Diseases Penis, Urethra, Scrotum Flashcards
(55 cards)
1
Q
Male urethra total length
A
- 15-25cm long
2
Q
Distal portion of the male urethra
A
- Fossa navicularis
3
Q
Portion of urethra that stretches during erection
A
- Pendulous urethra
- Longest segment of male urethra
4
Q
Male urethral site of voluntary control during voiding
A
- Membranous urethra
- Site of external urinary sphincter
5
Q
Dual blood supply of urethra
A
- Corpus spongiosum/urethra
*antegrade: bulbar artery
*retrograde: dorsal artery
6
Q
Prostatic urethra blood supply
A
- Inferior vesical artery
7
Q
Membranous, anterior urethra blood supply
A
- Bulbourethral artery
8
Q
Retrograde perfusion of the urethra artery
A
- Deep dorsal artery
9
Q
Urethral stricture
A
- Circumferential spongiofibrosis from scar or stenosis as ar esult of trauma
- Etiology
*trauma: pelvic fx. straddle injury
*iatrogenic: foley catheter, transurethral instrumentation
*infection: gonococcal urethritis
*inflammatory: lichen sclerosis/BXO
*congenital: Cobb’s collar- smooth muscle proliferation of bulbar urethra
10
Q
Urethral stricture presentation
A
- Spraying/splitting stream, weak stream, incomplete emptying, straining
- High voiding pressure w/ bladder remodeling over time
- Infection: UTI, prostatitis
- Urethrocutaneous fistula
11
Q
Urethral stricture dilation
A
- Surgical treatment for stricture
- Goal is to dilate stricture w/o tear
- High failure rates
*<2cm: 40% failure 1yr
*2-4cm: 50% failure 1yr (75% 4yr)
*>4cm: 80% at 1yr
- Repeat dilations increase risk of failure and stricture progression
12
Q
Urethral stricute DVIU
A
- Surgical treatment for stricture
- Laser or cold knife
*incise at 4 and 8 o’clock to avoid corporal injury
- Foley for 72hrs
- 100% failure at 48months
*related to degree of fibrosis
- Proceed to urethroplasty if (when) pt fails
13
Q
Excision and primary anastomosis (EPA)
A
- Treatment for urethral stricture
- Resect scar, spatulate ends, and tension free anastamosis
- Bulbar urethra: <3cm
- Penile urethra: <1cm
*can cause ventral chordee if too much penile urethra is excised
14
Q
Buccal mucosal graft Urethroplasty
A
- Treatment for urethral stricture
- Graft taken from oral cavity
- Dorsal onlay: penile urethra
- Ventral onlay: bulbar urethra
- Excellent long-term success (up to 85%)
15
Q
Urethral carcinoma
A
- Very rare
- HPV 16/18, STD, urethral stricture
- Squamous cell variant is most common
- Bulbomembranous junction is most common site
16
Q
Urethral carcinoma presentation
A
- Hematuria
- Palpable mass
- LUTS
17
Q
Urethral carcinoma diagnosis
A
- Cystoscopy
- Urethral biopsy
- Penile MRI
- CT abdomen and pelvis
18
Q
Anterior urethra carcinoma treatment
A
- Partial penectomy w/ 2cm neg. margin
- Inguinal LN dissection if palpable nodes and no distant mets
19
Q
Posterior urethra carcinoma treatment
A
- Total penectomy
- Cystoprostatecomy
- Pelvic LN dissection if no distant mets
20
Q
Penis clincal anatomy - structure
A
- Layers
*skin, dartos fasica, superficial dorsal v., Buck’s fascia, dorsal NVB, tunica albuginea, corpora cavernosa, cavernosal a.
