Urology Flashcards
Urinary Tract Obstruction Causes
Luminal
Stones
Blood clots
Sloughed papilla
Mural
Congenital / acquired stricture
Tumour: renal, ureteric, bladder
Neuromuscular dysfunction
Extramural
Prostatic enlargement
Abdo / pelvic mass / tumour
Retroperitoneal fibrosis
UT Obstruction Presentation
Acute
Upper Urinary Tract
Loin pain → groin
Lower Urinary Tract
Bladder outflow obstruction precedes severe
suprapubic pain w distended palpable bladder
Chronic
Upper Urinary Tract
Flank pain
Renal failure (may be polyuric)
Lower Urinary Tract
Frequency, hesitancy, poor stream, terminal
dribbling, overflow incontinence
Distended, palpable bladder ± large prostate
PR
UT obstruction Ix
Bloods: FBC, U+E
Urine: dip, MC+S
Imaging US: hydronephrosis or hydroureter Anterograde / retrograde ureterograms Allow therapeutic drainage Radionucleotide imaging: renal function CT / MRI
UT obstruction Mx
Upper Urinary Tract
Nephrostomy
Ureteric stent
Lower Urinary Tract
Urethral or suprapubic catheter
May be a large post-obstructive diuresis
Complications of Ureteric Stents
Common Infection Haematuria Trigonal irritation Encrustation
Rare
Obstruction
Ureteric rupture
Stent migration
Urethral Stricture
Trauma
Instrumentation
Pelvic #s
Infection (gonorrhoea)
Chemotherapy
Balanitis xerotica obliterans
Urethral Stricture Presentation + examination
Voiding difficulty Hesitancy Strangury Poor stream Terminal dribbling Pis en deux
Examination
PR: exclude prostatic cause
Palpate urethra through penis
Examine meatus
Urethral Stricture Ix + Mx
Urodynamics
↓ peak flow rate
↑ micturition time
Urethroscopy and cystoscopy
Retrograde urethrogram
Mx
Internal urethrotomy
Dilatation
Stent
Obstructive Uropathy
Acute retention on a chronic background may go
unnoticed for days due to lack of pain.
Se Cr may be up to 1500uM
Renal function should return to normal over days
Some background impairment may remain.
Obstructive Uropathy Complications
Hyperkalaemia
Metabolic acidosis
Post-obstructive diuresis
Kidneys produce a lot of urine in the acute phase
after relief of obstruction.
Must keep up c¯ losses to avoid dehydration.
Na and HCO3 losing nephropathy
Diuresis may → loss of Na and HCO3
May require replacement 1.26% NaHCO3
Infection
Urinary Retention Causes
Obstructive (Mechanical) BPH Urethral stricture Clots, stones Constipation (Dynamic): ↑ smooth muscle tone (α-adrenergic) Post-operative pain Drugs
Neurological Interruption of sensory or motor innervation Pelvic surgery MS DM Spinal injury / compression
Myogenic
Over-distension of the bladder
Post-anaesthesia
High EtOH intake
Acute Urinary Retention (AUR)
Clinical Features
Ix
Clinical Features Suprapubic tenderness Palpable bladder Dull to percussion Can’t get beneath it Large prostate on PR Check anal tone and sacral sensation <1L drained on catheterisation
Ix
Blood: FBC, U+E, PSA (prior to PR)
Urine: dip, MC+S
Imaging
US: bladder volume, hydronephrosis
Pelvic XR
Acute Urinary Retention
Mx
Conservative Analgesia Privacy Walking Running water or hot bath
Catheterise
Use correct catheter: e.g. 3-way if clots
± STAT gent cover
Hrly UO + replace: post-obstruction diuresis
Tamsulosin: ↓ risk of recatheterisation after retention
