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ICA > Men's Health - Urology > Flashcards

Men's Health - Urology Flashcards

1
Q

What is Phimosis?

A

When the prepuce (foreskin) cannot be fully retracted in adult

(1% of adult non-circumsised population)

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2
Q

Can Phimosis be normal?

A

Yes - physiological phimosis from ages 1-17

50% at 1 year, 10% at 3, 1% at 17

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3
Q

Causes of phimosis

A

Poor hygiene, increase risk of STDs - accumulation of smegma

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4
Q

How can phimosis progress?

A

Increase risk of STDs
Pain on intercourse, splitting/bleeding
Balanitis (inflamed glans)
Posthitis (inflamed foreskin/prepuce)
Balanitis Xerotica Obliterans - BXO
Paraphimosis
Urinary retention
Penile cancer

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5
Q

What is paraphimosis?

A

Painful constriction of glans penis by the retracted prepuce proximal to the corona - foreskin stuck pulled back, become oedematous forming tight ring

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6
Q

Commonest causes of paraphimosis (3)

A

Phimosis - got it back now can’t get it forward

Catheterisation (esp in elderly, catheterise someone and don’t pull foreskin back, should ALWAYS do this)

Penile cancer - tissue becomes tough and hard

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7
Q

Phimosis management

A

Can be associated with other pathologies in adult - check

BEWARE of phimosis wit balanitis (inflamed glans) - penile cancer?

Circumcision - best treatment

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8
Q

Paraphimosis treatment

A

Needs reduction - usually manually with some analgesia
Occasionally will need dorsal slit

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9
Q

What type of cancer is penile cancer?

A

Squamous cell carcinoma

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10
Q

Risk factors for penile cancer

A

Phimosis - hygiene problem –> smegma
HPV 16 and 18

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11
Q

Appearance of penile cancer

A

Red ulceration, can be crusted and lumpy

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12
Q

Who does penile cancer effect?

A

20% are <50 years old
350 new cases per year

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13
Q

Outlook for penile cancer

A

Most die within 2 years
Almost all within 5

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14
Q

Indications for paediatric circumcision

A

Religious
Recurrent balanitis/UTI’s

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15
Q

Indications for adult circumcision

A

Recurrent balanitis
Phimosis
Recurrent paraphimosis
Balanitis xerotica obliterans
Penile cancer

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16
Q

Acute scrotal pain causes (5)

A

Testicular torsion

Epididymitis / Orchitis (testes) / Epididymo-orchitis

Torsion of hyatid of Morgagni - little appendix off testes which can twist, embryological deformity

Trauma

Ureteric calculi - referred pain from vesicourethral junction (painful but not tender suggests this)

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17
Q

Causes of Epididymitis / orchitis / epdidymo-orchitis (3)

A

UTI
STI
Mumps

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18
Q

Testicular torsion typical history

A

Younger <30
SUDDEN onset - woke from sleep
Unilateral pain, may be nauseated/vomit - often no LUTs

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19
Q

What is found on examination for testicular torsion?

A

Testis tender
Lying high in scrotum with horizontal lie

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20
Q

Management of suspected testicular torsion

A

EMERGENCY SCROTAL EXPLORATION - do not waste time waiting for USS, refer and can do one while waiting if so

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21
Q

History for typical epididymo-orchitis

A

Age 20-40 (esp Chlamydia)
40/50+ - E-coli
Gradual onset - few days
Unilateral

Recent history of:
UTI
Unprotected intercourse
Catheter/urethral instrumentation
Check for MUMPS?

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22
Q

What is found on examination of epididymo-orchitis?

A

Pyrexial - septic?
Erythema on scrotum
Testis enlarged and tender
Fluctuant areas - abscess?
Reactive hydrocele?

RARE - necrotic area of scrotal skin - Fournier’s

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23
Q

What is the rare complication of epididymo-orhcitis called and what is it?

