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CP3 Surgery > Urology 2 > Flashcards

Urology 2 Flashcards

1
Q

What is urethritis?

A

Discharge and discomfort within the penis in men

Generally split into gonococcal urethritis and non-gonococcal urethritis (of which most common = chlamydia)

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2
Q

What is the cause of gonorrhoea?

A

Neisseria gonorrhoea - gram-negative intracellular diplococcus spread by sexual contact

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3
Q

What are the symptoms of gonorrhoea?

A

50% women, 10% men asymptomatic
Men: dysuria and urethral discharge and can ascend to cause epididymitis or prostatitis

Women: vaginal discharge, pelvic pain, dysuria and intermenstrual bleeding

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4
Q

What investigations are done for gonorrhoea?

A

Gram stain: gram negative diplococcus and culture of the discharge

NAAT from urine = highly sensitive alternative

Blood culture if suspecting disseminated gonococcus
Test for co-existing pathogens (chlamydia / syphilis)

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5
Q

What is the management of gonorrhoea

A

IM ceftriaxone
follow up and repeat cultures 72h after treatment
trace and treat all sexual contacts

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6
Q

What are the symptoms of chlamydia?

A

Asymptomatic in 50% men and 80% women
men: dysuria and discharge and can ascend (epididymitis)

in women: discharge, bleeding and lower abdominal pain (ascending infection leads to salpingitis)

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7
Q

What investigations are done for chlamydia?

A

First void in men, endocervical swabs in women
Cell culture = gold standard / direct immunofluorescence or NAAT e.g. PCR

Assess for co-existing gonorrhoea

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8
Q

What is the management of chlamydia?

A

7 days doxycycline / erythromycin
test of cure not required in simple infection
Trace sexual contacts

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9
Q

What is urethral syndrome

A

Abacteriuric frequency/dysuria

can be caused by post-coital bladder trauma, atrophic vaginitis or interstitial nephritis

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10
Q

What is the management of trauma to the urethra?

A

Specialist urological attention
if urethral Wall is partially in tact - can be treated by prolonged catheterisation

Complete tears: suprapubic catheterisation and then formal repair: urethroplasty

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11
Q

What is a urethral stricture?

A

Scar of the urethral epithelium which commonly extends into the underlying corpus spongiosum

the fibroblastic activity leads to a shortening of urethral length and narrowing of luminal size

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12
Q

What are the causes of urethral stricture?

A

Blunt perineal trauma: straddle injury, pelvic fracture
Iatrogenic: catheter / long term catheterisation
gonococcal/non-gonococcal urethritis: uncommon
Balanitis xerotica obliterans: characterised by white atrophic plaques leading to phimosis

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13
Q

What is the presentation of a urethral stricture

A 
Obstructive voiding symptoms that worsen gradually: 
initial frequency/dysuria 
Hesitancy / straining 
urinary retention 
Splayed stream
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14
Q

What are the examination findings in urethral stricture?

A

Firm areas consistent with periurethral scarring

No prostate abnormalities

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15
Q

What IX should be done for urethral stricture?

A

Uroflowmetry
Urethrogram
Urethroscopy

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16
Q

What is the management of urethral stricture?

A

Optical urethrotomy

Urethroplasty for those that recur (50%)

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17
Q

What is phimosis?

A

Inability to retract foreskin from the tip of the penis

most often idiopathic
other causes: congenital, chronic balanitis or traumatic forcible retraction of the foreskin

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18
Q

What is the presentation of phimosis in children?

A

Ballooning of the foreskin and poor stream during urination

Under 2 years - expectant approach

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19
Q

What is the presentation of phimosis in adults?

A

Pain during intercourse and inability to retract the foreskin

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20
Q

What is the management of phimosis?

A

Circumcision

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21
Q

What is paraphimosis?

A

Results from pulling a tight foreskin over the glans, obstructing venous return, leading to a swollen, painful glans

As the glans swells, it becomes increasingly difficult to replace the foreskin
Can occur after an erection or following urethral catheterisation

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22
Q

What is the emergency treatment of paraphimosis?

