinalysis
* **Post void bladder scan**
* **DRE** and **Prostate Specific Antigen**
* **USKUB** for prostate volume and hydronephrosis
* Prostate \>30ml is enlarged
* Urodynamic studies
Management
* Reassurance if it was incidental finding
* **Review their medications** if they have LUTS
* Tell them to keep a **symptom diary**
* Lifestyle = moderate caffeine and alcohol
* Medical
* **_A-blockers like tamsulosin_** relax prostatic smooth muscle
* Se = postural hypotension, retrograde ejaculation, floppy iris syndrome
* **_5a-reductase inhibitors like finasteride_** can be trialled too
* They prevent conversion of testosterone to DHT so decrease prostatic vol
* Surgical
* **_Transurethral Resection of Prostate (TURP)_**
* Endoscopic removal of obstructive prostate tissue using a diathermy loop
* Complications = sexual dysfunction, retrograde ejaculation, urethral stricture, Turp Syndrome
* TURP syndrome =
* Turp involves use of **hypoosmolar irrigation** which can result in significant **fluid overload and hyponatraemia** as fluid is absorbed through exposed venous beds.
* Patients present with confusion, nausea, agitation, visual changes
35
What is prostatitis?
What are the risk factors for both acute and chronic?
* Acute bacterial prostatitis is inflammation of the prostate gland
* Typically due to ascending urethral infection
* Common causes = E.Coli, Enterobacter, serratia, pseudomonas, proteus
* Rarely stis like chlamydia or gonorrhoea
* Chronic bacterial prostatitis is due to inadequately treated acute prostatitis
Risk factors for acute
* Indwelling catheters, immunocompromise, phimosis or urethral strictures, recent surgery eg. TRUS biopsy, cystoscopy etc
Risk factors for chronic
* Above + intraprostatic ductal reflux, neuroendocrine dysfunction, dysfunctional bladder
36
How would prostatitis present?
* Acute = LUTS, pyrexia, perineal/suprapubic pain, urethral discharge
* DRE = **_tender boggy prostate_**
* Inguinal Lymphadenopathy
* Chronic = pelvic pain or discomfort for at least 3 months + LUTS
37
How would you investigate and manage prostatitis?
Investigations
* Urine culture
* STI screen and routine bloods
* Transrectal prostatic ultrasound to rule out prostate abscess
Management
* Prolonged antibiotic treatment **(quinolone) + analgesia**
* 2nd line especially for chronic = **a-blocker or 5areductase inhibitors**
* Consider referral to chronic pain specialist
38
What is epididymitis?
* Inflammation of the epididymis (orchitis is inflammation of the testes)
* Sometimes occur together = epididymo-orchitis
* But mainly epididymitis on its own
* Rarely orchitis on its own
* **Bimodal** age distribution = 15-30 years old and \>60 years old.
Causes in _\<35 year olds_ is typically sexual transmission = **N.Gonorrhoea and C trachomatis**
Causes in _\>35 year olds_ is typically **enteric organism from a UTI = E Coli**, Proteus spp, Klebsiella pneumoniae, Pseudomonas aeruginosa
39
What are some risk factors for epididdymitis?
* Non-enteric = MSM, multiple sexual partners, known gonorrhoea contact
* Enteric = recent instrumentation or catheterisation, bladder outlet obstruction eg bph, immunocompromise
40
How would epididymitis present?
* Unilateral scrotal pain and swelling
* Sometimes fever and rigors
* O/E epididymis is tender on palpation, red and swollen
* **Cremasteric reflex intact**
* **Prehns sign +ve** (pain relieved on elevating scrotum)
41
How would you investigate and manage epididymitis?
Investigations
* Urine dipstick
* If evidence for infection then send for urine microscopy and culture
* **First void urine for NAAT** = n gonorrhoea, c trachomatis, m genitalium
* And further STI screening if necessary
* Routine bloods
* Blood cultures if systemic infection
* **_Ultrasound of testes with US doppler_** to confirm diagnosis
* And rule out complications eg. testicular abscess
* Epididymitis = **increased vascularity** of epididymis
Management
* Antibiotics and analgesia
* Enteric = **_ofloxacin_** 20mg PO BD for 14 days
* STI = **_ceftriaxone**_ 500mg IM single dose and _**Doxycycline_** 100mg PO BD for 10-14 days
* **Abstain from sexual activity** until finished antibiotics done and symptoms gone
* Education about **barrier contraception**
* **Orchidectomy** for chronic epididymitis that does not improve with other therapy
42
What is testicular torsion? What are some risk factors?
