Urology Flashcards
causes of urinary tract obstruction
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
presentation of urinary tract obstruction chronic vs acute
Acute • Upper Urinary Tract § Loin pain → groin • Lower Urinary Tract § Bladder outflow obstruction precedes suprapubic pain ¯c 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
inv and management upper and lower urinary tract obstruction
x • 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 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
- Infection
- Haematuria
- Trigonal irritation
- Encrustation
causes of urethral stricture
Aetiology • Trauma § Instrumentation § Pelvic #s • Infection: e.g. gonorrhoea • Chemotherapy • Balantitis xerotica obliterans
presentation urethral stricture
Presentation: voiding difficulty • Hesitancy • Strangury • Poor stream • Terminal dribbling • Pis en deux Examination • PR: exclude prostatic cause • Palpate urethra through penis • Examine meatus
inv and management urethral stricture
• Urodynamics § ↓ peak flow rate § ↑ micturition time • Urethroscopy and cystoscopy • Retrograde urethrogram Mx • Internal urethrotomy • Dilatation • Stent
complications of obstructive uropathy
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 ¯c 1.26% NaHCO3
Infection
causes of urinary retention
• 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 retetioni presetnation and inv
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
management acute urianry retention
Conservative
• Analgesia
• Privacy
• Walking
• Running water or hot bath
Catheterise
• Use correct catheter: e.g. 3-way if clots
• ± STAT gentamicin cover
• Hrly UO + replace: post-obstruction diuresis
• Tamsulosin: ↓ risk of recatheterisation after retention
• TWOC 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
• Failed TWOC
• Impaired renal func
presentation of chronic urinary retetntion
entation • Insidious as bladder capacity ↑↑ (>1.5L) • Typically painless • Overflow incontinence / nocturnal enuresis • Acute on chronic retention • Lower abdo mass • UTI • Renal failure
will be high or low pressure (decided on inv)
management of chronic urniary retetnion
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 of introducing infection • Early TURP § Often do poorly due to poor detrusor function § Need CISC or permanent catheter
suprapubic catheterisation
Advantages • ↓ UTIs • Avoids risk of urethral stricture formation • TWOC w/o catheter removal • Pt. preference: ↑ comfort • Maintain sexual function
Disadvantages
• More complex
• Serious complications can occur
Contraindications` • Known or suspected bladder carcinoma • Undiagnosed haematuria • Previous lower abdominal surgery § → adhesion of small bowel to abdo wall
categorise the causes of haematuria
False • Beetroot • Rifampicin • Porphyria • PV bleed
True
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
hx and inv for haematuria
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 Ix • Bloods: FBC, U+E, clotting • Urine: dip, MC+S, cytology • Imaging § Renal US § IVU § Flexible cystoscopy + biopsy § CT/MRI § Renal angio
urinary /kidney stones, who gets them, where
Epidemiology • Lifetime incidence: 15% • Young men § Peak age: 20-40yrs § Sex: M>F=3:1 Pathophysiology • ↑ 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
types of kidney stones
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)
risk factors kidney stones
Dehydration • Hypercalcaemia: 1O HPT, immobilisation • ↑ oxalate excretion: tea, strawberries • UTIs • Hyperuricaemia: e.g. gout • Urinary tract abnormalities: e.g. bladder diverticulae • Drugs: frusemide, thiazides
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
ureteric colic
eric Colic
• Severe, sudden onset loin pain radiating to the groin
• Assoc. ¯c n/v
• Pt. cannot lie still
inv kidney stones
Urine • Dip: haematuria • MC+S Blood • FBC, U+E, Ca, PO4, urate imaging CT KUB gold standard USS too
preventing kidney stones
Drink plenty
• Treat UTIs rapidly
• ↓ oxalate intake: chocolate, tea, strawberries
treating kidney stones
Analgesia
§ Diclofenac 75mg PO/IM or 100mg PR
§ Opioids if NSAIDs CI: e.g. pethidine
• Fluids: IV if unable to tolerate PO
• Abx if infection: e.g. cefuroxime 1.5mg IV TDS
Conservative: <5mm in lower 1/3 of ureter
• 90-95% pass spontaneously
• Can discharge pt. ¯c analgesia
• Sieve urine to collect stone for OPD analysis
medical management kidney stones
Indications • Stone 5-10mm • Stone expected to pass Drugs • Nifedipine or tamsulosin • ± prednisolone • Most pass w/i 48h, 80% w/i 30d
summarise kidney stones management
initial - pain relief, IV fluids, abx if obs off
if expected to pass but 5-10mm -> nifedipine or tamsulosin +/- pred
if not expected to pass, can do extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy or ureterorenoscopy
procedural interventions kidney stone
Indications
• Low likelihood of spontaneous passage: e.g. >10mm
• Persistent obstruction
• Renal insufficiency
• Infection
Extracorporeal Shockwave Lithotripsy (SWL)
• Stones <20mm in kidney or proximal ureter
• SE: renal injury may → ↑BP