A

Local anaesthesia and then applying pressure to the glans or slitting the foreskin distally

Circumcision is offered after a paraphimosis to prevent recurrence

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23
Q

What is the cause of carcinoma of the penis?

A

HPV 16/18

More common in smokers and immunocompromised

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24
Q

What is the presentation of carcinoma of the penis?

A

Persistent red patch on the penis, progressing to an infiltrating ulcer

Never any urethral involvement/symptoms

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25
Q

How is diagnosis of carcinoma of the penis done?

A

Punch biopsy - microscopically Squamous cell carcinomas

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26
Q

What is the management of carcinoma of the penis?

A

Radiotherapy or penis preserving excision

If inguinal lymph nodes are involved, more radical treatment is required and success rates are lower

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27
Q

What is priapism?

A

Persistent (hours to days) erection of the corpora cavernosa of the penis - corpora spongiosum remains flaccid

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28
Q

What is the cause of priapism?

A

Usually idiopathic, but can be associated with trauma, sickle cell disease and intracavernousal injections for impotence

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29
Q

What is the treatment of priapism?

A

Ice packs, alpha agonists, selective embolisation, aspiration of the corpus cavernous or surgical intervention

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30
Q

What Peyronie’s disease?

A

Upward curvature of the penis when erect

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31
Q

What is the cause of Peyronie’s disease?

A

Unknown

fibrous scarring following trauma?

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32
Q

What is the treatment of peyronie’s disease?

A

managing associated depression and surgical intervention may help penetration

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33
Q

What are the subtypes of testicular maldescent?

A

Ectopic testes
Undescended testis
Retractile testes

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34
Q

What are ectopic testes?

A

The testes have strayed from the normal line of descent

Most common site = superior inguinal pouch

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35
Q

What is an undescended testis?

A

The testis has followed the normal route of descent, but stopped short of the scrotum

36
Q

What is the cause of undescended testis?

A

local defect in development, and the affected testis is small and accompanied by a persistent processes vaginalis

37
Q

What is the presentation of undescended testes

What is the consequence of this?

A

Congenital inguinal hernia
if the testes are going to descend, they will do in teh first few months of life

If they do not descent, they will not be capable of spermatogenesis but secondary sex characteristics develop abnormally

38
Q

What are retractile testes?

A

Normal testes with an excessive cremasteric reflex
Often confused with maldescended testes, but on examination they can be found often at the external inguinal ring and can be coaxed down

39
Q

What is the treatment for retractile testes?

A

Normal - no treatment needed

40
Q

What is the treatment of ectopic / undescended testes?

A

surgically placed in the scrotum (orchidopexy) if they are to function as a reproductive organ at 6 months

41
Q

What are the complications of maldescent?

A

Defective spermatogenesis
Increased risk of torsion
Increased risk of malignancy
Increased risk of indirect inguinal hernia (processes vaginalis)

42
Q

What are the steps to examination of a scrotal swellings?

A
  1. can I get above it?
    NO: inguinal hernia - cough
    Proximally extending hydrocele - ?transilluminates
    YES - primary scrotal swelling
  2. Transilluminates?
    YES: testicular mass/no palpable tests: hydrocele
    Separate to testes? epididymal cyst/varicocoele

NO: solid lesion
testicular mass: tumour, orchitis/gumma
USSS

separate to testis: chronic epididymitis (TB, resolving infection)

43
Q

What is the presentation of a varicocele?

A

Bag of worms

44
Q

How should torsion be tested for?

A

Cremasteric reflex: absent

Phren’s sign: scrotal elevation relieves pain in epididymitis but NOT torsion

45
Q

What is the cause of an epididymal cyst?

A

Due to cystic degeneration of epididymal structures

Associated with PKD and CF

46
Q

What is the presentation of an epididymal cyst?

A

Cystic (transilluminates)
Separate from the testes, almost always at the upper pole

Fluid may be clear or contain sperm and be milky
Previously: spermatocoele

Can sometimes be painful or bulk can be troublesome

47
Q

What is the management of epididymal cyst?

