Urology (5) (Misc) Flashcards
BPH
BPH
Very common conditions affecting men in older age (usually >50).
Cause
Hyperplasia of the stromal and epithelial cells of the prostate- in the transitional zone.
presentation of BPH
Presentation
There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:
- Hesitancy – difficult starting and maintaining the flow of urine
- Weak flow
- Urgency – a sudden pressing urge to pass urine
- Frequency – needing to pass urine often, usually with small amounts
- Intermittency – flow that starts, stops and varies in rate
- Straining to pass urine
- Terminal dribbling – dribbling after finishing urination
- Incomplete emptying – not being able to fully empty the bladder, with chronic retention
- Nocturia – having to wake to pass urine multiple times at night
scoring system for LUTS
The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms
investigations BPH
- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
- Abdominal examination to assess for a palpable bladder and other abnormalities
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
-
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
- Unreliable- non-specific
- Counsel patients to make an informed decision
prostate examination
- A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
- A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
first line management of BPH
-
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
- Used to treat immediate treatment
second line management of BPH
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
- Used to treat the enlargement
- MOA: 5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone
- Inhibiting 5-alpha reductase reduces DHT in tissue, inc prostate- reduction in prostate size
- Takes up to 6 months to improve symptoms
surgical option for BPH
- Transurethral resection of the prostate (TURP)- most common
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- Open prostatectomy vis perineal incision
Transurethral resection of the prostate (TURP)
It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.
- Major complications:
- Bleeding
- Infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
- Urethral strictures
- Failure to resolve symptoms
erectile dysfunction RF
- Inactivity
- Obesity
- Smoking
- Hypercholesterolaemia
- Hypertension
- DM
causes of ED
-
Vascular factors (if person presents with ED vascular health should be investigated)
- CVD
- Atherosclerosis
- Hypertension
- DM
- Smoking
- Neurological
- Parkinsons
- MS
- Tumours
- TBI
- Peripheral
- Polyneuropathy
- Peripheral neuropathy
- DM
- Alcoholism
- Hormonal
- Hypogonadism
- Hyperprolactinaemia
- Anatomical
- Peyronies
- Drugs
- Antihypertensives
- B blocker
- Diuretics
- Antidepressants e.g. SSRI
- Psychosocial factors
management of ED -first line
- Vacuum devices – air pumped out, resulting in engorgement of penis with blood
- Oral agents
- Phosphodiesterase inhibitors e.g. sildenafil → improves relaxation of smooth muscle (contraindicated in pts on vasodilation)
management of ED- second line
- MUSE- intraurethral alprostadil (prostaglandin E1)
management of ED- third line
- Penile prosthesis
peyronies disease
Peyronie’s disease is where plaques (segments of flat scar tissue) form under the skin of the penis. These plaques can cause the penis to bend or become indented during erections. The plaques can often be felt through the skin and can be painful.
causes of peyronies disease
Minor injury to penis- e.g. caused by vigorous sex
presentation peyronies disease
- Form on the top of the penis normally
- Plaques make tunica albuginea less flexible and causes the penis to bend upwards during erection
other signs
- bent/curved penis
- lumps in the penis
- painful erections
- soft erections
- having trouble with sex because of a bent/curved penis
RF for peyronies
Connective tissue disorder
stages of peronie
- acute phase – 5-7 months
- chronic phase- plaque stops growing and penis doesn’t bend further
treatment of peyronies
- Oral drugs
- Oral vitamin e
- Tamoxifen
- Colchicine
- Penile injection
- Verapamil
- Interferon injections
- Surgery
Fournier’s gangrene
Acute necrotic infection of the scrotum, penis or perineum. Usually secondary to perirectal or periurethral infections associated with:
- Local trauma
- Operative procedures
- UT disease
RF for fourniers gangrene
- Immunosuppressed
- Males
presentation of fourniers gangrene
- Fever
- Malaise
- Scrotum pain and swelling
- Redness
- Rapid progression to gangrene
- Crepitus (palpable)
Investigations for fourneirs
- CT to diagnose portal of entry and extension of the process
- Xray useful to confirm location and extent of gas distribution in the wounds
management of fourniers gangrene
- STAT broad spectrum IV Abx
- Surgical debridement of all affected (necrotic) tissue and subcutaneous tissue involved
- SEPSIS 6
main foreskin problems
phimosis
paraphimosis
phimosis
- When prepuce cannot be fully retracted in adult
- Physiology phimosis: normal non-retractability up to adolescence
- Pathological: scarring, infection, inflammation
phimosis BEWARE
- In adulthood may be associated with other pathologies
- Beware of the elderly with phimosis and balanitis
causes of phimosis
- Poor hygiene (build-up of smegma)
- STDs
- Penile cancer
presentation of phimosis
- Pain on intercourse, splitting/bleeding
- Balanitis (inflamed glans)
- Posthitis (inflamed foreskin/prepuce)
- Balanitis xerotica obliterans (BXO)
- Urinary retention
management of phimosis
- Topical corticosteroid therapy
- Circumcision
paraphimosis
Inability to pull forward a retracted foreskin over the glans penis
- Painful constriction of the gland by the retracted prepuces proximal to the corona
- As the paraphimosis remains, the glans becomes increasingly oedematous due to reduced venous return, leading to vascular engorgement of the distal penis and further oedema
- Can lead to fourniers gangrene
commonest causes of paraphimosis
- Phimosis- presence of tight constricting bands as part of the foreskin that prevents the retraction over the glans
- Catheterisation esp in elderly (when you retract the foreskin and don’t put it back)
- Penile cancer
management of paraphimosis
- Needs reduction STAT
- Manual pressure to the glans can aid to reduce oedema, squeezing gently but constantly, before applying force to the glans to reduce it into the prepuce (use of lubricant jelly as required).
