Surgery - Urology

Question 1

What is the pathophysiology of renal stones, what are they made of?

Answer 1

• 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

Question 2

How do renal tract calculi present?

Answer 2

• Sudden onset severe pain radiating from flank to pelvis
• Nausea and vomiting
• Haematuria (typically microscopic)

Question 3

How would you investigate for renal tract calculi?

Answer 3

• 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

Question 4

How would you manage renal tract calculi?

Answer 4

• 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

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

Question 5

What are bladder stones?

Answer 5

• 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

Question 6

What is pyelonephritis?

Answer 6

• 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)

Question 7

What are some risk factors of pyelonephritis? (think about individual risk factors)

Answer 7

• 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)

Question 8

How does pyelonephritis present?

Answer 8

• 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

Question 9

How would you investigate and manage pyelonephritis?

Answer 9

• 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

Question 10

What kind of cancer is a renal cell carcinoma and what are some risk factors?

Answer 10

• 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

Question 11

How would RCC present?

Answer 11

• 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)

Question 12

How would you investigate and manage RCC?

Answer 12

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

Question 13

What are renal cysts? How would you classify them?

Answer 13

• Fluid filled sacs in the kidney
• Cysts can be Simple or Complex and are classified using the Bosniak classification

Question 14

What are some risk factors of kidney cysts?

Answer 14

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

Question 15

How do renal cysts present?

Answer 15

• Flank pain (if rupture of infection)
• Haematuria
• PKD = uncontrolled hypertension and a flank mass

Question 16

How would you investigate and manage renal cysts?

Answer 16

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

Question 17

Most of incontinence in Gynae…

How would you manage Stress and Urge incontinence?

Answer 17

• Lifestyle = weight loss, reduce caffeine, avoid excessive fluids, smoking cessation

Conservative

• Stress 1^st line = pelvic floor muscle training for 3 months
  
  • 2^nd line = duloxetine (SNRI)
• Urge 1^st line = bladder training for 6 weeks
  
  • 2^nd 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

Question 18

What kind of cancer is bladder cancer? Risk factors?

Answer 18

• 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

Question 19

How does bladder cancer present?

Answer 19

• Painless haematuria
• Recurrent UTIs or LUTS
• Pelvic pain

Question 20

How would you investigate and manage bladder cancer?

Answer 20

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
• Metastatic or locally advanced cancer
  
  • Chemotherapy
  • MDT team, palliative team

Question 21

What is the first thing you would do if you had a scrotal lump?

Answer 21

1^st 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

Question 22

What are 5 extratesticular causes of a scrotal lump and 4 testicular causes?

Answer 22

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

Question 23

What is a hydrocoele? (brief)

Answer 23

• 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

Question 24

What is a varicocoele? (brief)

Answer 24

• 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

Question 25

What is a spermatocoele? (brief)

Answer 25

• 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

Question 26

What is Acute urinary retention and what are some risk factors?

Answer 26

• 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

Question 27

How does acute urinary retention present?

Answer 27

• 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

Question 28

How would you investigate and manage acute urinary retention?

Answer 28

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

Question 29

What is Chronic urinary retention and what are some risk factors?

Answer 29

• 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)

Question 30

How would chronic urinary retention present?

Answer 30

• 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

Question 31

How would you investigate and manage chronic urinary retention?

Answer 31

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

Question 32

What is benign prostatic hyperplasia?

what are some risk factors?

Answer 32

• Non cancerous hyperplasia of prostate tissue
• Risk factors = old age, 1^st degree fhx, African/Caribbean, obesity

Question 33

How would BPH present?

Answer 33

• LUTS
  
  • Voiding = hesitancy, weak stream, terminal dribbling, incomplete emptying
  • Storage = urinary freq, nocturia, nocturnal enuresis, urge incontinence
  • Haematuria, haematospermia
• DRE = smooth firm symmetrical prostate

Question 34

How would you investigate and manage BPH?

Answer 34

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

Question 35

What is prostatitis?

What are the risk factors for both acute and chronic?

Answer 35

• 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

Question 36

How would prostatitis present?

Answer 36

• 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

Question 37

How would you investigate and manage prostatitis?

Answer 37

Investigations

• Urine culture
• STI screen and routine bloods
• Transrectal prostatic ultrasound to rule out prostate abscess

Management

• Prolonged antibiotic treatment (quinolone) + analgesia
• 2^nd line especially for chronic = a-blocker or 5areductase inhibitors
• Consider referral to chronic pain specialist

Question 38

What is epididymitis?

Answer 38

• 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

Question 39

What are some risk factors for epididdymitis?

Answer 39

• Non-enteric = MSM, multiple sexual partners, known gonorrhoea contact
• Enteric = recent instrumentation or catheterisation, bladder outlet obstruction eg bph, immunocompromise

Question 40

How would epididymitis present?

Answer 40

• 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)

Question 41

How would you investigate and manage epididymitis?

Answer 41

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

Question 42

What is testicular torsion? What are some risk factors?

Answer 42

• 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

Question 43

How would testicular torsion present?

Answer 43

• 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)

Question 44

How would you investigate and manage testicular torsion?

Answer 44

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

Question 45

What is torsion of hydatid of Morgagni?

Answer 45

• 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

Question 46

What is testicular cancer? What are the different types?

Answer 46

• 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

Question 47

What are some risk factors for testicular cancer?

Answer 47

cryptorchidism, prev testicular malignancy, +ve fhx, kleinfelters syndrome

Question 48

How would testicular cancer present?

Answer 48

• Painless unilateral testicular lump
  
  • Irregular, firm, fixed, does not transilluminate
• Evidence of met seg. Weight loss, back pain, dyspnoea

Question 49

how would you investigate and manage testicular cancer?

Answer 49

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

Question 50

What is forniers gangrene? What are some risk factors?

Answer 50

• 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

Question 51

How does fourniers gangrene present?

Answer 51

• 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

Question 52

How would you investigate and manage fourniers gangrene?

Answer 52

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

Question 53

What is paraphimosis?

What are some risk factors?

Answer 53

• 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

Question 54

How would you manage paraphimosis?

Answer 54

• 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

Question 55

What is priapism?

What are the 2 different types?

Answer 55

• 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

Question 56

What are some causes of priapism (both ischaemic and non ischaemic)

Answer 56

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

Question 57

How would priapism present?

Answer 57

• Ongoing and unwanted erection despite absence of sexual desires (>4 hours)
• Ischaemic = painful and rigid erection
• Non ischaemic = painless and not fully rigid erection

Question 58

How would you investigate and manage priapism?

Answer 58

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

• 1^st line = Corporeal aspiration
• 2^nd line = intracavernosal injection of a sympathomimetic agent like phenylephrine
• 3^rd line = surgical shunt to be inserted between corpus cavernosa and glans
  
  • Complications = erectile dysfunction

Question 59

What kind of cancer is penile cancer?

What are some risk factors?

Answer 59

• 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

Question 60

How does penile cancer present?

Answer 60

• A palpable or ulcerating lesion in the penis
  
  • Typically located on the glans
• Lesions are painless, but can have discharge and bleeding
• Inguinal lymphadenopathy

Question 61

How would you investigate and manage penile cancer?

Answer 61

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

Question 62

What is a penile fracture? What would it look like?

Answer 62

• 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

Question 63

How would you investigate and manage penile fracture?

Answer 63

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