• CI: pregnancy, AAA, bleeding diathesis
Ureterorenoscopy (URS) + Dormier Basket Removal
• Stone >10mm in distal ureter or if SWL failed
• Stone >20mm in renal pelvis
Percutaneous Nephrolithotomy (PNL)
• Stone >20mm in renal pelvis
• E.g. staghorn calculi: do DMSA first
summarise kidney stones management with fever
Febrile + Renal Obstruction
• Surgical emergency
• Percutaneous nephrostomy or ureteric stent
• IV Abx: e.g. cefuroxime 1.5g IV TDS
Rx Summary
• Conservative: stone <5mm in distal ureter
• MET: stone 5-10mm and expected to pass
• Active: stones >10mm, persistent pain, renal
insufficiency
renal cell carcinoma
main RF obestiy, smoing
Adenocarcinoma from proximal renal tubular epithelium • Subtypes § Clear Cell (glycogen): 70-80% § Papillary: 15% § Chromophobe: 5% § Collecting duct: 1%
presentation of RCC
- 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
paraneoplastic features
paraneo features RCC and spread
Paraneoplastic Features • EPO → polycythaemia • PTHrP → ↑ Ca • Renin → HTN • ACTH → Cushing’s syn. • Amyloidosis Spread • Direct: renal vein • Lymph • Haematogenous: bone, liver and lung
investigation of RCC
• Blood: polycythaemia, ESR, U+E, ALP, Ca • Urine: dip, cytology • Imaging § CXR: cannonball mets § US: mass § IVU: filling defect § CT/MRI
staging of RCC
Robson Staging • Confined to kidney • Involves perinephric fat, but not Gerota’s fascia • Spread into renal vein • Spread to adjacent / distant organs
management 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 Prognosis: 45% 5ys
transitional cell carcinoma
Risk Factors • Smoking • Amine exposure (rubber industry) • Cyclophosphamide Pathology • Highly malignant • Locations § Bladder: 50% § Ureter § Renal pelvis
transitional cell carcinoma management
Painless haematuria • Frequency, urgency, dysuria • Urinary tract obstruction Ix • Urine cytology • CT/MRI • IVU: pelviceal filling defect Mx • Nephrouretectomy • Regular f/up: 50% develop bladder tumours
Nephroblastoma: Wilm’s Tumour
• 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 p
other renal tumours aside from main 2-3
Benign
• Cysts: very common
• Renal papillary adenomas
• Oncocytoma: eosinophilic cells ¯c numerous
mitochondria
• Angiomyolipoma: seen in tuberous sclerosis
Malignant
• SCC: assoc. ¯c chronic infected staghorn calculi
NB. Benign tumours commonly require nephrectomy to
exclude malignancy
risk factors for bladder cancer
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
presentation and examination of bladder cancer
• Painless haematuria • Voiding irritability: dysuria, frequency, urgency • Recurrent UTIs • Retention and obstructive renal failure Examination • Anaemia • Palpable bladder mass • Palpable liver
staging grading bladder ca
TNM Staging
• 80% confined to mucosa
• 20% penetrate muscle (↑ mortality)
Spread • Local → pelvic structures • Lymph → iliac and para-aortic nodes • Haem → bones, liver and lungs Histological Classification • Grade 1: well differentiated • Grade 2: intermediate • Grade 3: poorly differentiated
inv and mangement bladderca
Urine: dip (sterile pyuria), cytology • IVU: filling defects • Cystoscopy c¯ biopsy: diagnostic • Bimanual EUA: helps to assess spread • CT/MRI: helps stage Mx superficial - 80% -diathermy in cystoscopy or TURBT, intravesicular chemotherapy/ immunoT
invasive - cystectomy, radioT, chemoT
v advanced - catheter and palliate
complications bladder ca
Complications
• Massive bladder haemorrhage
• Cystectomy → Sexual and urinary malfunction
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
pathophysiology BPH
90% menover 80 yrs
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.
presentation of benign prostatic hyperplasia
Storage Symptoms § Nocturia § Frequency § Urgency § Overflow incontinence
• Voiding Symptoms § Hesitancy § Straining § Poor stream/flow + terminal dribbling § Strangury (urinary tenesmus) § Incomplete emptying: pis en deux
- Bladder stones (2O to stasis)
- UTI (2O to stasis)
examination and inv of BPH
Examination • 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
management of BPH
Conservative
• ↓ caffeine, EtOH
• Double voiding
• Bladder training: hold on → ↑ time between voiding
Medical
tamsulosin, doxazosin,
(SE SE: drowsiness, ↓BP, depression, EF, wt. ↑,
extra-pyramidal signs)
finasteride (SE SE: excreted in semen (use condoms), ED)
Surgical
TURP
transurethral incision of prostate better SE profile
complications of TURP procedure
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 ca stats, presentation
Epidemiology • Commonest male Ca • 3rd commonest cause of male Ca death • Prevalence: 80% of men >80yrs • Race: ↑ in Blacks Pathology • Adenocarcinoma • Peripheral zone of prostate Presentation • Usually asymptomatic • Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction • Systemic: wt. loss, fatigue • Mets: bone pain Examination • Hard irregular prostate on PR • Loss of midline sulcus
inv prostate ca
Spread • Local: seminal vesicles, bladder, rectum • Lymph: para-aortic nodes • Haem: sclerotic bony lesions 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.
