The Urethra, Penis and Scrotum Flashcards
Describe the aetiology and clinical presentation of urethral stricture?
It is caused by scar tissue following inflammation, most commonly caused by:
- Iatogenic: Catheterisation, previous prostate surgery
- Infection: gonorrhoea urethritis
- Idiopathic
- BXO
- Congenital: rare
Presents with:
- Slow stream, dribbling.
- Hesitancy.
- Overflow incontinence*
- Haematuria
- UTI’s
- Retention
How is urethral stricture investigated and managed?
Can be investigated with:
- Uroflowmetry
- Retrograde urethrogram (Xray urinary tract with contrast)
- Urethroscope
Management is surgical:
-Dilation: under local anaesthetic gradual balloon dilation inserted via a catheter
-Urethrotomy: a laser at the end of the cystoscope is used to cut the stricture
-Anastomotic/substitution urethroplasty
Area with stricture is removed and the 2 sections are reconnected or where a urethra is constructed from other tissues.
What causes paraphimosis, how does it present and how should it be managed?
Urological Emergency
Patients foreskin is retracted and they cannot pull it back over the glans which blocks the venous drainage of the glans which can cause necrosis.
Most commonly caused following catheterisation if the patients foreskin isn’t pulled back over the glans.
Management:
Compression with saline soaked swab, followed by manual reduction (essentially pull it back over)
If simple methods fail then urgently refer to urology.
Urologist may insert multiple punctures in the oedematous foreskin to prevent necrosis, or occasionally may do dorsal incision (open up the foreskin essentially and stitch back up when the swelling has reduced.
How does varicocele present and how should it be managed?
When there are varicosities in the pampiniform plexus. 10% men
Presents with:
- Swelling (feels like a bag of worms)
- Achey pain
No medical treatment but they can be repaired surgically.
Reassurance of benign nature.
Surgical repair is only recommended for:
-Pain
-Infertility issues (mixed opinions)
-To prevent testicular atrophy
How does hydrocele present and how should it be managed?
A collection of fluid within the tunica vaginalis (the peritoneum surrounding the teste).
Presents as a global scrotal swelling, with or without pain.
Can be managed conservatively with reassurance and scrotal support in non-communicating hydrocele’s where other pathology has been ruled out.
Can be drained surgically under GA
Congenital is due to a patent processus vaginalis (communicating)
Can also be 2y to: epidiymo-orchitis, testicular tumour, trauma (secondary and non-communicating)
Note: A communicating hydrocele is where there is persistence of the processus vaginalis allows peritoneal fluid to communicate freely with the scrotal portion of the processus.
How does epididymal cyst present and how should it be managed?
Epididymal cyst also known as a spermatocele:
A collection of spermatic fluid in the epididymis usually presenting with a painless swelling. Rare in children.
No treatment is needed. Safety netting should involve patient coming back if it becomes painful or there is a sudden increase in size.
How does phimosis present and how should it be managed?
Patients foreskin is to tight and therefore they cannot retract it back over his bell end (glans penis), can be painful.
Can be congenital or acquired (associated with poor hygeine)
If a child is younger than 2 years may just be a physiological phimosis therefore should just be managed expectantly.
May present with poor stream in children, in adults may cause painful intercourse and inability to retract.
If older than 2 years likely to be a pathological phimosis treatment is with circumcision.
Discuss the presentation, examination findings and cause of testicular torsion?
Sudden, intense pain in the testis, radiating to the abdomen
May be associated vomiting, and a scrotal/inguinal swelling.
The testis may be hot, swollen and tender, it may be retracted, and the ipsilateral cremaster reflex will be absent.
It is most common in men under the age of 20
How is testicular torsion investigated and managed?
Investigation:
Doppler US may demonstrate lack of blood flow but should not delay surgery.
Management:
Surgery expose and untwist testes, suturing it to the tunica vaginalis, if colour is good return to scrotum and fix BOTH testes. If necrotic remove teste.
80% recovery if operated on within 6h
Discuss the presentation and pathology of epididymo-orchitis?
Infection of the epididymis usually caused by infectious spread from the urethra, commonly from UTIs, STI’s (chlamydia/gonorrhea) or gram -ve’s in the elderly.
- Unilateral scrotal pain and swelling.
- UTI or STI symptoms
- 2y hydrocele common
- Phrens test positive (lifting testis relieves pain)
The pain is not as sudden as with torsion.
Orchitis is just swelling of the testes and is most commonly caused by mumps.
How is epididymo-orchitis investigated and treated?
Urinalysis
MSU
Urethral swab for STI’s
Antibiotic treatment should be given the regimen should be guided by the investigation results.
- 6 weeks ciprofloxacin
- Analgesia
If the cause is likely due to STI’s important to perform contact tracing.
Describe the main pathological classifications of tumours of the testis?
5 year survival rate?
Seminomatous germ cell tumours (95%)
- Seminomas
- Non-seminomatous germ cell tumours
Non seminomatous - germ cell tumours NSGCT
- Lymphomas (4%)
- Teratomas
- Yolk Sac Tumours
Node negative cases have nearly a 100% 5 year survival.
How do testicular tumours present?
How do they spread and where do they met too?
Most common in 25-35 yo and has a very good prognosis.
Present with a painless swelling in the testes. Which will be fixed, hard and nodular. Patient may also have: – Testicular/abdo pain – Hydrocele – Gynecomastia
Spread is principally along the spermatic cord through lymphatics and blood vessels. (follows testicular aa to para-aortic nodes)
Mets symptoms: lungs (Abdo swelling or breathlessness)
How should suspected testicular Ca be investigated?
Bloods:
•Alpha-fetoprotein (AFP) only produced by yolk sac tumours (teratomas)
•Beta-hCG is produced by trophoblastic elements may be elevated in teratomas or seminomas. (mostly seminomas)
Imaging:
- USS of testes
- Staging thoarco-abdomial CT
How is testicular Ca treated?
Radical orchidectomy should be performed when possible. Prosthetic testicles are available. +/- lymph node dissection
Surgical exploration + biopsy and frozen section if diagnosis is unclear
Adjuvant chemo/radiotherapy may also be needed depending on staging of tumour.
Seminomas are highly sensitive to radiotherapy so often do post surgery radiotherapy
NSCGT are not radiosensitive so need post surgical chemo
Sperm storage can be offered to young men that will need chemo/radiotherapy.