- 2 corpora cavernosa
*erectile bodies
- 1 corpus spongiosum
*urethra
21
Q
Penis clinical anatomy - vascular
A
- External pudendal artery
*skin/prepuce
- Internal pudendal artery
*bulbar a.: bulbar urethra
*bulbourethral a: corpus spongiosum/urethra, glans
*cavernosal a: corpora cavernosa—>erections
-Dual blood supply: corpus spongiosum/urethra
*antegrade: bulbar artery
*retrograde: dorsal artery
22
Q
Papilloma (pearly papules) of the penis
A
- Benign lesion
- 1-2mm papules on glans/coronal edge
- Does NOT contain HPV
- NOT transmissible
- Tx: reassurance, observe
23
Q
Condyloma acuminatum/HPV
A
- Benign lesion
- Non-tender, papillary
- STD, caused by HPV
- 90%: HPV 6, 11
- Malignancy: 16, 18
*cervical, penile, anal
- Dx: PE, biopsy (some pts)
- Tx: imiquimod, podofilox, excision, laser ablation
*topical may take 3months
- Prevention: quadrivalent HPV recombinant vaccine (types 6, 11, 16, 18)
24
Q
Zoon’s balantis
A
- Benign penile lesion
- Glans of uncirced males
- PE: asx, macular, well defined erythema, pinpoint “cayenne pepper”
- Dx: biopsy (plasma cells)
- Tx: topical steroids, circumcise, laser ablation
25
Buschke-Lowenstein tumor
- Pre-malignant penile lesion
- "Giant conyloma", cauliflower appearance
- May be locally invasive, but no metastasis
- Rare malignant conversion
\*HPV 6, 11
- Tx: wide, completeexcision
\*high recurrence rates
26
Bowenoid papulosis
- Pre-malignant penile lesion
- Red brown papules on the shaft of younger circumcised pts
- Malignant transformation in immunosuppressed pts
- Dx: biopsy (+HPV)
- Tx: surveillance, topical 5-FU, or ablation
27
Lichen sclerosis
- Pre-malignant penile lesion
- Arises from chronic infection or inflammation
- Flat, white mosaic patches
- Meatal stenosis/urethral stricture---\> voiding sx/LUTS
- Consider cystoscopy
- Bx if spreading rapidly
- 2-8% malignat
- Tx: observe if asx, topical steroids, circumcision if phimotic, meatotomy, urethroplasty
28
Penile carcinoma in situ
- Involving either the shaft or the glans
- Shaft---\> Bowen's dx (top image)
- Glans/prepuce---\> erythroplasia of Qeuyrat (bottom image)
- Uncirc. male, 50-60
- Red, velvety plaques
- 10% develop penile ca
- Dx: biopsy
- Tx: topical 5-FU, laser ablation, excision
29
Penile cancer
- Rare, \<1% of all adult cancer in US
- Annual incidence: 2120 new cases in US 2017
\*1:100,000 adult males
- 360 disease-specific deaths per year
- More common in Africa, Asia, and South America
- Males, 50-70
- Squamous cell carcinoma is the most common type
- Most common paraneoplastic syndrome: hypercalcemia
30
Penile cancer risk factors
- Uncircumcised, smoking, phimosis, chronic inflammation, HPV (16, 18), pre-malignant lesions
\*neonatal circ virtually eliminates risk (postpubertal circ does not change risk)
31
Squamous cell carcinoma of penis
- HPV 16, 18
- Location: glans (50%), shaft (30%), prepuce (20%)
- Sx: non-healing wound, papule, wart, induration, fungating lesion, ulcer
- Can invade locally and metastasize
32
Squamous celll carcinoma of the penis metastasis
- Inguinal lymph nodes
\*superfical
\*b/l
- Distant mets (\<10%)
\*lung (#1 site of distant mets)
\*liver, bone, brain
33
Squamous cell carcinoma of the penis workup
- +/- biopsy if unclear
- Chest x-ray
- CT of abdomen/pelvis
- Labs: CMP, LFTs
- MRI/penile US: organ sparing surgery (corporal involvement)
- Bone scan: bone pain, hypercalcemia, inc. alk phos
34
Squamous cell carcinoma clinical staging
- Depth of invasion (T) and node (N)/Met (M) status
- Ta: no-invasive
- T1a: low grade subepithelial
- T1b: lymphovascular invasion or any high grade
- T2: cavernosa/spongiosum invasion
- T3: urethral invasion
- T4: into adjacent organs
35
Squamous cell carcinoma of the penis treatment
- Surgical excision = gold standard
\*partial penectomy: must maintain 2cm of phallic length for voiding function
\*must resect to neg. margin
\*total penectomy: \>T2 disease
\*penil sparing: Tis, Ta, T1a
- Chemo/radiation: pelvic nodes, b/l inguinal nodes, distant mets
\*paclitaxel, ifosfamide, cisplatin
- Intensive follow up first 2yrs, then annually (CT, CXR, PE)
36
Scrotal layers
- Skin
- Dartos fascia
- External spermatic fascia
- Cremaster muscle and fascia
\*regulates the tonicity of the skin
- Internal spermatic fascia
- Tunica vaginalis
37
Testicular blood supply
1. Testicular artery
\*aorta
2. Cremasteric artery
\*inferior epigastric artery
3. Deferential artery
\*internal iliac artery