TWOC - Trial Without Catheter after 24-72h
May d/c and f/up in OPD
More likely to be successful if predisposing factor
and lower residual volume (<1L)
TURP (trans-urethral-resection of prostate)
- failed TWOC
- Impaired renal function
- Elective
Chronic Urinary Retention
Classification
High Pressure
High detrusor pressure @ end of micturition
Typically bladder outflow obstruction
→ bilateral hydronephrosis and ↓ renal function
Low Pressure
Low detrusor pressure @ end of micturition
Large volume retention w very compliant bladder
Kidney able to excrete urine
No hydronephrosis :. normal renal function
Chronic Urinary Retention
Presentation
Insidious as bladder capacity ↑↑ (>1.5L)
Typically painless
Overflow incontinence / nocturnal enuresis
Acute on chronic retention
Lower abdo mass
UTI
Renal failure
Chronic Urinary Retention
Mx
High-Pressure
Catheterise if Renal impairment Pain Infection Hrly UO + replace: post-obstruction diuresis Consider TURP before TWOC
Low-Pressure
Avoid catheterisation if possible - Risk infection
Early TURP
Often do poorly due to poor detrusor function
Need CISC or permanent catheter
Suprapubic Catheterisation
adv disadv C/I
Advantages ↓ UTIs ↓ stricture formation TWOC w/o catheter removal Pt. preference: ↑ comfort Maintain sexual function
Disadvantages
More complex: need skills
Serious complications can occur
CI
Known or suspected bladder carcinoma
Undiagnosed haematuria
Previous lower abdominal surgery → adhesion of small bowel to abdo wall
Clean Intermittent Self-Catheterisation
Alternative to indwelling catheter in AUR and CUR
Also useful in pts. who fail to void after TURP
False Haematuria causes
Beetroot
Rifampicin
Porphyria
PV bleed
True Haematuria causes
General
HSP
Bleeding diathesis
Renal Infarct Trauma: inc. stones Infection Neoplasm GN Polycystic kidneys
Ureter
Stone
Tumour
Bladder Infection Stones Tumour Exercise
Prostate
BPH
Prostatitis
Tumour
Urethra Infection Stones Trauma Tumour
Haematuria Clinical Features
Timing?
Beginning of stream: urethral
Throughout stream: renal / systemic, bladder
End of stream: bladder stone, schisto
Painful or painless?
Obstructive symptoms?
Systemic symptoms: wt. loss, appetite
Haematuria Ix
Bloods: FBC, U+E, clotting
Urine: dip, MC+S, cytology
Imaging Renal US IVU Flexible cystoscopy + biopsy CT/MRI Renal angio
Peri-Aortitis
Idiopathic retroperitoneal fibrosis
Inflammatory AAAs
Perianeurysmal RPF
RPF 2ndary to malignancy: e.g. lymphoma
Idiopathic Retroperitoneal Fibrosis
Autoimmine vasculitis
Fibrinoid necrosis of vasa vasorum
Affects aorta + small/medium sized retroperitoneal vessels
Ureters are embedded in dense, fibrous tissue > bilateral obstruction
Peri-aortitis ass/ Presentations
Ass/
Drugs: β-B, bromocriptine, methysergide, methyldopa
AI disease: thyroiditis, SLE, ANCA+ vasculitis
Smoking
Asbestos
Presentation Middle–aged male Vague loin, back or abdo pain ↑ BP Chronic urinary tract obstruction
Peri-aortitis Ix Rx
Ix
Blood: ↑U and Cr, ↑ESR/CRP, ↓Hb
US: bilateral hydronephrosis + medial ureteric deviation
CT/MRI: peri-aortic mass
Biopsy: exclude Ca
Rx
Relieve obstruction: retrograde stent placement
Ureterolysis: dissection of ureters from retroperitoneal
tissue.
