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D3 > Urology > Flashcards

Urology Flashcards

1
Q

Urinary Tract Obstruction Causes

A

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

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2
Q

UT Obstruction Presentation

A

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

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3
Q

UT obstruction Ix

A

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
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4
Q

UT obstruction Mx

A

Upper Urinary Tract
 Nephrostomy
 Ureteric stent

Lower Urinary Tract
 Urethral or suprapubic catheter
 May be a large post-obstructive diuresis

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5
Q

Complications of Ureteric Stents

A 
Common
 Infection
 Haematuria
 Trigonal irritation
 Encrustation

Rare
 Obstruction
 Ureteric rupture
 Stent migration

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6
Q

Urethral Stricture

A

Trauma
 Instrumentation
 Pelvic #s

Infection (gonorrhoea)
Chemotherapy
Balanitis xerotica obliterans

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7
Q

Urethral Stricture Presentation + examination

A 
Voiding difficulty 
 Hesitancy
 Strangury
 Poor stream
 Terminal dribbling
 Pis en deux

Examination
 PR: exclude prostatic cause
 Palpate urethra through penis
 Examine meatus

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8
Q

Urethral Stricture Ix + Mx

A

Urodynamics
 ↓ peak flow rate
 ↑ micturition time

Urethroscopy and cystoscopy

Retrograde urethrogram

Mx
 Internal urethrotomy
 Dilatation
 Stent

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9
Q

Obstructive Uropathy

A

 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.

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10
Q

Obstructive Uropathy Complications

A

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

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11
Q

Urinary Retention Causes

A 
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

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12
Q

Acute Urinary Retention (AUR)

Clinical Features

Ix

A 
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

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13
Q

Acute Urinary Retention

Mx

A 
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
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14
Q

Chronic Urinary Retention

Classification

A

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

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15
Q

Chronic Urinary Retention

Presentation

A

 Insidious as bladder capacity ↑↑ (>1.5L)
 Typically painless
 Overflow incontinence / nocturnal enuresis
 Acute on chronic retention
 Lower abdo mass
 UTI
 Renal failure

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16
Q

Chronic Urinary Retention

Mx

A

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

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17
Q

Suprapubic Catheterisation

adv disadv C/I

A 
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

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18
Q

Clean Intermittent Self-Catheterisation

A

 Alternative to indwelling catheter in AUR and CUR

 Also useful in pts. who fail to void after TURP

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19
Q

False Haematuria causes

A

 Beetroot
 Rifampicin
 Porphyria
 PV bleed

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20
Q

True Haematuria causes

A

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
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21
Q

Haematuria Clinical Features

A

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

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22
Q

Haematuria Ix

A

Bloods: FBC, U+E, clotting

Urine: dip, MC+S, cytology

Imaging
 Renal US
 IVU
 Flexible cystoscopy + biopsy
 CT/MRI
 Renal angio
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23
Q

Peri-Aortitis

A

 Idiopathic retroperitoneal fibrosis
 Inflammatory AAAs
 Perianeurysmal RPF
 RPF 2ndary to malignancy: e.g. lymphoma

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24
Q

Idiopathic Retroperitoneal Fibrosis

A

Autoimmine vasculitis
Fibrinoid necrosis of vasa vasorum
Affects aorta + small/medium sized retroperitoneal vessels
Ureters are embedded in dense, fibrous tissue > bilateral obstruction

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25
Q

Peri-aortitis ass/ Presentations

A

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
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26
Q

Peri-aortitis Ix Rx

A

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

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27
Q

Urolithiasis

A

 ↑ 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
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28
Q

Stone types (Urolithiasis)

A

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

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29
Q

Urolithiasis Associated factors

A

 Dehydration
 Hypercalcaemia: primary HPT, immobilisation
 ↑ oxalate excretion: tea, strawberries
 UTIs
 Hyperuricaemia: e.g. gout
 Urinary tract abnormalities: e.g. bladder diverticulae
 Drugs: frusemide, thiazides

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30
Q

Urolithiasis Presentation

A

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
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31
Q

Urolithiasis Ix

A

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

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32
Q

Functional Urinary System Scans

A

 DMSA: dimercaptosuccinic acid
 DTPA: diethylenetriamene penta-acetic acid
 MAG-3

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33
Q

Urolithiasis Prevention

A

 Drink plenty
 Treat UTIs rapidly
 ↓ oxalate intake: chocolate, tea, strawberries

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34
Q

Urolithiasis Mx

A

<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

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35
Q

Febrile renal obstruction

A

surgical emergency
percutaneous nephrostomy or ureteric stent

IV abx - cefuroxime 1.5g IV TDS

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36
Q

Renal Cell Carcinoma RF

A 
 Obesity
 Smoking
 HTN
 Dialysis (15% of pts. develop RCC)
 4% heritable: e.g. VHL syndrome
37
Q

Renal Cell Carcinoma Path and Subtypes

A

Adenocarcinoma from proximal renal tubular epithelium (90%)

Subtypes
 Clear Cell (glycogen): 70-80%
 Papillary: 15%
 Chromophobe: 5%
 Collecting duct: 1%
38
Q

Renal Cell Carcinoma Presentation

A

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

39
Q

Renal Cell Carcinoma Paraneoplasms

A 
 EPO → polycythaemia
 PTHrP → ↑ Ca
 Renin → HTN
 ACTH → Cushing’s syn.
 Amyloidosis
40
Q