A

Fournier’s Gangrene - necrotic area of scrotal skin
HIGH mortality rate - 50%

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24
Q

Investigations for epididymo-orchitis

A

Bloods - FBC, U&Es, cultures if septic
Urine - MSU for MC&S
Radiology - scrotal USS if suspect abscess

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25
Q

Management for epididymo-orchitis

A

Simple - Abx

If abscess - surgical drainage and abx

Fournier’s gangrene - emergency debridement and antibiotics

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26
Q

Key questions in history to ask about scrotal lump

A

How long?
Is it painful?

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27
Q

Examining a scrotal lump:

A

Can i get above it - if not, could be hernia

Is it in body of testis - could be testicular tumour if yes

Is it seperate from testes?

Does it flucuate/transilluminate?

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28
Q

Diagnosis for painless scrotal lump

A

Testicular tumour
Epididymal cyst
Hydrocele
Reducible inguino-scrotal hernia

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29
Q

Diagnosis for painless/aching at the end of the day not tender scrotal lump

A

Varicocele - bag of worms

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30
Q

Acute presentation of scrotal lump - painful diagnoses

A

Strangulated inguino-scrotal hernia - EMERGENCY
Epididymitis
Epididymo-orchitis

31
Q

History of testicular tumour

A

Painless
Germ cell tumour - teratoma/seminoma men aged <45
Older men - lymphoma?

32
Q

Risk for testicular tumour

A

Undescended testes history - had orchidopexy when younger

33
Q

Examination for testicular tumour

A

Can get above
Not tender

34
Q

Management for suspected testicular tumor

A

Refer 2 week wait to urology
Urology will arrange USS of scrotum to confirm and check testis tumour markers

35
Q

Tumour markers for testicular cancer

A

alpha fetoprotein (aFP)
human chorionic gonadotrophin (hCG)
Lactate dehydrogenase (LDH)

36
Q

History for hydrocele

A

Slow/sudden onset
Uni/bilateral scrotal swelling

37
Q

Cause of hydrocele

A

Imbalance of fluid production between tunica albuginea and tunica vaginalis

38
Q

Examination for hydrocele

A

Testes not palpable separately
Can usually ‘get above’
Transilluminates - when shone with torch, glows

39
Q

Epididymal cyst on examination

A

Separate from testis
Can get above mass
Transilluminates

40
Q

Varicocele history

A

Ache at end of day
Left teste more than right affected (due to drainage of left gonadal vein into left renal vein)
Can be associated with subfertility

41
Q

Examination for varicocele

A

Bag of worms above testes
NOT tender
Check for palpable renal/abdominal mass - need to exclude kidney tumour causing (+USS)

42
Q

Treatment for testicular tumour

A

Inguinal orchidectomy

43
Q

Epididymal cyst treatment

A

Reassure
Excise if large

44
Q

Adult hydrocele treatment

A

If normal testes on USS reassure
Surgical removal if large/symptomatic

45
Q

Varicocele treatment

A

Reassure

If symptomatic, infertile or present in adolescent and growth of teste is affected:
Radiological embolization - inject dye and embolise veins

46
Q

Treatment for inguino-scrotal hernia

A

Surgery - emergency if strangulated

47
Q

Causes of urinary retention

A

Prostatic enlargement - BPH or cancer

Phimosis/urethral stricture/meatal stenosis

Constipation

UTI

Drugs - anticholinergics

Over-distension - too much fluids

Surgery

Neurological

48
Q

Urinary retention types

A

Acute
Chronic
Acute on chronic

49
Q

Acute urinary retention described (3)

A

PAINFUL - relieved by catheter
Residual volume <1000mls
No kidney insult

50
Q

Chronic urinary retention described (3)

A

PAINLESS/less painful - May just have a bit of abdo swelling
Residual volume >300mls (largest 5L)
May have kidney insult

51
Q

Acute on chronic described (3)

A

PAINFUL
Residual volume >1000mls
Usually have kidney insult

52
Q

Urinary retention treatment for each type

A

Acute - TWOC after treating exacerbating factor

Chronic - learn to self catherise

Acute on chronic - Long term catheter or surgical intervention (TWOC not usually work as kidney insult and yeah)

53
Q

What does older men with nocturnal enuresis suggest?