± immunosuppression
Urolithiasis
↑ concentration of urinary solute
↓ urine volume
Urinary stasis
Common anatomical sites Pelviureteric junction Crossing the iliac vessels at the pelvic brim Under the vas or uterine artery Vesicoureteric junction
Stone types (Urolithiasis)
Calcium oxalate: 75%
↑ risk in Crohn’s
Triple phosphate (struvite): 15%
Ca Mg NH4 – phosphate
May form staghorn calculi
Assoc. c¯ proteus infection
Urate: 5% (radiolucent)
Double if confirmed gout
Cystine: 1% (faint)
Assoc. c¯ Fanconi Syn
Urolithiasis Associated factors
Dehydration
Hypercalcaemia: primary HPT, immobilisation
↑ oxalate excretion: tea, strawberries
UTIs
Hyperuricaemia: e.g. gout
Urinary tract abnormalities: e.g. bladder diverticulae
Drugs: frusemide, thiazides
Urolithiasis Presentation
Ureteric colic (severe loin to groin pain, n/v, pt cannot lie still)
Bladder or Urethral Obstruction
Bladder irritability: frequency, dysuria, haematuria
Strangury: painful urinary tenesmus
Suprapubic pain radiating → tip of penis or in labia
Pain and haematuria worse at the end of micturition
Other features UTI Haematuria Sterile pyuria Anuria
Urolithiasis Ix
Urine
Dip: haematuria
MC+S
Blood
FBC, U+E, Ca, PO4, urate
Imaging
KUB XR
90% of stones radio-opaque
Urate stones are radiolucent, cysteine stones are faint
USS: hydronephrosis
Spiral non-contrast CT-KUB
99% of stones visible
Gold standard
IVU
600x radiation dose of KUB
IV contrast injected and control, immediate and serial
films taken until contrast @ level of obstruction
>Abnormal findings
Failure of flow to the bladder
Standing column of contrast
Clubbing of the calyces: back pressure
Delayed, dense nephrogram: no flow from kidney
C/I - Contrast allergy, Severe asthma, Metformin, Pregnancy
Functional Urinary System Scans
DMSA: dimercaptosuccinic acid
DTPA: diethylenetriamene penta-acetic acid
MAG-3
Urolithiasis Prevention
Drink plenty
Treat UTIs rapidly
↓ oxalate intake: chocolate, tea, strawberries
Urolithiasis Mx
<5mm and lower 1/3 - conservative
Medical - stone 5-10mm
- Nifedipine or tamsulosin
+/- prednisolone
Active stone >10mm, persistent, renal insufficiency, infection
Extracorporeal shockwave lithotripsy
Ureteronoscopy + dormier basket removal
Percutaneous
Lap or open surgery rare
Febrile renal obstruction
surgical emergency
percutaneous nephrostomy or ureteric stent
IV abx - cefuroxime 1.5g IV TDS
Renal Cell Carcinoma RF
Obesity Smoking HTN Dialysis (15% of pts. develop RCC) 4% heritable: e.g. VHL syndrome
Renal Cell Carcinoma Path and Subtypes
Adenocarcinoma from proximal renal tubular epithelium (90%)
Subtypes Clear Cell (glycogen): 70-80% Papillary: 15% Chromophobe: 5% Collecting duct: 1%
Renal Cell Carcinoma Presentation
50% incidental finding
Triad: Haematuria, loin pain, loin mass
Systemic: anorexia, malaise, wt. loss, PUO
Clot retention
Invasion of L renal vein → varicocele (1%)
Cannonball mets → SOB
Renal Cell Carcinoma Paraneoplasms
EPO → polycythaemia PTHrP → ↑ Ca Renin → HTN ACTH → Cushing’s syn. Amyloidosis
Renal Cell Carcinoma Spread Ix
Spread
Direct: renal vein
Lymph
Haematogenous: bone, liver and lung
Ix
Blood: polycythaemia, ESR, U+E, ALP, Ca
Urine: dip, cytology
Imaging CXR: cannonball mets US: mass IVU: filling defect CT/MRI
Robson Staging
Renal Cell Carcinoma
- Confined to kidney
- Involves perinephric fat, but not Garota’s fascia
- Spread into renal vein
- Spread to adjacent / distant organs
Renal Cell Carcinoma Mx
Medical
Reserved for pts. c¯ poor prognosis
Temsirolimus (mTOR inhibitor)
Surgical
Radical nephrectomy
Consider partial if small tumour or 1 kidney
SCC of kidney
assw chronic staghorn calucli
Transitional Cell Carcinoma Kidney
RF Smoking, amine exposure, cyclophosphamdie
Highly malignant
locations - bladder 50%, ureter, renal pelvis
Ix
- urine cytology
- CT/MRI
- IVU - pelviceal filling defect
Mx - nephrourectomy
- regular f/up - 50% develop bladder tumours
Nephroblastoma
Childhood tumour of primitive renal tubules and
mesenchymal cells
May be assoc. c¯ Chr 11 mutation
May be assoc. c¯ WAGR syndrome
Wilms, Aniridia, GU abnormalities, Retardation
Presentation 2-5yrs 5-10% bilat Abdo mass (doesn’t cross the midline) Haematuria Abdo pain HTN
Bladder Tumours Presentation
Painless Haematuria
Voiding irritability (dysuria, frequency, urgency
Recurrent UTI
Retention + obstructive renal failure
Bladder Tumours RF
Smoking Amine exposure (rubber industry) Previous renal TCC Chronic cystitis Schistosomiasis (SCC)
Urechal remnants (adenocarcinomas)
Embryological remnant of communication
between umbilicus and bladder
Pelvic irradiation
Bladder Tumour Ix
Urine: dip (sterile pyuria), cytology IVU: filling defects Cystoscopy c¯ biopsy: diagnostic Bimanual EUA: helps to assess spread CT/MRI: helps stage
Bladder Tumours Mx
TIS, Ta and T1 (Superficial)
80% of all pts.