A

If troublesome, may be excised

48
Q

What is the cause of a hydrocele?

A

Fluctuant swelling that transilluminates

Caused by excessive collection of serous fluid in the processus vaginalis

49
Q

What is the cause of a congenital hydrocele?

A

Associated with a hernia sac and patent processes vaginalis

Most spontaneously resolve prior to one year

50
Q

What are primary / secondary hydroceles?

A

Primary (idiopathic) - vaginal hydrocele, separate from the peritoneal cavity

Secondary: fluid collects due to underlying inflammation in the epididymus / testes, or an underlying cancer

51
Q

What is the ix for hydrocele?

A

USS to rule out underlying pathology

52
Q

What is the management of hydrocele?

A

reassurance that it is Benign

If swelling causing problems, then excision of the hydrocele sac is possible (again, aspiration leads to recurrence)

53
Q

What is a varicocele?

A

Varicosities of the pampiniform plexus, most commonly on the left

54
Q

What is the presentation of varicocele?

A

Dragging sensation / ache
‘bag of worms’ on palpation, may only be palpable in standing position

Subfertility

55
Q

Explain why varicocele happens?

A

The left testicular vein drains into the left renal vein at right angles, rather than the right testicular vein which drains obliquely into the IVC

Valvular incompetency at the junction of the left renal vein is the pathological process leading to a varicocele

Rarely - caused by left renal tumour or other pathology compressing the left renal vein

56
Q

What are the management options for varicocele?

A

Reassurance

Treatment: radical embolisation of the left renal vein, or surgical ligation and division of the testicular veins

57
Q

What are the risk factors for testicular tumours?

A

Undescended / ectopic testes - greater if not in the anatomical position before the age of 13
Infertility
hypospadias
family / personal history

58
Q

What are the two main tumour types in testicular tumours?

A

Seminomas and non-seminomatous germ cell tumours (NSGCTs) - teratoma.

50% each

Both germ cell tumours. can sometimes be stromal tumours or lymphomas

59
Q

What tumours can occur in NSGCTs?

A

Teratomas, yolk sac tumours and choriocarcinomas

‘terror’- worse prognosis and raised bhcg/afp

60
Q

Where do seminomas come from?

A

Cells of semineferous tubules, in 30-40 year olds
Has a solid appearance macroscopically and microscopically can range from well-differentiated spermatocyte cells to undifferentiated round cells

61
Q

Where does a teratoma arise from?

A

Totipotent germ cells, in 20-30 year olds

Has a cystic appearance macroscopically and variable cell types microscopically

62
Q

How do testicular tumours spread?

A

Through the capsule

Lymph spread to para-aortic nodes and blood Bourne spread is early to the lungs and liver

63
Q

What is the presentation of a testicular tumour?

A

Painless lump in the testes
hydrocele
Haematospermia

Symptoms of metastases (abdominal swelling or breathlessness)

Rarely: painful rapidly enlarging swelling (similar to orchitis)

Rarely - gynaecomastia due to paraneoplastic hormone production

64
Q

Where do testicular tumours drain to?

A

Para-aortic nodes, so the first palpable node is likely to be supraclavicular

65
Q

What investigations should be done for ?testicular tumours?

A

Scrotal USS: can reveal a solid tumour in the presence of a hydrocele

Tumour markers: NSGCTs: usually produce AFP, some produce bHCG
Seminomas: never produce AFP, 10% produce bHCG
Useful in diagnosis and also follow up

CT CAP: for staging

66
Q

What is the management of a testicular tumour?

A

Early surgical exploration through an inguinal incision is indicated:
Orchidectomy for obvious / previously diagnosed tumours
Biopsy and frozen section if diagnosis unclear

Retroperitoneal lymph node dissection

Post surgical radiotherapy: for seminomas
Post surgical combination radiotherapy: for NSGCTs

Sperm banking used to to risks of infertility

67
Q

What is the prognosis of testicular tumours?

