Urological Conditions Flashcards
Varicocele
etiology
symptoms & signs
diagnosis
treatment
Etiology
- dilation of the spermatic veins in the superiod scrotum (part of the spermatic cord)
- most frequenlty left-sided & can cause infertility!!
- most commonly young adolescents or early adult
- if right sided: think clot because closer to IVC
Symptoms and Signs
- dull pain, achy in scrotum (standing/valsalva makes it worse)
- decreased fertility: can be the reaosn then come in!!
- bag of worms: nontender, soft mass
- can cause atrophy of the testicle
Diagnosis
- scrotal US
- if needed: abdomnial/pelvic US
Treatment : depends on age and size and sperm count!!
males under 21
- if the testicle is small (hypotrophic) or low sperm count = surgicial ligation or embolization: to divert the flow away from the dilated veins
- if the testicle is normal size and normal semen counts = monitr Q1-2years for fertility
-if child < 9 years old: do US to r/o retroperitonal mass
males over 21
- monitor semen levels – if abnormal do surgery
- if fertilitiy no issue: NSAIDS and elevations as conservitive management
Hydrocele
Etiology
Symptoms & Signs
Diagnosis
Treatment
Etiology
- a collectionf of fluid from the peritoneiu which gets caught in the viseral and parietal peritoneium within the tunica vaginalis the connection between the abdomen and the scrotum
- thus, a collection of fluid accumulates around the scrotum
2 types
- communicating: open to the peritoneium & flows freely
- noncommunicating: NOT open fluid flowing from peritoneum in
Symptoms & Signs
- idopathic in nature
- the fluid can cause inflammation of the scrotal contents (epydidymitis, torsion, etc.) = acute reactive hydrocele which need to reat underlying condition
- soft collection of fluid in the scrotum- transillumination shows mass, blood or fluid
Diagnosis
- clinical dx.
- can do scrotal US
Treatment
- idopathic: no needed to treat but can surgically excise
- aspiration NOT helpeful: it will just come back
- inflammatory: treat underlying cause
Epididymal cyst/spermatocele
Etiology
Symptoms & Signs
Diagnosis
Treatment
Etiology
- spermatocele = an epididymal cyst > 2cm
- a cystic mass containing fluid & sperm
Symptoms & Signs
- hard, PAINLESS mass in the scrotum
- can be chronic
- alwasy rule out cystadenocarcinomas (VHL disease)
Diagnosis
- scrotal US to dx. (and r/o cancer)
Treatmnet
- not needed
- excision if chronic or painful
Testicular Torsion
Etiology
Symptoms & Signs
Diagnosis
Treatement
Etiology
- testis should be attached to the tunica vaginalis – if its not anchored down –> freely able to twist around and cuts off blood supply to the testis - TRUE EMERGENCY!!!
- most common: neonates & post-puberty
Symptoms & Signs
- PAINNNNN usually unilateral
- can see nausea, vomiting, lower abdominal pain
- usually after vigourous exercise or trauma to scrotum
- TENDER upper scrotum (hemi-scrotum)
- horizontal testes
- NEGATIVE cremasteric reflex (testis doesnt rise up)
- prehn’s sign: if relief with elevated = epididymitis, no relief = torsion
Diagnosis
- scrotal US: to see blood flow & position
Treatment
- EMERGENCY surgery = 6 hours to save the testis
- if you can’t get surgery in 6 hours –> manual detrose 540 degrees (pre-treat with opioids)
Appendageal Torsion
Etiology
Symptoms and Signs
Diagnosis
Treatment
Etiology
- there are nonfunctioning portions of the testis, epidid., etc which are deemed “appendix”
- these can easily torse too – like the testes themselves
- more common in kids
Symptoms and Signs
- mild pain: less severe than testicular
- no N/V associated
- blue dot sign
- temper to palpate
Diagnosisi
- can do US to confirm
Treatment
- can resolve on its own
- NSAIDS, rest
- surgery if it doesnt self-resolve
Epididymitis
Etiology
Symptoms and Signs
Diagnosis
Treatment
Etiology
- infection of the epididymits (“top hat of the testis”) due to chalymida, gonorrhea, enteris (e.coli) or mycobacterium
Symptoms and Signs
- posterior swelling/pain of the scrotum; gradual onset & can spead to abdomen or inguinal region
- Prehn’s sign: pain releaved with elevation of the scrotum
- systemic signs: fever, n/v, LUTI
- cremaster reflex preserved it will go up
- can spread to the testes: orchitis
Diagnosis
- can be clinical
- if urinalysis: pyuria (leukocytes & nitrites)
- can do NAAT test to confirm gonorrhea or chalymidia
Treatment
high risk STI pts.
