Miscellaneous

Question 1

Management of Benign Prostatic Hyperplasia

Answer 1

1st Alpha-adrenoceptor antagonist - Tamsulosin / Prazosin
- Results in smooth muscle relaxation in the prostate and bladder neck.
2nd add 5-Alpha-Reductase Inhibitor - Dutasteride / Finasteride
- Inhibits conversion of testosterone to dihydrotestosterone to reduce prostate growth and volume
Minimise consumption of caffeine / acidic or spicy food
Reduce evening fluid intake
Ensure regular bowel motions
Bladder training
Transurethral reduction of prostate

Question 2

Erectile Dysfunction

Answer 2

Definition
- Inability to achieve or maintain an erection for satisfactory sexual performance
- 80% have an organic cause
- Neurovascular disease, diabetes, medication SE
- 20% are psychogenic

Risk factors
- Increasing age
- CVD - BMI, Diabetes, Sedentary lifestyle, dyslipidaemia, OSA, smoking
- Endocrine - Diabetes, Androgen deficiency, Thyroid disorders, hyperprolactinaemia
- Neurological conditions
- Medications (b-blockers, thiazides, anti-depressants, antipsychotics, anti-androgens)
- Penile disorders - Peyronie disease, fibrous penile placques
- Recreational drug or etOH use.
- Psychogenic (Performance anxiety, inter-relational conflict)

Management
- Treat underlying cause
- Referral to psychosexual or relationship therapy
- PDE5-i (Sildenafil, Tadalafil)

Question 3

Priapism

Answer 3

Erection lasting > 2 hours

Risk factors
- Intracavernosal therapy
- PDE5i SE

Management
- Take cold shower
- Go for gentle jog
- Pseudoephedrine IR 120mg PO stat
- > 4 hours? hospital presentation for drainage of corpora cavernosa.

Question 4

Male infertility endocrine evaluation

Answer 4

Measure FSH, morning testosterone
- If low morning testosterone, repeat morning testosterone and perform free testosterone, LH and prolactin

Differential of endocrine cause for male infertility

Hypogonadotropic Hypogonadism
- vFSH, vLH, vTest, N/^ Prolactin

Abnormal spermatogenesis
- N/^ FSH, N LH, N Test, N Prolactin

Testicular failure or hypergonadotropic hypogonadism
- ^FSH, ^LH, vTest, N Prolactin

Prolactinoma
- N/v FSH, N/v LH, vTest, ^Prolactin.

Question 5

Haematospermia

Answer 5

Most cases are benign and self-limiting.

Causes
- UTI, STI, Prostatitis (Especially if pain on ejaculation), recent urological procedure, prolonged sexual intercourse or masturbation, prolonged abstinence, tuberculosis, schistosomiasis, anticoagulant use, prostate cancer.

Red flags
- Age > 40, recurrent or persistent haematospermia, prostate cancer risk factors (+’ve family history, African heritage)
- Constitutional symptoms of cancer (Weight loss, anorexia, bone pain)

Investiation
- Baseline
- Urine MCS ?UTI
- Cytology ?Cancer
- FBC ?Anaemia / Infection
- Coags ?bleeding risk
- Red flags for cancer as per above?
- PSA + Urology referral
- Consider Urine STI screening, TB or schistosomiasis urine testing.

Question 6

Chronic Bacterial Prostatitis

Answer 6

<10% of men with chronic prostatitis have a bacterial infection

Diagnosis
- ‘Two-glass test’ - Pre and post-prostatic massage urine samples
- Review leucocyte count and culture results.

If confirmed, treat with PO Abx

1 - Ciprofloxacin 500mg PO BD x 4 weeks
2 - Norfloxacin 400mg PO BD x 4 weeks
2 - Trimethoprim 300mg PO OD x 4 weeks

Question 7

Risk factors for urological malignancy in macroscopic haematuria

Answer 7

• Age > 40
• Gross haematuria
• Irritative LUTS
• Smoking
• Occupational exposure to dyes, benzenes, aromatic amines
• Cyclophosphamide exposure
• History of chronic UTI
• History of pelvic irradiation

CT IVP if risk factors present
Renal tract US if No risk factors present
-> Urology for cystoscopy

Urine cytology often added to investigation. Highly sensitive for high-grade bladder cancer but has low sensitivity for low-grade tumours. Not recommended for sole diagnostic tool but is a useful adjunct investigation.
Urine cytology x 3 = 3 mid-morning, mid-stream urine samples taken on 3 consecutive days.

Question 8

Acute bacterial prostatitis management

Answer 8

1 - Trimethoprim 300mg PO OD x 14 days
2 - Cephalexin 500mg PO QID x 14 days

Question 9

Overactive Bladder Syndrome

Answer 9

Unstable bladder contractions resulting in urinary urgency, frequency and nocturia.

Diagnosis of exclusion of other important differentials (neuopathic bladder disease from CNS, urothelial carcinoma, OSA, CHF, DM

Causes
- Detrusor muscle overactivity.

Management

1: Conservative
- Reduction of bladder stimulants (alcohol, caffeine, smoking, carbonated beverages)
- Avoid constipation. Soft stool passage every 1-2 days.
- Restrict fluid intake to 6-8 glasses of water per day.
- Physio review for pelvic floor exercises
- Incontinence pads
- Bladder training with scheduled voiding.
- Use urge control techniques
- When feeling urge to urinate, contract pelvic floor for 10 seconds or for a burst of 5 rapid activations until the urgency is relieved.

2: Pharmacotherapy
- Non-selective anti-cholinergic - Oxybutinin 5mg PO TDS
- Selective Anti-cholinergic - Solifenacin 5mg PO OD
- Note: Anticholinergics block acetylcholine neurotransmitter synapse in CNS and PNS, reducing involuntary movement of smooth muscle such as those present in the bladder. SE: Dry mouth, constipation, dry eyes.
- Contraindicated in Glaucoma.

• Beta-3 agonist - Mirabegron 25mg PO OD
  
  • Beta-3 adrenergic receptor agnosit. Upregulated sympathetic activity promoting smooth muscle relaxation and reducing muscle spasms.

3: Minimally invasive procedures
- Intravesical botox
- Sacral nerve neuromodulation
- Peripheral tibial nerve stimulation.

4: Invasive Procedure
- Bladder augmentation
- Urinary diversion.

Question 10

Paraphimosis Treatment

Answer 10

Urologic Emergency
- Foreskin gets trapped behind the corona. Forms a tight band of constricting tissue that works as a tourniquet for the glans

Management
- Urgent transfer to ED for urologist review
- Anaesthetise penile head with local anaesthetic / penile nerve block / ring block
- Apply circumferential pressure to glans of penis to disperse oedema.
- Apply ice intermittently to glans of penis.
- Consider aspiration of blood form head of penis.
- Analgesia (oxycodone / paracetamol)

Question 11

Premature ejaculation

Answer 11

Classification
- Lifelong - Occurs before 1 minute of vaginal penetration throughout patient’s life.
- Acquired - Occurs before 3 minutes of vaginal penetration and is secondary to other factors (psychological, relationship problems, erectile difficulty, prostatitis, hyperthyroidism, withdrawal from SSRI)

Treatment
- EMLA cream (Lidocaine + Prilocaine) topically to glans and distal shaft of penis 10-20minutes prior to intercourse. Wash off residual cream and apply condom before contact with partner.
- SSRI
- Dapoxetine 30mg PO 1-3 hours prior to sexual activity.
- Can also consider combination treatment with PDE5i such as sildenafil 50mg PO 60mins prior + dapoxetin30mg PO 60 mins prior.