Diathermy via transurethral cystoscopy / Transurethral
Resection of Bladder Tumour (TURBT)
Intravesicular chemo: mitomycin C
Intravesicular immunotherapy: Bacille Calmette-Guérin
T2, T3 (Invasive)
Radical cystectomy w ileal conduit is gold standard
Radiotherapy: worse 5ys but preserves bladder
Salvage cystectomy can be performed
Adjuvant chemo: e.g. M-VAC
Neoadjuvant chemo may have a role
T4
Palliative chemo / radiotherapy
Long-term catheterisation
Urinary diversions
Complications
Massive bladder haemorrhage
Cystectomy → Sexual and urinary malfunct
Bladder tumour follow up
Up to 70% of bladder tumours recur therefore intensive
f/up is required.
History, examination and regular cystoscopy
High-risk tumours: every 3mo for 2yrs, then every 6mo
Low-risk tumours: @ 9mo, then yrly
Benign Prostate Hypertrophy Path
Benign nodular or diffuse hyperplasia of stromal and
epithelial cells
Affects inner (transitional) layer of prostate (cf. Ca) → urethral compression
DHT produced from testosterone in stromal cells by 5α-reducatase enzyme.
DHT-induced GFs → ↑ stromal cells and ↓ epithelial cell
death.
Benign Prostate Hypertrophy
Presents
Storage Sx Nocturia Frequency Urgency Overflow incontinence
Voiding Sx Hesitancy Straining Poor stream/flow + terminal dribbling Strangury (urinary tenesmus) Incomplete emptying: pis en deux
Bladder stones and UTI (2ndary to stasis)
BPH O/E, Ix
PR
Smoothly enlarged prostate
Definable median sulcus
Bladder not usually palpable unless acute-on-chronic
obstruction
Ix Blood: U+E, PSA (after PR) Urine: dip, MC+S Imaging (Transrectal US ± biopsy) Urodynamics: pressure / flow cystometry Voiding diary
BPH Mx Conservative, Medical
Conservative
↓ caffeine, EtOH
Double voiding
Bladder training: hold on → ↑ time between voiding
Medical
Useful in mild disease and while awaiting TURP
1st: α-blockers Tamsulosin, doxazosin Relax prostate smooth muscle SE: drowsiness, ↓BP, depression, EF, wt. ↑, extra-pyramidal signs
2nd: 5α-reductase inhibitors
Finasteride
Inhibit conversion of testosterone → DHT
Preferred if significantly enlarged prostate.
SE: excreted in semen (use condoms), ED
BPH Mx Surgical
Indications
Symptoms affect QoL
Complications of BPH
TURP
Cystoscopic resection of lateral and middle lobes
≤14% become impotent
Transurethral incision of prostate (TUIP)
< destruction → ↓ risk to sexual function
Similar benefits to TURP if small prostate (<30g)
Tranurethral ElectroVaporisation of Prostate
Electric current → tissue vaporisation
Laser prostatectomy
↓ ED and retrograde ejaculation
Similar efficacy as TURP
Open retropubic prostatectomy
Used for very large prostates (>100g)
TURP Complications
Immediate
TUR syndrome -
Absorption of large quantity of fluids → ↓Na
Haemorrhage
Early
Haemorrhage
Infection
Clot retention: requires bladder irrigation
Late Retrograde ejaculation: common ED: ~10% Incontinence: ≤10% Urethral stricture Recurrence
Prostate Cancer Pathology
Presentation
Adenocarcinoma
Peripheral Zone of prostate
Presentation Usually asymptomatic Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction Systemic: wt. loss, fatigue Mets: bone pain
Prostate Cancer O/E, Spread
Examination
Hard irregular prostate on PR
Loss of midline sulcus
Spread
Local: seminal vesicles, bladder, rectum
Lymph: para-aortic nodes
Haem: sclerotic bony lesions
Prostate Cancer Ix
Bloods: PSA, U+E, acid and alk phos, Ca
Imaging XR chest and spine Transrectal US + biopsy Bone scan Staging MRI >Contrast enhancing magnetic nanoparticles ↑s detection of affected nodes.
