Urology P2 Flashcards
What is the most common cause of scrotal swelling in primary care?
epididymal cysts
Features of epididymal cysts:
- separate from body of testicle
- posterior to testicle
What are epididymal cysts associated with?
- polycystic kidney disease
- cystic fibrosis
- Von Hippel Lindau syndrome
Diagnosis and management of epididymal cysts?
- ultrasound
- supportive management
- symptomatic: surgery or sclerotherapy
What is testicular torsion?
- twist of spermatic cord resulting in ischaemia and necrosis
- males 10-30yo
Features of testicular torsion:
- severe and sudden pain
- pain referred to lower abdomen
- nausea and vomiting
- swollen, tender testis retracted upwards
- cremasteric reflex lost
- elevation of testis does not ease pain (Prehn’s sign)
Management of testicular torsion:
- urgent surgical exploration
- both tests as condition of bell clapper testis often bilateral
Diagnosis of prostate cancer:
- few symptoms early on
- metastatic - bone pain
- locally advanced: pelvic pain or urinary
- PSA measurement
- digital rectal
- trans rectal USS (biops) - TRUS
- MRI/CT and bone scan for staging
What to do if irregular prostate felt:
refer urology 2 weeks
-multiparametric MRI
TRUS complications:
- sepsis
- pain
- fever
- haematuria and rectal bleeding
PSA test results:
- upper limit 4ng/ml
- poor specificity and sensitivity
- 50-59yo: 3
- 60-69yo: 4
- > 70yo: 5
Causes of false positive PSA test:
- prostatitis
- UTI
- BPH
- vigorous DRE
- vigorous exercise
- urinary retention
- ejaculation
Risk factors prostate cancer:
- increasing age
- obesity
- afro-caribbean
- family history
Features prostate cancer:
- bladder outlet obstruction: hesitance, urinary retention
- haematuria, haematospermia
- pain: back, perineal or testicular
- DRE: asymmetrical, hard, nodular enlargement with loss of median sulcus
Pathology of prostate cancer:
- 95% adenocarcinoma
- often multifocal
- graded using Gleason grading system
- lymphatic spread occurs first to obturator nodes and local extra prostatic spread to seminal vesicles associated with distant disease
Treatment options prostate cancer:
-watch and wait
-radiotherapy (external): late radiation proctitis and rectal malignancy
-internal: brachytherapy
-surgery: radical prostatectomy with obturator nodes
ADR erectile dysfunction
-hormonal therapy: 95% testosterone from testis so bilateral orhidectomy, or LHRH analogues (goserelin) and anti-androgens (flutamide)
-active surveillance: have at least 10 biopsy cores, one re-biopsy
What is acute bacterial prostatitis?
- caused by gram negative bacteria entering prostate via urethra
- e.coli mostly
Risk factors acute bacterial prostatitis:
- recent UTI
- urogenital instrumentation
- intermittent bladder catheterisation and recent prostate biopsy
Features of acute bacterial prostatitis:
- pain of prostatitis - perineum, penis, rectum, back
- obstructive voiding
- fevers and rigors
- DRE: tender, boggy
Management of acute bacterial prostatitis:
- 14 days quinolone
- screen STI
Acute urinary retention:
- sudden inability to pass urine
- men - BPH
- urethral obstruction: calculi, strictures, cystocele, constipation, masses
- medications: anticholinergics, TCA, antihistamines, opioids and benzodiazepines
- neurological - UTI
- postoperative and postpartum
Features of acute urinary retention:
- inability to pass urine
- lower abdo discomfort
- considerable pain or distress
- confusion in elderly
- if already chronic, overflow incontinence
- palpable distended urinary bladder on abdominal or rectal exam
- lower abdominal tenderness
Management of acute urinary retention:
- bladder US
- decompress with catheter
- underlying cause investigate
Complications of acute urinary retention:
post operative diuresis:
- kidneys may diverse due to loss of medullary conc gradient
- volume depletion and worsening AKI
- may need IV fluids
What is balanitis?