- ceftriaxone + doxycycline
- PCN allergy: gentamycin AND azithromycin (and the doxy.)
high risk STI AND insertitve anal intercourse
- ceftriaxone + doxycycline + florquinolone (cipro or levo)
low risk STI
- levofloxicin OR bactrum
if no imporvement – US to R/O abscess
Orchitis
etiology
symptoms and signs
diagnosis
treatment
etiology
- usually a result of epididymitis
- almost always infectious: GC/chalymydia, enterics
- think about mumps!! seen 2-5 days after the parotitis!!!! – can lead to subfertility
Symptoms
- scrotal pain, swelling and tenderness
Diagnosis
- need to rule out leukemic infiltration – Acute lymphocytic leukemia (ALL) likes to go here
- physical exam: can be clinical diagnosisi
Treatment: same as epididymitits
high risk STI
- ceftriaxone + doxycycline
- PCN allergy: do gentamicycin + azythromycin + doxy.
high risk STI + insertitive anal intercourse
- ceftriaxone + doxycycline + florquinolone (cipro or levo)
low risk STI
- levofloxicin or bactrum
Balanitis & Balanoposthitis
Etiology
Symptoms & Signs
Diagnosis
Treatment
Balanitis: infection in glans of penis only
balanoposthitis: infection of glands and foreskin of penis
Etiology
- most commonly: group A strep difficult to differentiate from other derm lesions!!
Treatment
- proper hygeine
- fungal: clotrimazole or miconazole (alleergy: nystatin)
- bacterial: mupirocin if severe = amoxicill/clavlanic acid
- recurrent infections: need a dorsal slit procedure
always evaluate because could be first sign or DM or HIV
Fournier Gangrene
Etiology
Symptoms & Signs
Diagnosis
Treatment
Etiology
- necortizing fasciitis of the perineum (men or women)
- pathogens: e. coli, klebsiella, fuso, bacteriodies, clostridum
Symptoms and Signs
- fever, pain, edema of tissues
- can present with sepsis!!
- pts. on SGLT2 inhibitors at an increased risk
Diagnosis
- CT scan to identify the extent of disease
Treatment
- surgery!!!, IV antibiotics, hyperbaric oxygen
Urethritis
Etiology
Symptoms and Signs
Diagnosis
Treatment
Etiology
- infection of the urethra most commonly from sexually transmitted disease
- classification of gonococcal or non-gonnococcal
- gonorrhea, chalymida, mycobacterium
Symptoms
- majortiy are asymptomatic
- discharge, buring/pain
Diagnosis & treatment : need gram staining
- no gram stain avalible: treat for gon/chalm = ceftriazone and doxy.
- if gram - diplococci: think gon BUT treat for chalymida too! – ceftriaxone and doxy
- if no organisims seen on stain: treat with doxycycline alone
- NAAT test: treat whatever is identified
- Treat partners!!
- test for cure after 3 months (gonorrhea)
Phimosis
Etiology
Treatment
Etiology
- unable to retract the foreskin
- physiologic: the tissue wone retract kids under 5
- pathologic: due to scarring via fiberosis or inflammation see fiberous ring on glans
Treatment
- circumcision
Paraphimosis
- etiology
- treatment
urological emergency
Etiology
- prolonged retraction of the foreskin such that inflammation and edma leads to the inability to return to normal
Treatment
- pain control: extremely painful
- compression of the glans (after meds) to return to normal
- dorsal slit of foreskin if unable to return to normal
Hematospermia
etiology
symptoms and signs
diagnosis
treatment
etiology & symptoms
- bloody/pink colored semen
Diagnosis & treatment
-usually benign condition
- can be post transurethral procedure
- over 40 = think malignancy
Penile Trauma (bent)
etiology
treatment
urologic emergency
etiology
- forceable bending of the corpus cavernosa during sexual activity
- pt. will usually hear a snap or a pop
- severe pain, discoloration and swelling (not erect)
Treatment
- surgery immediately to fix
Penile Trauma (Zipper) (ring injury) (constrictive)
treatment
Zipper entrapment
treatment
- mineral oil to lubercant & lidocaine to numb = pull zipper
- cut zipper
Ring Injury
- ring at base causes edema and gets stuck
treatment
-compression of shaft
ring cutters
constrictive
- hair tourniquet or strings –> pain and ischemia
treatment: cut to remove
Basics of Erectile Dysfunction
- why it can occur
- key history taking points
reasons for
- rapid ED
- nonsustained ED
- depression
- loss of notural erections
- erection: smooth muscle relaxation allows for arterial flow into the penis, cutting of venous return and leaving it erect –> when it needs to become flaccid, the muscle constricts, blocks arterial flow and releases the “stop” of venous return– so blood can exit
needs..