- Application of dextrose-soaked gauze to act as an osmotic effect, drawing fluid out of the glans, reducing the oedema present, and allowing for glans reduction as above. Similar technique for reducing oedema can be performed with ice packs
- The “Dundee Technique” involves the use of needle punctures into the glans penis, squeezing the area to allow drainage of oedematous fluid, before attempting reduction of the glans, as discussed above
- Occasionally dorsal slit may be necessary
- Suitable analgesia
scrotal lumps
Abnormal mass or swelling within the scrotum- can be testicular or extra-testicular.
- hydrocele
- varicocele
- epidiymal cyst
- indirect inguinal scrotal hernia
history of a scrotal lump
Clinical features
- Time of onset
- Associated symptoms (pain)
- Previous episodes
- Inspection of lump
- Size
- Site
- Shape
- Symmetry
- Skin changes
- Scars
- Palpating the lump (CAMPFIRE)
- Tenderness, Temperature, Transillumination
- Consistency
- Attachments
- Mobility
- Pulsation
- Fluctuation
- Irreducibility
- Regional lymph nodes,
- the Edge.
investigation for scrotal lump
- US of the scrotum
- Biopsy not warranted – due to risk of seeding
- Blood tests
- LDH
- AFP
- Beta-hCG
- Diagnosis is purely on clinical features, US and histopathological examination of testes following orchidectomy
hydrocele
- Extra-testicular
- A hydrocoele is an abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis.
causes of hydrocele in infants
-
Congenital hydrocoeles affect up to 3% of male neonates and generally regress spontaneously by one or two years of age.
- No treatment is typically needed
- Caused by a patent processus vaginalis requiring ligation to stop recurrence.
causes of hydrocele in adults
- hydrocoeles may be primary (idiopathic) or secondary due to trauma, infection, or malignancy.
- Those presenting with a hydrocoele aged between 20-40yrs (or where the testis cannot be palpated) should undergo urgent ultrasound scan
*
- Those presenting with a hydrocoele aged between 20-40yrs (or where the testis cannot be palpated) should undergo urgent ultrasound scan
presentation of hydrocelee
- They typically present* as a painless fluctuant swelling that will transilluminate, either unilateral or bilateral.
- Occasionally they can grow very large and cause discomfort when sitting and walking necessitating surgical management.
management of hydrocele
A hydrocele that doesn’t disappear on its own might need to be surgically removed, typically as an outpatient procedure. The surgery to remove a hydrocele (hydrocelectomy) can be done under general or regional anesthesia. An incision is made in the scrotum or lower abdomen to remove the hydrocele
varicocele
Abnormal dilatation of the pampiniform venous plexus within the spermatic cord
Complications: infertility and testicular atrophy (increasing intra-scrotal temp)
could be a sign of renal cancer
presentation of varicocele
- Lump
- Bag of worms
- Dragging sensation
- Disappears when lying flat
-
Usually found on left hand side
- Spermatic vein drains directly into the left renal vein
management of varicocele
- Semen analysis
- Surgery: embolization by interventional radiologist and surgical approaches either open or laparoscopic approach for ligation
complications of varicocele
infertility and testicular atrophy (increasing intra-scrotal temp)
epididymal cysts
Benign fluid-filled sacs arising from the epididymis.
They are common scrotal pathology and are classically seen in middle-aged men.
presentation of epidiymal cysts
- Smooth fluctuant nodule, found above and separate from the testis that will transilluminate, often they are multiple.
- The cysts rarely cause symptoms, have no association to malignancy, and generally do not need treatment.
management of epididymal cyst
In rare instances, they are very large or painful and therefore surgery may be required, but is best avoided in younger men as surgery may lead to infertility.
Indirect inguinoscrotal hernia
Inguinal hernia can pass into the scrotum via the deep inguinal ring, entering the inguinal canal initially at the internal ring (indirect hernia) or through Hesslebach’s triangle (direct hernia). Passing into the scrotum they run alongside the spermatic cord.