* When spermatic cord and its contents **twist within the tunica vaginalis**, compromising blood supply to testicle
* Testicle will infarct within hours!! Surgical emergency
Risk factors =
* bell clapper deformity (horizontal lie to testes), 12-25 years old, previous testicular torsion, fhx of testicular torsion, undescended testes
43
How would testicular torsion present?
* Sudden onset severe unilateral testicular pain, sometimes referred to abdo
* Nausea and vomiting
* O/E **high lying and horizontal** lying testicle. Swollen and v tender
* **_Cremasteric reflex is absent_**
* **Negative Prehns sign** (positive in epididymoorchitis)
44
How would you investigate and manage testicular torsion?
Investigations
* Clinical diagnosis, take for **scrotal exploration in theatre**
* **Doppler Ultrasound**
* Urine dipstick
Management
* **Urgent surgical exploration** to assess for torsion
* If confirmed, do **_Bilateral orchidopexy_**
* If testis are non-viable then do an **orchidectomy**
* Risk of chronic pain, palpable suture, risk to fertility, etc.
* Analgesia and antiemetics
45
What is torsion of hydatid of Morgagni?
* This is a remnant of the Mullerian duct that can become torted and present similarly
* More common in younger ages.
* Scrotum is usually less erythematous with a normal lie of testis.
* Blue dot sign may be present in the upper half of the hemiscrotum = visible infarcted hydatid
46
What is testicular cancer? What are the different types?
* Most common in 20-40 years old
* Classified into **germ cell tumours (95%)** and **Non germ cell tumours**
* GCT can then be classified into **seminomas** and **non-seminomatous GCT**
* GCT are normally malignant
* NGCT are usually benign – typically **Leydig cell** or **Sertoli cell tumours**
47
What are some risk factors for testicular cancer?
cryptorchidism, prev testicular malignancy, +ve fhx, kleinfelters syndrome
48
How would testicular cancer present?
* Painless unilateral testicular lump
* Irregular, firm, fixed, does not transilluminate
* Evidence of met seg. Weight loss, back pain, dyspnoea
49
how would you investigate and manage testicular cancer?
Investigations
* Tumour markers = **BHCG, AFP, LDH**
* **Scrotal ultrasound**
* CT contrast CAP
* Do not do a trans-scrotal percutaneous biopsy!!! Causes seeding of cancer
* **Royal Marsden Classification** for testicular cancer
Management
* Main options are surgery, radiotherapy, chemo depending on tumour type and risk etc.
* Surgery = **_inguinal radical orchidectomy_**
* Do a _pre fertility assessment, semen analysis and cryopreservation_
* NS GCT
* Stage 1 = **orchidectomy** then potentially **adjuvant chemotherapy** if high risk
* **Surveillance with ct scan** at 3 and 12 months
* Mets NSGCT = chemotherapy
* Seminomas
* Stage 1 = **orchidectomy** and surveillance
* **Chemotherapy** with high relapse risk
* Mets = radiotherapy or chemotherapy
50
What is forniers gangrene? What are some risk factors?
* A form of necrotising fasciitis that affects the perineum
* Rapidly spreading necrosis of subcutaneous tissue and fascia
Common organisms = Group A strep, C. perfringes, E Coli
Risk factors
* DM, excess alcohol, poor nutritional state, steroid use, haematological malignancies, recent trauma to the region
51
How does fourniers gangrene present?
* Severe **pain out of proportion** to clinical signs
* Pyrexia
* As the disease progresses = crepitus, skin necrosis, haemorrhagic bullae, sensory loss of overlying skin
* Patients deteriorate rapidly and become severely unwell --\> septic shock
52
How would you investigate and manage fourniers gangrene?
Investigations
* Clinical diagnosis
* Surgical exploration
* Routine bloods and blood cultures
* CT imagine
* Laboratory Risk Indicator for necrotising fasciitis (LRINEC)
Management
* **Urgent surgical debridement asap**
* Partial or total orchidectomy
* **Broad spectrum antibiotics**
* Transfer to HDU
* Fluid resus and close monitoring
53
What is paraphimosis?
What are some risk factors?
* _Inability to pull forward a retracted foreskin over a glans penis_
* **Glans becomes increasingly oedematous** due to reduced venous return, resulting in **vascular engorgement** of distal penis and **further oedema**
* Leads to **penile ischaemia** and worsening **infection** eg. Fourniers gangrene.