- inflammation of glass and sometimes underside of foreskin - balanoposthitis
- most commonly infective
Candidiasis causing balanitis:
- acute
- usually after intercourse and associated with itching and white non-urethral discharge
- children and adults
- topical clotrimazole 2 weeks
Dermatitis causing balanitis (contact or allergic):
- acute
- itchy
- sometimes painful
- occasionally clear non-urethral discharge
- no other body area affected
- both children and adults
- mild potency topical corticosteroids
Dermatitis causing balanitis (eczema or psoriasis):
- both acute and chronic
- very itchy but not associated with any discharge
- history of inflammatory skin condition
- both adults and children
- mild potency topical corticosteroids
Bacterial infection causing balanitis:
- acute
- painful
- can be itchy with yellow non-urethral discharge
- both adults and children
- mostly staph spp or group B strep spp
- treated with flucloxacillin or clarithromycin
Anaerobic bacterial infection causing balanitis:
- acute
- itchy but most associated with very offensive yellow non-urethral discharge
- both children and adults
- topical/oral metronidazole
Lichen planus causing balanitis:
- both chronic and acute
- itchy, presence of Wickham’s striae
- violaceous papules
- more commonly adults
Lichen sclerosis (balanitis xerotica obliterans):
- chronic
- itchy
- associated with white plaques
- significant scarring
- both adults and children
- high potency topical steroids e.g. clobetasol
- circumcision if recurrent balanitis
Plasma cell balanitis of Zoon:
- chronic
- itchy with clearly circumscribed areas of inflammation
- both adults and children
- high potency topical steroids e.g. clobetasol
Circinate balanitis:
- both chronic and acute
- not itchy
- no discharge
- painless erosions
- can be associated with Reiter’s
- adults
- mild potency topical corticosteroids
Investigations balanitis:
- suspected infective - swab fro microscopy and culture which may show bacteria or candida albicans
- biopsy if extensive skin changes
Treatment balanitis general:
- gentle saline washes
- severe irritation and discomfort - 1% hydrocortisone
High pressure chronic urinary retention:
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction
Lowe pressure chronic urinary retention:
-normal renal function and no hydronephrosis
What is depcomression haematuria?
- after catheterisation for chronic retention
- rapid decrease in pressure
- no further treatment
Benefits of circumcision:
- reduced risk of penile cancer
- reduce risk UTI
- reduced risk of acquiring STI including HIV
Medical indications circumcision:
- phimosis
- recurrent balanitis
- balanitis xerotica obliterans
- paraphimosis
What must you exclude before circumcisions:
exclude hypospadias
What is epididymo-orchitis?
-infection of epididymis with or without testes
-pain and swelling
-spread from genital tract
e.g. chlamydia trachomatis and neisseria gonorrhoea or bladder
if low STI risk - e.coli
Features and management of epididymo-orchitis:
-unilateral testicular pain and swelling
-urethral discharge may be present, urethritis often asymptomatic
unknown organism - ceftriaxone 500mg IM single dose
doxycycline 100mg by mouth x2 daily for 10-14 days
Factors favouring an organic cause of erectile dysfunction:
- gradual onset of symptoms
- lack of tumescence
- normal libido
Factors favouring a psychogenic causes:
- sudden onset symptoms
- decreased libido
- good quality spontaneous or self-stimulated erections
- major life events
- problems or changes in relationship
- previous psychological
- history premature ejaculation
Risk factors erectile dysfunction:
- increasing age
- CVD
- alcohol
- drugs: SSRIs, beta blockers
Investigations and management erectile dysfunction:
- free testosterone morning 9-11am
- if low/borderline, repeat with FSH, LH and prolactin
- abnormal - endocrinology
- PDE-5 inhibitors (sildenafil - viagra)
- vacuum erection devices 1st line if not
