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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
How is diagnosis of carcinoma of the penis done?
Punch biopsy - microscopically Squamous cell carcinomas
26
What is the management of carcinoma of the penis?
Radiotherapy or penis preserving excision If inguinal lymph nodes are involved, more radical treatment is required and success rates are lower
27
What is priapism?
Persistent (hours to days) erection of the corpora cavernosa of the penis - corpora spongiosum remains flaccid
28
What is the cause of priapism?
Usually idiopathic, but can be associated with trauma, sickle cell disease and intracavernousal injections for impotence
29
What is the treatment of priapism?
Ice packs, alpha agonists, selective embolisation, aspiration of the corpus cavernous or surgical intervention
30
What Peyronie's disease?
Upward curvature of the penis when erect
31
What is the cause of Peyronie's disease?
Unknown | fibrous scarring following trauma?
32
What is the treatment of peyronie's disease?
managing associated depression and surgical intervention may help penetration
33
What are the subtypes of testicular maldescent?
Ectopic testes Undescended testis Retractile testes
34
What are ectopic testes?
The testes have strayed from the normal line of descent | Most common site = superior inguinal pouch
35
What is an undescended testis?
The testis has followed the normal route of descent, but stopped short of the scrotum
36
What is the cause of undescended testis?
local defect in development, and the affected testis is small and accompanied by a persistent processes vaginalis
37
What is the presentation of undescended testes What is the consequence of this?
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
What are retractile testes?
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
What is the treatment for retractile testes?
Normal - no treatment needed
40
What is the treatment of ectopic / undescended testes?
surgically placed in the scrotum (orchidopexy) if they are to function as a reproductive organ at 6 months
41
What are the complications of maldescent?
Defective spermatogenesis Increased risk of torsion Increased risk of malignancy Increased risk of indirect inguinal hernia (processes vaginalis)
42
What are the steps to examination of a scrotal swellings?
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
What is the presentation of a varicocele?
Bag of worms
44
How should torsion be tested for?
Cremasteric reflex: absent | Phren's sign: scrotal elevation relieves pain in epididymitis but NOT torsion
45
What is the cause of an epididymal cyst?
Due to cystic degeneration of epididymal structures | Associated with PKD and CF
46
What is the presentation of an epididymal cyst?
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
What is the management of epididymal cyst?
If troublesome, may be excised
48
What is the cause of a hydrocele?
Fluctuant swelling that transilluminates | Caused by excessive collection of serous fluid in the processus vaginalis
49
What is the cause of a congenital hydrocele?
Associated with a hernia sac and patent processes vaginalis | Most spontaneously resolve prior to one year
50
What are primary / secondary hydroceles?
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
What is the ix for hydrocele?
USS to rule out underlying pathology
52
What is the management of hydrocele?
reassurance that it is Benign | If swelling causing problems, then excision of the hydrocele sac is possible (again, aspiration leads to recurrence)
53
What is a varicocele?
Varicosities of the pampiniform plexus, most commonly on the left
54
What is the presentation of varicocele?
Dragging sensation / ache 'bag of worms' on palpation, may only be palpable in standing position Subfertility
55
Explain why varicocele happens?
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
What are the management options for varicocele?
Reassurance | Treatment: radical embolisation of the left renal vein, or surgical ligation and division of the testicular veins
57
What are the risk factors for testicular tumours?
Undescended / ectopic testes - greater if not in the anatomical position before the age of 13 Infertility hypospadias family / personal history
58
What are the two main tumour types in testicular tumours?
Seminomas and non-seminomatous germ cell tumours (NSGCTs) - teratoma. 50% each Both germ cell tumours. can sometimes be stromal tumours or lymphomas
59
What tumours can occur in NSGCTs?
Teratomas, yolk sac tumours and choriocarcinomas 'terror'- worse prognosis and raised bhcg/afp
60
Where do seminomas come from?
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
Where does a teratoma arise from?
Totipotent germ cells, in 20-30 year olds | Has a cystic appearance macroscopically and variable cell types microscopically
62
How do testicular tumours spread?
Through the capsule | Lymph spread to para-aortic nodes and blood Bourne spread is early to the lungs and liver
63
What is the presentation of a testicular tumour?
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
Where do testicular tumours drain to?
Para-aortic nodes, so the first palpable node is likely to be supraclavicular
65
What investigations should be done for ?testicular tumours?
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
What is the management of a testicular tumour?
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
What is the prognosis of testicular tumours?
Node negative cases nearly 100% 5 year survival | Overall 5-year survival = >90%
68
What is the cause of testicular torsion?
Usually a congenital abnormality e.g. maldescention / bell clapper testes Testicle twists upon its pedicle, obstructing venous return
69
Who gets testicular torsion?
Adolescents (12-18 years) | hx of mild trauma or previous attacks of pain due to a partial torsion and spontaneous resolution
70
What is the presentation of testicular torsion?
PAIN - acute abdomen! Unilateral, hot, swollen, tender testis, sometimes lying high and transverse within the scrotum absent cremasteric reflex
71
What are the ddx of testicular torsion?
Epididymitis or torsion of the testicular appendage | If any doubt - surgical exploration
72
How is testicular torsion investigated / managed?
doppler USS - lack of blood supply to testes | Manual distortion can be attempted but surgical still needed
73
What is the surgical management of testicular torsion?
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
What is torsion of the testicular appendage?
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
What is the cause of epididymo-orchitis?
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
What is the presentation of epididymo-orchitis?
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
What investigations should be done for epidiymo-orchitis?
First catch urine MCS and STI screen | USS
78
What is the treatment of epididymo-orchitis?
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
What is the presentation of acute bacterial prostatitis?
``` 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
What is the treatment of acute bacterial prostatitis?
6 weeks ciprofloxacin
81
What is impotence?
Inability to achieve or sustain an erection for sex
82
What mediates erection?
Increased arterial inflow and occlusion of venous inflow | Mediated by parasympathetic fibres from S2-S4
83
What are the causes of impotence?
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
How is impotence investigated?
HX and examination urine dipstick hormone screen
85
What is the conservative treatment of impotence?
``` Treat reversible medical causes correct hormone disturbances stop smoking reduce alcohol intake treating diabetes ```
86
What is the medical management of impotence?
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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