Renal Cell Carcinoma Spread Ix

A

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
41
Q

Robson Staging

A

Renal Cell Carcinoma

  1. Confined to kidney
  2. Involves perinephric fat, but not Garota’s fascia
  3. Spread into renal vein
  4. Spread to adjacent / distant organs
42
Q

Renal Cell Carcinoma Mx

A

Medical
 Reserved for pts. c¯ poor prognosis
 Temsirolimus (mTOR inhibitor)

Surgical
 Radical nephrectomy
 Consider partial if small tumour or 1 kidney

43
Q

SCC of kidney

A

assw chronic staghorn calucli

44
Q

Transitional Cell Carcinoma Kidney

A

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

45
Q

Nephroblastoma

A

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
46
Q

Bladder Tumours Presentation

A

Painless Haematuria
Voiding irritability (dysuria, frequency, urgency
Recurrent UTI
Retention + obstructive renal failure

47
Q

Bladder Tumours RF

A 
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

48
Q

Bladder Tumour Ix

A 
 Urine: dip (sterile pyuria), cytology
 IVU: filling defects
 Cystoscopy c¯ biopsy: diagnostic
 Bimanual EUA: helps to assess spread
 CT/MRI: helps stage
49
Q

Bladder Tumours Mx

A

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

50
Q

Bladder tumour follow up

A

 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

51
Q

Benign Prostate Hypertrophy Path

A

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.

52
Q

Benign Prostate Hypertrophy

Presents

A 
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)

53
Q

BPH O/E, Ix

A

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
54
Q

BPH Mx Conservative, Medical

A

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

55
Q

BPH Mx Surgical

A

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)

56
Q

TURP Complications

A

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
57
Q

Prostate Cancer Pathology

Presentation

A

Adenocarcinoma
Peripheral Zone of prostate

Presentation
 Usually asymptomatic
 Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction
 Systemic: wt. loss, fatigue
 Mets: bone pain
58
Q

Prostate Cancer O/E, Spread

A

Examination
 Hard irregular prostate on PR
 Loss of midline sulcus

Spread
 Local: seminal vesicles, bladder, rectum
 Lymph: para-aortic nodes
 Haem: sclerotic bony lesions

59
Q

Prostate Cancer Ix

A

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.
60
Q

Prostate Specific Antigen

A

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

61
Q

Gleason Grade (Prostate cancer)

A

 Score two worst affected areas

 Sum is inversely proportional to prognosis

62
Q

Prostate Cancer TNMStaging

A

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

63
Q

Prognostic Factors Prostate Cancer

A 
Help determine whether to pursue radical Rx 
Age
Pre-Rx PSA
Tumour stage
Tumour grade
64
Q

Prostate Cancer Mx Conservative + Radical

A

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%)

65
Q

Prostate Cancer Medical management

A

Medical

Used for metastatic or node +ve disease

LHRH analogues
 E.g. goserelin
 Inhibit pituitary gonadotrophins → ↓ testosterone

Anti-androgens
 E.g. cyproterone acetate, flutamide

66
Q

Prostate Cancer Symptomatic Treatment

A

 TURP for obstruction
 Analgesia
 Radiotherapy for bone mets / cord compression

67
Q

Prostitis

A

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

68
Q

Male Urinary Incontinence

A

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.

69
Q

Women Urinary Incontinence (Stress)

A

 Leakage from incompetent sphincter when IAP ↑
 Loss of small amounts of urine when coughing
 Pelvic floor weakness

70
Q

Women Urinary Incontinence (Urge/Overactive bladder)

A

 Can’t hold urine for any length of time
 May have precipitant: arriving home, running water,
coffee

Dx: urodynamic studies

71
Q

Urinary Incontinence Mx

A

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

72
Q

Undescended testes Mx

A

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

73
Q

Testicular Torsion

A

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

74
Q

Testicular Torsion Presentation

A

 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

75
Q

Testicular Torsion O/E

Ix

A

 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

76
Q

Testicular torsion Mx

A

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.

77
Q

Testicular Torsion DDx

A

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

78
Q

DDx Lumps in groin and scrotum

A

 Can’t get above: inguinoscrotal hernia
 Separate, cystic: epididymal cyst
 Separate, solid: varicocele, sperm granuloma, epididymitis
 Testicular, cystic: hydrocele
 Testicular, solid: tumour, orchitis, haematocele

79
Q

Epididymal Cyst

A

Develop in adulthood
contain clear or milky (spermatocele) fluid
Lie above and behind testis
Remove if Sx

80
Q

 Remove if symptomatic

A

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)

81
Q

Sperm Granuloma

A

Painful lump of extravasated sperm after vasectomy

82
Q

Hydrocele

A

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
83
Q

Haematocele

A

 Blood in the tunica vaginalis
 Hx of trauma
 May need drainage or excision

84
Q

Epididymo-Orchitis

O/E presentation

A

 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
85
Q

Epididymo-Orchitis Ix Complications Mx

A 
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
86
Q

Balanitis

A

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

87
Q

Phimosis

A

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

88
Q

Paraphymosis

A

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

89
Q

Hypo/epi-spadias

A

Developmental abnormality of the position of the urethral
opening

 Hypospadia: opens on ventral surface of penis
 Epispadia: opens on dorsal surface

D3 (14 decks)

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