A

Chronic retention with overflow incontinence

54
Q

Types of LUTs - lower urinary tract symptoms and examples

A

Voiding:
- hesitancy
- poor flow
- post micturition dribble

Storage:
- urgency
- frequency
- nocturia

55
Q

How to describe LUTS?

A

NOT by saying prostatism - may not be caused by prostate

56
Q

Causes of storage LUTs

A

Irritative eg bladder infection/inflammation, bladder stone, cancer

Overactive bladder - idiopathic or neuropathic (stroke, parkinsons, MS)

Low compliance of bladder - scarred eg after TB, schistosomiasis, pelvic radiotherapy

Polyuria - can be global (eg from uncontrolled diabetes) or nocturnal (venous stasis, sleep apnoea - these pts have raised ANP levels)

57
Q

Causes of voiding LUTs

A

Bladder outflow obstruction:
- urethra (phimosis, structure), prostate (BPH, cancer, bladder neck)
- Dynamic - prostate and bladder neck?
- Neurological - lack of co-ordination between bladder and sphincters - upper motor neurone problem?

Reduced contractility:
- physical
- neurological - lower motor neurone lesion (eg cauda equina?)

58
Q

What symptom suggests stricture?

A

Spraying of urine

59
Q

Why can the prostate cause bladder outflow obstruction?

A

Sympathetic muscular tone in prostate can be too strong and compress urethra
Works by stimulus of alpha 1 adrenoreceptors

60
Q

How do we assess LUTs?

A

International Prostate Symptom Score - IPSS
Score 7 categories out of 5

61
Q

What is asked on IPSS?

A

Incomplete emptying?
Freq?
Intermittency?
Urgency?
Weak stream?
Straining?
Nocturia?

If you were to spend rest of life with it how would you feel? - assess impact on life

62
Q

Score of IPSS

A

Mild - 0-7
Moderate - 8-19
Severe - 20-35

63
Q

Examination for LUTs

A

DRE
Is bladder palpable?
Neurological exam if history suggests

64
Q

Investigations for LUTs

A

Dipstick - UTI? Blood?

Consider PSA - not surrogate for DRE and if UTI treat first and wait 4-6 weeks before PSA as can affect result

65
Q

Lifestyle management for BPH

A

Reduce caffeine, fizzy drinks
Do not need to drink more than 2.5L per day

66
Q

Medication managment for BPH (2)

A

Alpha blockers
5 alpha reductase inhibitors

67
Q

How do alpha blockers work for BPH

A

Relax smooth muscle of prostate and IUS of bladder - bladder neck (alpha 1 receptors here)
RAPID symptom relief

68
Q

Example of alpha blocker

A

Tamsulosin

69
Q

How do 5 alpha reductase inhibitors work?

A

Shrink prostate by depriving it of androgens (prevents testosterone being converted to dihydrotestosterone)

Slower relief than alpha blockers - 6 months?
Slow progression of BPH
Reduced risk of retention

70
Q

Example of 5 alpha reductase inhibitors

A

Finasteride
Dutasteride

71
Q

Managing BPH in secondary care first step:

A

Do flow rate before considering surgery
Prostatic obstruction will be wavy flow
Normal is up and then down
Urethral structure is slow, mound

72
Q

Indications for surgery for BPH

A

Failed lifestyle and medical management

Urinary retention needing intervention

73
Q

Standard surgery for BPH

A

Transurethral resection of prostate (TURP)
Cut out section of prostate to widen canal for urethra using laser etc

ICA (13 decks)

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