Risk factors
* Phimosis, indwelling urethral catheter, poor hygiene, prior paraphimosis
54
How would you manage paraphimosis?
* Suitable analgesia eg. **penile block** via local anaesthetic
* Reduction asap
* If **_manual reduction**_ fails, then a _**dorsal slit**_ or _**emergency circumcision_** may be required
* After reduction ensure definitive management like circumcision Is arranged as an outpatient
55
What is priapism?
What are the 2 different types?
* Unwanted painful erection lasting more than 4 hours
High flow (non-ischaemic) priapism
* **Arterial blood rapidly enters** corpus cavernosum more quickly than it can be drained
Low flow (ischaemic) priapism
* **Blockage to the venous drainage** of the corpus cavernosum = prolonged venous stasis results in ischaemia --\> fibrosis --\> impotence
56
What are some causes of priapism (both ischaemic and non ischaemic)
Non ischaemic = penile or perineal trauma, spinal cord injury
Ischaemic =
* iatrogenic = impotence drugs (like papaverine or alprostadil), antipsychotics, anticoagulants, antidepressants)
* sickle cell disease
* haematological disorders like leukaemia and thalassaemia
* pelvic malignancy
57
How would priapism present?
* Ongoing and unwanted erection despite absence of sexual desires (**\>4 hours)**
* Ischaemic = **painful** and **rigid** erection
* Non ischaemic = **painless** and **not fully rigid** erection
58
How would you investigate and manage priapism?
Investigations
* **_Corporeal blood gas_** to determine whether it is ischaemic or non ischaemic
* Routine bloods + bone profile, haemoglobin electrophoresis (+/- drug screen)
* Non ischaemic = assess for potential spinal injury
Management
* 1st line = **_Corporeal aspiration_**
* 2nd line = intracavernosal injection of a sympathomimetic agent like **phenylephrine**
* 3rd line = **surgical shunt** to be inserted between corpus cavernosa and glans
* Complications = erectile dysfunction
59
What kind of cancer is penile cancer?
What are some risk factors?
* Typically **squamous cell carcinoma**
* Can also be basal cell, sarcomas, melanomas, urethral carcnomas
Risk factors
* HPV (16,6,18), phimosis, smoking, lichen sclerosis, HIV infection (untreated), Psoralen-UV-A Photochemotherapy
* Circumcision is deemed protective
Premalignant conditions = Condyloma acuminatum (genital warts), Bowens disease, Lichen Sclerosis
60
How does penile cancer present?
* A palpable or ulcerating lesion in the penis
* Typically located on the glans
* Lesions are painless, but can have discharge and bleeding
* Inguinal lymphadenopathy
61
How would you investigate and manage penile cancer?
Investigations
* Refer to specialist regional centre for investigation
* **Penile biopsy** to confirm diagnosis
* Then try to confirm Inguinal lymphadenopathy via PET-CT
* Then do CT CAP if inguinal lymphadenopathy is +ve to complete the staging
* TNM staging is used
Management
* Superficial non-invasive =
* topical chemo like **_imiquimod or 5fluorouracil_**
* Then repeated **biopsy** and **long term surveillance**
* Or laser ablation or glans resurfacing
* Most will need surgical treatment
* Invasive but confined to glans =
* local excision and partial **_glansectomy_** OR total glansectomy with **reconstruction**
* **Radical circumcision** for just foreskin tumours
* Invasive penile cancer =
* Partial **amputation** with reconstruction OR total **penectomy** **with perineal urethrostomy**
* + radical **neoadjuvant radiotherapy or chemo**
* ****If inguinal node involvement = **_radical inguinal lymphadenectomy_** + neo adj chemo or radio
* **_Phallic reconstruction_** is possible
62
What is a penile fracture? What would it look like?
* Traumatic rupture of corpus cavernosa and tunica albuginea in an erect penis
Presentation
* Hx of blunt trauma on erect penis
* Popping sensation or a “**snap**” with **immediate pain, swelling,** detumescence
* O/E penile swelling and discolouration (**haematoma**) = “aubergine sign”
* **Deviation away** from lesion
* Firm immobile haematoma can be palpated in the shaft = “**rolling sign”**
* **Butterfly shaped haematoma in perineum** = urethral injury
63
How would you investigate and manage penile fracture?
Investigations
* Pre-op bloods and routine bloods as this will typically be diagnosed clinically and needs urgent repair
Management
* Analgesia and anti-emetics
* Urgent surgical exploration and repair
* Abstinence from sexual activities for 6-8 weeks post op
