Urology 2 Flashcards
What is urethritis?
Discharge and discomfort within the penis in men
Generally split into gonococcal urethritis and non-gonococcal urethritis (of which most common = chlamydia)
What is the cause of gonorrhoea?
Neisseria gonorrhoea - gram-negative intracellular diplococcus spread by sexual contact
What are the symptoms of gonorrhoea?
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
What investigations are done for gonorrhoea?
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)
What is the management of gonorrhoea
IM ceftriaxone
follow up and repeat cultures 72h after treatment
trace and treat all sexual contacts
What are the symptoms of chlamydia?
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)
What investigations are done for chlamydia?
First void in men, endocervical swabs in women
Cell culture = gold standard / direct immunofluorescence or NAAT e.g. PCR
Assess for co-existing gonorrhoea
What is the management of chlamydia?
7 days doxycycline / erythromycin
test of cure not required in simple infection
Trace sexual contacts
What is urethral syndrome
Abacteriuric frequency/dysuria
can be caused by post-coital bladder trauma, atrophic vaginitis or interstitial nephritis
What is the management of trauma to the urethra?
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
What is a urethral stricture?
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
What are the causes of urethral stricture?
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
What is the presentation of a urethral stricture
Obstructive voiding symptoms that worsen gradually: initial frequency/dysuria Hesitancy / straining urinary retention Splayed stream
What are the examination findings in urethral stricture?
Firm areas consistent with periurethral scarring
No prostate abnormalities
What IX should be done for urethral stricture?
Uroflowmetry
Urethrogram
Urethroscopy
What is the management of urethral stricture?
Optical urethrotomy
Urethroplasty for those that recur (50%)
What is phimosis?
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
What is the presentation of phimosis in children?
Ballooning of the foreskin and poor stream during urination
Under 2 years - expectant approach
What is the presentation of phimosis in adults?
Pain during intercourse and inability to retract the foreskin
What is the management of phimosis?
Circumcision
What is paraphimosis?
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
What is the emergency treatment of paraphimosis?
Local anaesthesia and then applying pressure to the glans or slitting the foreskin distally
Circumcision is offered after a paraphimosis to prevent recurrence
What is the cause of carcinoma of the penis?
HPV 16/18
More common in smokers and immunocompromised
What is the presentation of carcinoma of the penis?
Persistent red patch on the penis, progressing to an infiltrating ulcer
Never any urethral involvement/symptoms
How is diagnosis of carcinoma of the penis done?
Punch biopsy - microscopically Squamous cell carcinomas
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
What is priapism?
Persistent (hours to days) erection of the corpora cavernosa of the penis - corpora spongiosum remains flaccid
What is the cause of priapism?
Usually idiopathic, but can be associated with trauma, sickle cell disease and intracavernousal injections for impotence
What is the treatment of priapism?
Ice packs, alpha agonists, selective embolisation, aspiration of the corpus cavernous or surgical intervention
What Peyronie’s disease?
Upward curvature of the penis when erect
What is the cause of Peyronie’s disease?
Unknown
fibrous scarring following trauma?
What is the treatment of peyronie’s disease?
managing associated depression and surgical intervention may help penetration
What are the subtypes of testicular maldescent?
Ectopic testes
Undescended testis
Retractile testes
What are ectopic testes?
The testes have strayed from the normal line of descent
Most common site = superior inguinal pouch
What is an undescended testis?
The testis has followed the normal route of descent, but stopped short of the scrotum
What is the cause of undescended testis?
local defect in development, and the affected testis is small and accompanied by a persistent processes vaginalis
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
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
What is the treatment for retractile testes?
Normal - no treatment needed
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
What are the complications of maldescent?
Defective spermatogenesis
Increased risk of torsion
Increased risk of malignancy
Increased risk of indirect inguinal hernia (processes vaginalis)
What are the steps to examination of a scrotal swellings?
- can I get above it?
NO: inguinal hernia - cough
Proximally extending hydrocele - ?transilluminates
YES - primary scrotal swelling - 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)
What is the presentation of a varicocele?
Bag of worms
How should torsion be tested for?
Cremasteric reflex: absent
Phren’s sign: scrotal elevation relieves pain in epididymitis but NOT torsion
What is the cause of an epididymal cyst?
Due to cystic degeneration of epididymal structures
Associated with PKD and CF
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
What is the management of epididymal cyst?
If troublesome, may be excised
What is the cause of a hydrocele?
Fluctuant swelling that transilluminates
Caused by excessive collection of serous fluid in the processus vaginalis
What is the cause of a congenital hydrocele?
Associated with a hernia sac and patent processes vaginalis
Most spontaneously resolve prior to one year
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
What is the ix for hydrocele?
USS to rule out underlying pathology
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)
What is a varicocele?
Varicosities of the pampiniform plexus, most commonly on the left
What is the presentation of varicocele?
Dragging sensation / ache
‘bag of worms’ on palpation, may only be palpable in standing position
Subfertility
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
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
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
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
What tumours can occur in NSGCTs?
Teratomas, yolk sac tumours and choriocarcinomas
‘terror’- worse prognosis and raised bhcg/afp
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
Where does a teratoma arise from?
Totipotent germ cells, in 20-30 year olds
Has a cystic appearance macroscopically and variable cell types microscopically
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
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
Where do testicular tumours drain to?
Para-aortic nodes, so the first palpable node is likely to be supraclavicular
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
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
What is the prognosis of testicular tumours?
Node negative cases nearly 100% 5 year survival
Overall 5-year survival = >90%
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
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
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
What are the ddx of testicular torsion?
Epididymitis or torsion of the testicular appendage
If any doubt - surgical exploration
How is testicular torsion investigated / managed?
doppler USS - lack of blood supply to testes
Manual distortion can be attempted but surgical still needed
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’
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
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
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
What investigations should be done for epidiymo-orchitis?
First catch urine MCS and STI screen
USS
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
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
What is the treatment of acute bacterial prostatitis?
6 weeks ciprofloxacin
What is impotence?
Inability to achieve or sustain an erection for sex
What mediates erection?
Increased arterial inflow and occlusion of venous inflow
Mediated by parasympathetic fibres from S2-S4
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
How is impotence investigated?
HX and examination
urine dipstick
hormone screen
What is the conservative treatment of impotence?
Treat reversible medical causes correct hormone disturbances stop smoking reduce alcohol intake treating diabetes
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
