Urology Flashcards
What is phimosis?
The inability to retract the foreskin over the glans
Incidence: 1% of non-circumcised population
What is physiological phimosis?
Phimosis that is normal up to adolescence
- 50% at 1 year
- 10% at 3 years
- 1% at 17 years
What are some of the consequences of phimosis?
- Poor hygeine - increased STDs
- Pain on intercourse - splitting/ bleeding of foreskin
- Balanitis (inflamed glans)
- Posthisis (inflamed foreskin/ prepuce)
- Balanitis Xerotica Obliterans (BXO)
- Parphimosis - when trying to retract forekin and it gets stuck
- Urinary retention
- Penile cancer
What is balanitis xerotica obliterans? (BXO)?
Whitening of the tip of the glans caused by scar tissue
Can cause urethral strictures
What is paraphimosis?
The painful constriction of the gland penis by the retracted prepuce
(retracted foreskin that can’t be pulled back)
What are the commonest causes of paraphimosis?
- Phimosis
- Catheterisation (esp in elderly) - the most common
- Penile cancer- if there’s a lump underneath
How is paraphimosis treated?
- Need reduction
- can be achieved manually under local anaesthetic
- Occasional a dorsal slit may be necessary
How common is penile cancer?
Rare- c. 350 cases/ year UK
What type of cancer is penile cancer?
Squamous cell carcinoma
What are some risk factors for developing penile cancer?
- Phimosis - hygeine and smegma (build up of sebaceous secretion in folds of skin)
- HPV 16 & 18
What is the mortality of penile cancer if left untreated?
- Most die within 2 years
- Almost all within less than 5 years
What are some reasons for circumcision?
Peadiatric:
- Religious
- Recurrent balanitis/ UTI
Adult:
- Reccurrent balanitis
- Phimosis
- Recurrent paraphimosis
- Balanitis Xerotica Obliterans
- Penile cancer
What are some of the causes of acute scrotal pain?
- Testicular torsion
- Epididymtitis/ Orchitis (inflamed testes), epididymo-orchitis
- UTI
- STI
- Mumps (can be 1st presentation of mumps)
- Torsion of hydatid of Morgagni (top of testis)
- Trauma
- Uretetic Calculi (rare) - get referred pain to testicle
What is the typical history of testicular torsion?
- Usually a younger patient (<30 years)
- Sudden onset (e.g. woke from sleep)
- Unilateral pain
- May have nausea/ vomiting
What would you find on examination if someone presents with testicular torsion?
- Testis is very tender
- Lying high in the scromtum with horizonal lie
- Needs emergency scrotal exploration within 6 hours
What is epididymo-orchitis?
Epididymo-orchitis is an inflammation of the epididymis and/or testicle (testis) usually due to infection
What is the typical history of someone with epididymo-orchitis?
- Age:
- 20-40/50- STI (esp Chlaymdia)
- 40-50 - UTI (esp E.Coli)
- Gradual onset
- Usually unilateral
- Recent history of
- UTI
- Unprotected sex
- Catheter/ urethral instrumentation
- Check for mumps history
What might you find on examination of a patient with epididymo-orchitis?
- May be pyrexial (can be septic)
- Scrotum erythematous (red)
- Testis/ epididymis enlarged and tender
- Fluctuant areas (fluid filled) may represent abscess
- May have reactive hydrocele
- Rarely necrotic (Fournier’s Gangrene) - high mortality rate!
What investigations should you do if you suspect epididymo-orchitis?
- Bloods
- FBC, U&E, Cultures (if septic)
- Urine
- midstream specimen of urine for
- Radiology
- Scrotal ultrasound is suspected abscess
How do you treat epididymo-orchitis?
- Epididymo-orchitis: antibiotics
- Abscess: surgical drainage and antibiotics
- Fournier’s gangrene: emergency debridement and antibiotics
What key questions should you ask in the history of someone presenting with scrotal lumps?
- Is it painful?
- How quickly has it appeared?
What should establish on examination of a patient who presents with a scrotal lump?
- Can i get above it?
- if not its likely to a hernia
- Is it in the body of the testis?
- if yes this could be a testicular tumour
- Is is separate to the testis?
- Does it fluctuate and transilluminate?
What are some of the differential diagnosis of a painless scrotal lump? (non tender)
- Testis tumour (90% are painless)
- Epididymal cyst
- Hydrocele
- Reducible inguino-scrotal hernia
What is the likely diagnosis of a scrotal lump that is painless but aches at the end of the day
Varicocele (bag of worms)
What are the differential diagnosis of a painful, tender, acute presentation of a scrotal lump?
- Epididymtitis
- Epididymo-orchitis
- Strangulated inguino-scrotal hernia (emergency!)
What history is typical of testicular tumour?
- Usually painless
- Germ cell tumours (seminoma/ teratoma) usually in men <45 years
- Older men could be lymphoma
- On examination - can get above the lump
What are the testis tumour markers?