Prostate Specific Antigen
Proteolytic enzyme used in liquefaction of ejaculate
Not specific for prostate Ca
↑ ¯c age, PR, TURP, and prostatitis
> 4ng/ml: 40-90% sensitivity, 60-90% specificity
Only 1-in-3 will have Ca
Normal in 30% of small cancers
Gleason Grade (Prostate cancer)
Score two worst affected areas
Sum is inversely proportional to prognosis
Prostate Cancer TNMStaging
TIS Carcinoma in situ
T1 Incidental finding on TURP or ↑PSA
T2 Intracapsular tumour c¯ deformation of prostate
T3 Extra-prostatic extension
T4 Fixed to pelvis + invading neighbouring structures
N1-4 1 or more lymph nodes involved
M1 Distant mets, e.g. spine
Prognostic Factors Prostate Cancer
Help determine whether to pursue radical Rx Age Pre-Rx PSA Tumour stage Tumour grade
Prostate Cancer Mx Conservative + Radical
Conservative: Active Monitoring
Close monitoring c¯ DRE and PSA
Radical Therapy
Radical prostatectomy (+ goserelin if node +ve)
Performed laparoscopicaly w robot
Only improves survival vs. active monitoring if
<75yrs
Brachytherapy: implantation of palladium seeds
SEs: ED, urinary incontinence, death (0.2-0.5%)
Prostate Cancer Medical management
Medical
Used for metastatic or node +ve disease
LHRH analogues
E.g. goserelin
Inhibit pituitary gonadotrophins → ↓ testosterone
Anti-androgens
E.g. cyproterone acetate, flutamide
Prostate Cancer Symptomatic Treatment
TURP for obstruction
Analgesia
Radiotherapy for bone mets / cord compression
Prostitis
Aetiology
S. faecalis
E. coli
Chlamydia
Presentation Usually >35yrs UTI / dysuria Pain (Low backache/on ejaculation) Haematospermia Fever and rigors Retention Malaise
Examination
Pyrexia
Swollen / boggy / tender prostate on PR
Examine testes to exclude epididymo-orchitis
Ix
Blood: FBC, U+E, CRP
Urine: dip, MC+S
Rx
Analgesia
Levofloxacin 500mg/d for 28d
Male Urinary Incontinence
Usually caused by prostatic enlargement
Urge incontinence or dribbling may result from
partial retention.
Retention may → overflow (palpable bladder after
voiding)
TURP and pelvic surgery may weaken external urethral
sphincter.
Women Urinary Incontinence (Stress)
Leakage from incompetent sphincter when IAP ↑
Loss of small amounts of urine when coughing
Pelvic floor weakness
Women Urinary Incontinence (Urge/Overactive bladder)
Can’t hold urine for any length of time
May have precipitant: arriving home, running water,
coffee
Dx: urodynamic studies
Urinary Incontinence Mx
Check
PR: faecal impaction
Palpable bladder after voiding: retention c¯ overflow
UTI
DM
CNS: MS, Parkinson’s stroke, spinal trauma
Diuretics
Stress Incontinence Pelvic floor exercises Ring pessary Duloxetine Surgery: tension-free vaginal tape
Urge Incontinence
Bladder training
Wt. loss
Anti-AChM: tolterodine, imipramine
Undescended testes Mx
Surgical: Orchidopexy by Dartos Pouch Procedure
Perform before 2yrs
Mobilisation of testis and cord
Removal of patent processus
Testicle brought through a hole made in the dartos
muscle to lie in a subcutaneous pouch.
Dartos prevents retraction.
Hormonal
β-HCG may be tried if testis is in inguinal canal
Testicular Torsion
Occurs because testicle doesn’t have a large “bare
area” to attach to scrotal wall.
