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:
- Catheterisation
- Infection (gonorrhoea or recurrent UTI’s)
- Invasive tumour
- renal caliculi
- idiopathic
You can also have congenital strictures.
Presents with: Slow stream, dribbling. Hesitancy. Overflow incontinence* Haematuria UTI's
*Incomplete emptying of the bladder due to some sort of obstruction which leads to you leaking urine.
How is urethral stricture investigated and managed?
Can be investigated with:
- Urodynamic studies to assess flow
- 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.
Presents with:
- swelling (feels like a bag of worms)
- achey pain
No medical treatment but they can be repaired surgically. 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).
May be congenital or caused by trauma, tumour, infection, or peritoneal dialysis.
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.
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.
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 retract, and the 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, if colour is good return to scrotum and fix BOTH testes. If necrotic remove teste.
Discuss the presentation and pathology of epididymo-orchitis?
Infection of the epididymis usually caused by infectious spread from the urethra, commonly from STI’s (chlamydia/gonorrhea) or gram -ve’s in the elderly.
Presents with unilateral scrotal pain and swelling. May be associated with signs of UTI or STI depending on the aetiology of the ascending infection.
The pain is not as sudden as with torsion.
Orchitis is just swelling of the teste 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.
If the cause is likely due to STI’s important to perform contact tracing.
Describe the main pathological classifications of tumours of the testis?
Germ cell tumours (95%)
- Seminomas
- Non-seminomatous germ cell tumours
Non germ cell tumours
Lymphomas (4%)
Teratomas
Yolk Sac Tumours
How do testicular tumours present? Briefly outline their biological behaviour?
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.
How should suspected testicular Ca be investigated?
Bloods:
•Alpha-fetoprotein (AFP) produced by yolk sac tumours
•Beta-hCG is produced by trophoblastic elements may be elevated in teratomas and in 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.
Adjuvant chemo/radiotherapy may also be needed depending on staging of tumour.
Sperm storage can be offered to young men that will need chemo/radiotherapy.