- aFP (alpha feto protein)
- hCG
- LDH
If abnormal high usually indicitive
If normal it doesn’t rule out testicular tumour!
What is a hydrocele?
An imbalance of fluid production and resorption between the tunica albuginea and tunica vaginalis
Presents as slow/sudden onset uni/bilateral scrotal swelling
What do you find on examination of a man with hydrocele?
- Testis is not separately palpable
- Can usually get above it
- Transilluminates
What do you find on examination of an epididymal cyst?
- Usually painless
- Separate from testis
- Can get above it
- Transilluminates
How does varicocele present?
- Dull ache at end of the day
- May be associated with reduced fertility (if bilateral)
- Bag of worms
- non-tender
- May have palpable abdominal/ renal mass
- Will leave alone in most adults- can treat in young men
What is the treatment for testicular tumours?
- Inguinal orchidectomy
- Remove the nearest lymph nodes (inguinal lymph nodes)
How do you treat an epididymal cyst?
- Reassure
- Excise if large
How do you treat an adult hydrocele?
- If testis are normal on ultrasound:
- reassure
- Surgical removal if large/ symptomatic
How do you treat a varicocele?
- Reassure
- Radiological embolisation if symptomatic, infertile, affecting growth of testis in adolescent
What is urinary retention?
The inability to pass urine (rather than the inability to make urine)
Common in males, rare in females
What are some of the causes of urinary retention?
- Prostatic enlargement
- BPH
- Cancer
- Phimosis/ urethral stricture/ meatal stenosis
- Constipation
- UTI
- Drugs (anticholinergic drugs given for overactive bladder can go opposite way)
- Over-distension (too much fluid and not urinating stretches bladder)
- Post surgical
- Neurological e.g. cauda equina
How do you treat acute, painful urinary retention?
- Pain relieved by drainage (catheter)
- Residual volume <1,000 ml
- No kidney insult
How do you treat chronic urinary retention?
- May have kidney insult
- Residual volume >300 ml
- Learn to self catheterise
How do you treat acute on chronic urinary retention?
- Usualyl have kidney insults
- Residual volume >1,000 ml
- Long term catheterisation or surgical intervention
What is the cause of nocturnal enuresis in older men? (until proven otherwise)
Chronic retention with overflow incontinence
What symtpoms sugests a voiding issue in men?
- Hesitancy
- Poor flow
- Post micturition dribbling
- Suggestive of ladder outflow obstruction
What symptoms suggest an issue with urine storage?
- Increased frequency
- Increased urgency
- Nocturia (bedwetting)
What are some of the causes of a bladder storage issue?
- Irritative
- e.g. infection, inflammation, bladder stone, bladder cancer
- Overactive bladder
- idiopathic or neuropathic e.g. CVA, Parkinson’s, MS
- Low bladder compliance (scarred)
- e.g. after TB, Schistosomiasis, Pelvic Radiotherapy
- Polyuria (making too much urine)
- Gobal - uncontrolled diabetes
- Nocturnal - venous stasis, sleep apnoea
What type of things can cause Bladder Outflow Obstruction?
Physical:
- Urethra - phimosis, stricture
- Postate - benign, malignant, bladder neck
Dynamic:
- tone of muscle in bladder neck, prostate
Neurological:
- lack of coordination between bladder and urinary sphincter
- Upper Motor Neurone
What sort of things cause reduced bladder contractility?
- Physical problem
- Neurological
- lower motor neurone
- Cauda equina
- Extreme B12 deficiency
What may spraying of urine suggest?
Urethral stricture
Which receptors are responsible for maintaining sympathetic smooth muscular tone?
Principally alpha 1 receptors in the prostate and bladder neck
What factors are assessed on the international prostate symptom score?
- Incomplete Emptying
- Frequency
- Intermittency
- Urgency
- Weak Stream
- Straining
- Nocturia
Mild: 0-7
Moderate: 8-19
Severe: 20-35
Why can you not perform prostate specific antigen tests if patient has a UTI?
Must treat UTI first - wait 4-6 weeks
UTI’s spike PSA levels
What lifestyle factors can you modify in management of BPH?
- Reduce caffeine intake
- Avoid fizzy drinks
- Don’t drink more than 2.5L p/day
What drugs can you give to treat BPH?
1. TAMSULOSIN
An alpha blocker
Works by relaxing smooth muscle within the prostate and the bladder for rapid symptom relief
2. 5a- REDUCTASE INHIBITORS
FINASTERIDE or DUTASTERIDE
Act by shrinking the prostate by androgen deprivation. Slower symptoms relief than alpha blocker, slows progression and reduces risk of retention
What do the green, yellow and red lines of this flow rate chart suggest?
Green: normal
Yellow: suggestive of urethral stricture
Red: Suggestive of prostatic obstruction