A

Node negative cases nearly 100% 5 year survival

Overall 5-year survival = >90%

68
Q

What is the cause of testicular torsion?

A

Usually a congenital abnormality e.g. maldescention / bell clapper testes
Testicle twists upon its pedicle, obstructing venous return

69
Q

Who gets testicular torsion?

A

Adolescents (12-18 years)

hx of mild trauma or previous attacks of pain due to a partial torsion and spontaneous resolution

70
Q

What is the presentation of testicular torsion?

A

PAIN - acute abdomen!
Unilateral, hot, swollen, tender testis, sometimes lying high and transverse within the scrotum
absent cremasteric reflex

71
Q

What are the ddx of testicular torsion?

A

Epididymitis or torsion of the testicular appendage

If any doubt - surgical exploration

72
Q

How is testicular torsion investigated / managed?

A

doppler USS - lack of blood supply to testes

Manual distortion can be attempted but surgical still needed

73
Q

What is the surgical management of testicular torsion?

A

If the testis is still viable: it is untwisted and sutured to the tunica vaginalis with fixation of the contralateral testicle also

If non-viable orchidectomy and fixation of the contralateral testis should occur

Salvage rate of 80% is achievable in patients operated on within 6 hours of initial torsion
‘time is testes’

74
Q

What is torsion of the testicular appendage?

A

Similar to testicular torsion, but an embryological remnant that twists
Less painful, and causes a small blue nodule to become visible under the scrotum
there will be no elevation of the testis
Classically occurs at the start of puberty

75
Q

What is the cause of epididymo-orchitis?

A

Ascending infection via the vas deferens
After gonococcal/non-gonococcal urethritis

After UTI due to E.coli
Can spread haematogenously e.g. in mumps or TB

76
Q

What is the presentation of epididymo-orchitis?

A

Painful swelling of the epididymis
Often with secondary hydrocele
History of discharge (STI)/ dysuria (UTI)

Examination may reveal co-existent prostatitis with a positive Phren’s test

77
Q

What investigations should be done for epidiymo-orchitis?

A

First catch urine MCS and STI screen

USS

78
Q

What is the treatment of epididymo-orchitis?

A

6 weeks ciprofloxacin
Add doxycycline if suspecting chlamydia

Analgesia and scrotal support may provide pain relief

May be a residual, firm swelling of the epididymis which can be difficult to separate from the tuberculous epididymitis

79
Q

What is the presentation of acute bacterial prostatitis?

A 
Fever/rigors, perineal pain, difficulty voiding, UTI symptoms 
Perineal pain 
difficult voiding 
UTI symptoms 
Pain on ejaculation / haematospermia

On PR, prostate is very tender and enlarged

80
Q

What is the treatment of acute bacterial prostatitis?

A

6 weeks ciprofloxacin

81
Q

What is impotence?

A

Inability to achieve or sustain an erection for sex

82
Q

What mediates erection?

A

Increased arterial inflow and occlusion of venous inflow

Mediated by parasympathetic fibres from S2-S4

83
Q

What are the causes of impotence?

A

Ageing
Neurogenic: spinal cord lesion, cerebral infarction, hypothalamic lesion, post-surgical nerve drainage

Vascular: hypertension or arterial disease (aorta-iliac disease leading to impotence and buttocks symptoms: LERICHE)

Hormonal: DM (due to neuropathy) or pituitary failure

Pharmacological: alcohol, antihypertensives, oestrogens and tranquillisers are common causes

Psychogenic

84
Q

How is impotence investigated?

A

HX and examination
urine dipstick
hormone screen

85
Q

What is the conservative treatment of impotence?

A 
Treat reversible medical causes 
correct hormone disturbances 
stop smoking 
reduce alcohol intake 
treating diabetes
86
Q

What is the medical management of impotence?

A

Sildenafil (Viagra): causes vasodilation of the corpus cavernosum
Contra-indicated if patient is on hypotensives

Intracavernosal alprostadil (PGE1) injection

Vacuum condoms or inflatable intra-penile prosthesis if these fail

CP3 Surgery (12 decks)

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