38
Spermatocele
- Benign aquired cyst of the testicle
- Dilation of the efferent ductules of the **epididymal head**
- Painless, slow growing
- Dx: PE, U/S
- Tx: observe, elective excision
\***excision will not improve fertility in subfertile male**
39
Hydrocele
- Serous fluid collection of tunica vaginalis
- 1% of males
- Sx: painless, "heavy" sensation
- PE: **translucent swelling** of scrotum, may extend into inguinal canal
- 2 types:
\*congential
\*acquired
40
Hydrocele types
- Congenital: due to patent processus vaginalis, communicating, **fluctuates in size (w/ valsalva)**, bulges into inguinal crease
- Acquired: defective fliuid absorption or excess production within tunica vaginalis
- Hydrocele of cord: isolated, often subclinical
41
Hydrocele treatment
- Always assess the contralateral testicle, scrotal US
- Observation, elective resection
**\*peds: will often resolve by 1yo**
**\*DO NOT ASPIRATE: recurrence**
42
Varicocele
- Group of dilated veins in the pampiniform plexus
- Most common finding in subfertile males
- Inguinal or scrotal pain, testicular atrophy, infertility, "bag of worms"
**\*stress pattern:** decreased motility, low sperm count, abnormal morphology
- Left testicle
\*more common ~85%
\*gonadal v inserts into left renal v (longer course, more back pressure)
- Right testicle
\*gonadal v inserts directly into IVC
**\*consider abdominal, retroperitoneal, or IVC mass w/ unilateral right varicocele (especially if acute onset)**
43
Varicocele grades
- Grade 1: not visible, only palpable with valsalva
- Grade 2: not visible, but easily palpated standing
- Grade 3: large, grossly visible
44
Varicocele treatment
- Indications for surgery: symptomatic, abnormal semen analysis, adolescent w/ ipsilateral atrophic testicle **(may reverse atrophy)**
**\*highest rate of success: Microsurgical surgery approach** (lowest recurrence rate)
**\*highest rate of recurrence: retroperitoneal surgery approach**
- Observe: consider annual semen analysis for men wishing to father children
45
Varicocele surgical treatment side effects
- Hematoma (microsurgical)
- Hydrocele (RP, inguinal, laparoscopic)
- Repair will improve semen anlysis in 70% of subfertile males after 3-6 months
46
Testicular cancer
- Males 20-40
\*can occur at any age
- Incidence 1:300 (white\>black)
- High cure rate
- PE: painless mass or lump in testes
- Risk factors:
\*family hx
\*cryptochidism
\*klinefelter's
\*androgen insensitivity syndrome
47
Testicular cancer metastasis
- Usually metastasize via lymphatics
\*most common site: retroperitoneal lymph nodes
- Choriocarcinoma and yolk sac tumor spread hematogenously
\*choriocarcinoma: brain mets
- Distant, non-LN sites: lung, liver, brain, bone
48
Testicular cancer work up
- Scrotal US
- Tumor markers
\*B-hCG, AFP, LDH
- CT abdomen and pelvis
- CXR
- CBC, LFTs, BMP, LDH
**- Radical inguinal orchiectomy**
49
Testicular cancer tumor markers
- Draw before AND after radical orchiectomy
- Obtain post-orchiectomy tumor markers **after 5 half lives** (they should normalize if orchiectomy has completely resected disease and there are no mets)
- B-hCG: secreted by syncytiotrophoblasts
\*may be elevated in **choriocarcinoma, embryonal, and 20% of seminoma**
\*falsely elevated: marijuana use, hypergonadotropic hypogonadism
**\*t1/2: 2 days**
- AFP: secreted by fetal yolk sac, liver and intestine
**\*NEVER elevated in pure choriocarcinoma or pure seminoma**
**\*t1/2: 5 days**
- LDH: marker of bulky disease
50
Seminoma
- "Fried egg" nucleus
- Sensitive to chemo **and radiation**
**\*only germ cell tumor sensitive to radiation**
- 20% have B-hCG elevation
- If pathology reveal seminoma mixed w/ NS-GCT, treat as seminoma
51
Embryonal testicular cancer
- Papillary projections
- B-hCG and AFP elevated
52
Yolk sac tumor
- Schiller-Duval bodies
- Always AFP elevated
- Most common pediatric testicular tumor
53
Choriocarcinoma
- Syncytiotrophoblasts
- Always HCG elevated
- Brain mets common
- Worst prognosis of testicular tumors, but rare
54
Teratoma
- Cystic
- Endoderm, mesoderm and ectoderm elements
- Chemo and radiation resistant---\> surgical excision
55
Testicular cancer treatment
- Always begins w/ a radical inguinal orchiectomy
\*trans-scrotal approach risks tumor seeding
- Radiation: **seminoma only**
- Chemotherapy: B.E.P.
\*bleomycin, etoposide, and cisplatin
- Retroperitoneal lymph node dissection
- Pt may require multimodal therapy