- psychological
- neural
- vascular
- hormonal
to all work togeher
history
- erection enough for penitration, stimuli? intermittent or not
- evaluate for other midecial conditions: vascular issues, neruologica, cardiac, PVD, kidney
- drug use!!!
- medication use!!!
rapid ED: think psychogenic or trauma to area
nonsustained: think anxiety or venous leak
depression/drugs: think of these
lost noctural: vascular disease, neurologica disease
Labs and Managemnet of ED
labs
- glucose A1C
- lipids
- liver/LFTs
- TSH
- testosterone levels
- nocturnal tumescence testing
those with high risk CVD need to have a cardio wrokup before treatment for ED
Management
psychologic: work on underlying cause; trazodone
- treat underlying depression/anxiety with SSRI (buproprion can be best)
PDE-5: good initial thearpy
- sildenafil, vardenifil, tadalifil –> still need the stimuli!
- watch with nitroglycerin!!! over vasodilate
- sidenafil: more SE; take daily (4-5hr.last)
- tadalaifl: take low does daily (36hr. last)
- sildenafil & vardenafil: empty stomach!!
other options
- vaccum assiste device
- alprostadil: injection or suppository
- penile implants
Priapism
etiology
symptoms and signs
Etiology
- a persistant, painful erection lasting > 4 hours not including the glans or corpus spongiosum
- can be idopathic, malignant (leukemia), trauma,
- medication-induced: ED meds! or illicit drugs
- kids = sickle cell disease
Ischemic Priapism
- impaired ability of the cavernosal smooth muscle to relax (paralysis) –> impedes outflow and leads to compartment syndrome
- leads to blood not getting oxygenated–> ischemia of the tissue that is irrerversible after 24-48 hours
Non-ischemic priapsim
- result of a fisula between cavernosal artery and the corpus cavernosum itself –> results in an increased arterial influx!!!
- the blood is well-oxygenated- so its not as bad as ischemic * this can resolve
Priapsim
Diagnosis
Treatment
Diagnosis: decide if ischemic or non-ischemia
- aspirate blood to get blood gas analysis
- ischmic: black blood (hypoxia, hypercarbia, acidemia)
- non-ischemic: red blood
- can get CBC (sickling or leukemia)
- urine tox. for drugs
Treatment
ischemic:
first line = aspiration and irrigation
- can inject phenylephrine (sympathomimic to relax)
- surgical shunting if needed
non-ischemic
- can resolve on own
- injected phenylephrine (to relax via SNS)
Peyronie Disease
etiology
symptoms
diagnosis
treatment
etiology
- localized fibration of tunica albuginea creatinga deformity of the penis (bent), mass and ED
Diagnosis
- clinical
- can palapate plaque
Treatment
- can resolve on own
- collagen clostridum hystolitica (CCH) injection will get rid of plaque
- surgery if not
Premature Ejaculation
treatment
Delayed Ejaculation
treatment
Premature Treatment
- SSRI: paroxitine (will cause later ejaculation)
- clomipramine (TCA)
- tramadol
- topical anesthetics
Delayed Ejaculation
- due to meds (alpha blockers (BPH), 5-alpha reductase (BPH) , SSRIs
- cure the prostate disorder
Low Libido
Etiology
- Low lipido
- stess
- relationship issues
- systemic illess
- depression
medications can cause it!!
- SSRIs, antiandrogens (finasteride), 5-alpha reductase, opioids
- weed