Tunica vaginalis invests whole of testicle
Free-hanging “clapper bell” testicle can twist on
its mesentery.
usually 2ndary to exertion or minor trauma
Testicular Torsion Presentation
Usually 10-25yrs
Sudden onset severe pain in one testis
May have lower abdominal pain (testis supplied by T10)
Assoc. c¯ n/v
May be Hx of previous testicular pain or torsion
Testicular Torsion O/E
Ix
Inflam of one testis: hot, swollen, extremely tender
Testis rides high and lies transversely
Ix
Doppler US -may demonstrate absence of flow > MUST NOT DELAY SURGICAL EXPLORATION
Testicular torsion Mx
Surgical emergency
4-6h window from onset of pain to salvage testis
Inform senior
NBM
IV access
Analgesia
Bloods: FBC, U+E, G+S, clotting
Surgery
Consent for possible orchidectomy
Bilateral orchidopexy: suture testes to scrotum
If no torsion found and epididymo-orchitis Dx, take fluid sample from scrotum for bacteriology and Rx c¯ Abx.
Testicular Torsion DDx
Epididymo-orchitis
Older pt.
UTI symptoms
More gradual onset
Torted Hydatid of Morgagni Remnant of Mullerian duct Younger pt. Less pain Tiny blue dot visible on scrotum
Tumour
Trauma
Strangulated hernia
Appendicitis
DDx Lumps in groin and scrotum
Can’t get above: inguinoscrotal hernia
Separate, cystic: epididymal cyst
Separate, solid: varicocele, sperm granuloma, epididymitis
Testicular, cystic: hydrocele
Testicular, solid: tumour, orchitis, haematocele
Epididymal Cyst
Develop in adulthood
contain clear or milky (spermatocele) fluid
Lie above and behind testis
Remove if Sx
Remove if symptomatic
Dilated veins of pampiniform plexus
Presentation Feel like bag of worms in the scrotum May be visible dilated veins ↓ size on lying down Pt. may c/o dull ache May → oligospermia (↓ fertility)
Pathology
1O: Left side commoner: drain into left renal vein
2O: left renal tumour has tracked down renal vein →
testicular vein obstruction.
Mx
Conservative: scrotal support
Surgical: clipping the testicular vein (open or lap)
Sperm Granuloma
Painful lump of extravasated sperm after vasectomy
Hydrocele
Collection of serous fluid w/i tunica vaginalis
Primary
assoc. w patent processus vaginalis
Commoner, larger, tense, younger men
Secondary
Tumour, trauma, infection
Smaller, less tense
Ix - US testicle to exclude tumour
Mx
May resolve spontaneously
Surgery Lord’s Repair: plication of the sac Jaboulay’s Repair: eversion of the sac Aspiration Usually recur so not 1st line. Send fluid for cytology and MC+S
Haematocele
Blood in the tunica vaginalis
Hx of trauma
May need drainage or excision
Epididymo-Orchitis
O/E presentation
STI: Chlamydia, gonorrhoea
Ascending UTI: e. coli
Mumps
Features
Sudden onset tender swelling
Dysuria
Sweats, fever
Examination Tender, red, warm, swollen testis and epididymis Elevating testicle may relieve pain Secondary hydrocele Urethral discharge
Epididymo-Orchitis Ix Complications Mx
Ix Blood: FBC, CRP Urine: dip, MC+S (fist catch may be best) Urethral swab and STI screen US: may be needed to exclude abscess
Complications
May → infertility
Mx Bed rest Analgesia Scrotal support Abx: doxycycline or cipro Drain abscess if present
Balanitis
Acute inflammation of the foreskin and glans
Cause: Strep, staph infection, Candida (DM)
RFs: DM, young children c¯ tight foreskin
Rx: hygiene advice, Abx, circumcision
Phimosis
Foeskin occludes the meatus
Children Pres: recurrent balanitis and ballooning
Mx: Gentle retraction, steroid creams, circumcision
Adult Pres dyspareunia, infection
Mx: circumcision
Assoc. c¯ balanitis xerotica obliterans: thickening of
foreskin and glans → phimosis + meatal narrowing
Paraphymosis
Tight foreskin retracted becomes irreplaceable
↓ venous return → oedema and swelling of the glans
Can rarely → glans ischaemia
Causes: catheterisation, masturbation, intercourse
Mx:
Manual reduction: use ice and lignocaine jelly
May require glans aspiration or dorsal slit
Hypo/epi-spadias
Developmental abnormality of the position of the urethral
opening
Hypospadia: opens on ventral surface of penis
Epispadia: opens on dorsal surface