staging for prosatate ca
Gleason Grade
• Score two worst affected areas
management prostate ca
conservative - especially if elderly, may be more prudent to monitor
radical prostatectomy if under 75 improves survival but poor SE profile
meds - goserelin
prostatitis cause and prsetnation
Prostatitis Aetiology • S. faecalis • E. coli • Chlamydia Presentation • Usually >35yrs • UTI / dysuria • Pain § Low backache § Pain on ejaculation • Haematospermia • Fever and rigors • Retention • Malaise
prostatitis treat and inv
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 incontinence cause
Male
• 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.
female incontinence cause
Women
• Stress Incontinence
§ Leakage from incompetent sphincter when IAP ↑
§ Loss of small amounts of urine when coughing
§ Pelvic floor weakness
• Urge Incontinence / Overactive Bladder
§ Can’t hold urine for any length of time
§ May have precipitant: arriving home, running water,
coffee
§ Dx: urodynamic studies
management of 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
categorise undescended testicle x 4
Cryptorchidism
• Complete absence of testis from scrotum
• Anorchism = absence of both testes
Retractile Testis
• Normal development but excessive cremasteric reflex
• Testicle often found at external inguinal ring
• Will descend: no Rx required
Maldescended Testis
• Found anywhere along normal path of descent
• Testis and scrotum are usually under-developed
• Often assoc. ¯c patent processus vaginalis
Ectopic Testis
• Found outside line of descent
• Usually in sup. inguinal pouch (ant. to external
oblique aponeurosis)
• Abdominal, perineal, penile, femoral triangle
complications of undesc testicle
Complications
• Infertility
• 10x ↑ risk of malignancy (remains after surgery)
• ↑ risk of trauma
• ↑ risk of torsion
• Assoc. ¯c hernias (90%) or urinary tract abnormalities
managmeent of undesc testcile
Mx
• Restores potential for spermatogenesis
• Makes Ca easier to Dx
Surgical: Orchidopexy by Dartos Pouch Procedure
• Perform before 2yrs
β-HCG may be tried if testis is in inguinal canal.
cause and presentation testicular torision
Usually 2O to some exertion or minor trauma
• 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.
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
examination and inv torsion testicle
Examination
• 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
ddx torted testcile
Differential • 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
management of 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.
ddx male lumps in groin/ scrote
Differential
• 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 symptomatic
varicocoele summarise
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)
hydrocoele summarise
Hydrocele • Collection of serous fluid w/i tunica vaginalis • Primary § assoc. ¯c 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
epididymo orchitis cause exam present
Aetiology • 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 inv and manage
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
testicular ca presentation risk factors
Commonest male malignancies from 15-44yrs • Whites > Blacks = 5:1 Presentation • Painless testicular lump § Often noticed after trauma • Haematospermia • 2O hydrocele • Mets: SOB from lung mets • Abdo mass: para-aortic lymphadenopathy • Hormones: gynaecomastia, virilisation • Contralateral tumour in 5% Risk Factors • Undescended testis § 10% occur in undescended testes • Infant hernia • Infertility
types of testicular tumours
<5 ALL
germ cell tumour (seminoma or non seminoma 95%, otherwise sex cord stromal)
> 65 NHL
staging inv management testicle tumour
Staging: Royal Marsden Classification • Disease only in testis • Para-aortic nodes involved (below diaphragm) • Supra- and infra-diaphragmatic LNs involved • Extra-lymphatic spread: lungs, liver Ix • Tumour markers § Useful for monitoring § ↑AFP and ↑hCG in 90% of teratomas § ↑hCG in 15% of seminomas § Normal AFP in pure seminomas • Scrotum US • Staging § CXR § CT NB. Percutaneous biopsy should not be performed as it may → seeding along needle tract
Mx
• If both testes are abnormal, semen can be
cryopreserved
seminomas = orchidectomy + radiotherapy (stage1/2)
+ chemotherapy stage3/4
Close f/up to detect relapse
• Typically w/i 18-24mo
• Repeat CT scanning and tumour markers
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
Foreskin occludes the meatus • Children § Pres: recurrent balanitis and ballooning § Mx: Gentle retraction, steroid creams, circumcision
• Adults
§ Pres: dyspareunia, infection
§ Mx: circumcision
§ Assoc. ¯c balanitis xerotica obliterans: thickening
of foreskin and glans → phimosis + meatal
narrowing
paraphimosis
Tight foreskin is retracted and 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
hypospadia
Hypo- / epi-spadias
• Developmental abnormality of the position of the urethral
opening
• Hypospadia: opens on ventral surface of penis
• Epispadia: opens on dorsal surface
penile ca
pretty rare compared to others
entation
• Chronic fungating ulcer
• Bloody / purulent discharge
• 50% have inguinal nodes at presentation
Mx
• Medical
§ Early growths ¯c no urethral involvement
§ DXT and iridium wires
• Surgical
§ Amputation required if urethral involvement
§ Lymph node dissection
