Quiz 1- Male GU Flashcards
Epispadias
congenital malformation of urethral meatus: on the upper (dorsal) side of the penis
Hypospadias
congenital malformation of urethral meatus on the lower (ventral) side of the penis
Balanitis
inflammation of glans penis
inflammation of the foreskin
Posthitis
inflammation of the foreskin and the glans penis
Balanoposthitis
Causes of: Balanitis, Posthitis and Balanoposthitis
Infectious (candida, GC, Chlamydia, scabies, etc)
Non-infectious (contact dermatitis, psoriasis, etc)
More commonly with poor hygiene, diabetics
May predispose to meatal stricture, phimosis, paraphimosis, cancer
lichen sclerosis of penis
indurated, white area on glans penis, from chronic inflammation
Balanitis xerotica obliterans (BXO)
Foreskin cannot be retracted back away from the glans penis
Phimosis
a. Physiologic: In boys, 50% of normal retractability by age 10, (but up to 15) Do not force retraction! Often cited as reason for circumcision b. Pathologic: Pain, constriction, meatus blockage due to adhesion
what are the red flags for erectile dysfunction?
erection lasting longer than 4 hrs
what are the red flags for hematospermia?
sx lasting longer than 1 mo, palpable mass, hematuria, obstructive sx
what are the red flags for urethral d/c?
pelvic pain, fever, chills, urinary retention
what are the red flags for scrotal pain?
acute onset, N&V, abdominal pain
r/o testicular torsion
Foreskin stuck in retracted position
Paraphimosis
becomes inflamed->reduced blood flow to the glans->may cause gangrene or necrosis
Scarring of the tunica albuginea in the corpora cavernosa
Peyronie’s disease
can cause painful erection and dorsal curvature
PE: palpable plaque on the dorsal surface of penis
Genital herpes usually caused by what?
HSV-2 (10-30% caused by HSV-1)
Genital herpes lesion appearance:
clusters of vesicles erupt and form superficial ulcers, erythematous base
concomitant sx: urinary hesitancy, dysuria, constipation, sacral neuralgia, flu-like sx, fever
dx: clinical eval of lesions, Tzanck test, viral culture
Genital warts usually caused by what?
HPV
90% are caused by HPV 6 & 11 (low risk)
cancer-causing type of HPV are 16 & 18
Genital warts lesion appearance:
Soft consistency, raised, irregular surface
painless but may cause discomfort due to location or itching
Syphilitic chancre caused by what?
Treponema pallidum
appearance of syphilitic chancre?
solitary, painless ulcer, non-exudative, indurated edge
test: serologic testing
Chancroid is caused by what?
Haemophilus ducreyi
appearance of chancroid?
painful, shallow non-indurated ulcers, irregular edges and red borders , gray or yellow purulent exudate
test: PCR testing
premalignant lesion: intraepithelial neoplasia
well circumscribed area of reddish, velvety pigmentation usually. on the glans or at the corona, most often in intact (uncircumcised) males
Carcinoma in situ/ Erythroplasia of Queyrat
More common in uncircumcised males with poor local hygiene habits
HPV types 16 and 18 play a role
Non-painful “sore that does not heal”
Squamous Cell Carcinoma of the Penis
dx: biopsy
soft papular angiofibromas around the corona—hair-like projections
Pearly Penile Papules
benign
What are some of the questions you’d want to ask a patient with an erectile dysfunction?
are you taking drugs such as anti-depressants, NSAIDs, substance abuse?
any history of neurogenic disorders like spinal cord or brain injuries? nerve disorders such as Parkinson’s, Alzheimer’s, MS?
any history of psychogenic causes such as performance anxiety? stress? mental health disorders?
history of DM?
history of surgery?
What PE would you include for an erectile disorder?
cardiovascular, neurological, and mental status exam
what’s the condition called when a male has a prolonged, painful erection longer than 4 hrs?
Priapism
considered an emergency because can result in ischemia/necrosis
Causes:
Idiopathic: usually from prolonged sexual excitement
Secondary: assoc with sickle cell dz, DM, CML, penile trauma, drugs, alcohol, cocaine, black widow spider bite
what should you consider scrotal masses until proven otherwise?
consider any hard swelling testicular cancer until proven otherwise
Painless scrotal masses/Swellings
tumors, abscess, hematocele (blood filled, does not transilluminate), hydrocele (serous fluid filled, transilluminates), varicocele, sebaceous cysts, scrotal edema, indirect inguinal hernia, spermatocele
condition that has a “bag of worms” appearance, located along spermatic cord (80% on left)
worsens with valsalva maneuver and with standing
Varicocele
Non-tender, may have “dragging” sensation
Development of a new varicocele or worsening of an old one in an older man:
a. On L: may be a tumor or other mass occluding the L renal or testicular vs.
b. On R: occlusion of the vena cava possible.
Possible sequellae: infertility from dec spermatogenesis (inc scrotal temp)
Diagnosis – angiography
Painful scrotal masses/swellings
epididymitis, testicular torsion, testicular trauma, mumps orchitis
testicular torsion
Emergency–assume until proven otherwise! Needs to be de-torsed <6hrs!
Severe scrotal pain after an episode of trauma or during intensive exercise; or spontaneous in sleep. Common age range 10-25 yo
ssx for testicular torsion
Sudden, acute onset unilateral, constant pain, poss N&V
Swollen, tender, erythematous scrotum: difficult to discern structures
Affected testicle higher, epididymis may be anterior; reactive hydrocele possible
Pain may radiate to the abdomen “acute abdomen”
Elevation of the scrotum does not relieve pain (negative Prehn’s sign)
Cremasteric reflex absent
Dx: doppler US
spermatocele
small, painless cyst on the superior posterior pole of the testicle
benign
cause of acute epididymitis
Infectious: result of an ascending LUT infection (from UTI or STI)
Non-infectious: urine reflux/chemical irritation into ejaculatory ducts from heavy lifting or local trauma
acute epididymitis
SSX
PE
DX
SSX:
Painful, swollen epididymis; pain may radiate along spermatic cord to abdomen
Hydrocele may develop
Overlying skin may look like peau d’orange; skin is movable (fixed suggests abscess)
May be febrile.
Discharge (if ascending infection), urinary frequency, dysuria may be present
Toxic appearance if sepsis from widespread bacterial infection (rare)
Sequelae: chronic epididymitis
PE:
exquisitely tender, swollen epididymis
Scrotum often indurated, erythematous
elevating the testicle eases pain (positive Prehn’s sign)
no change in cremaster reflex
DX:
UA reveals pyuria
Urine culture, NAAT (Nucleic Acid Amplification Test) testing for GC/chlamydia
Scrotal ultrasound to rule out torsion in those <30
cause of chronic epididymitis
inflammation with no infection present
with chronic epididymitis PE reveals
enlarged, thickened, non-tender epididymis
what is the name of the condition where the testes fail to descend into the scrotum during infancy?
cryptorchidism
there are several types:
a. true cryptorchidism - testis remains in abd. cavity from mechanical obstruction or hormonal abnormality
b. incomplete – testis in inguinal canal, obstructed by mechanical means
c. ectopic testis - lies outside the usual course of descent
d. hypermobile or retractile testis - may lie in the scrotum at times (e.g. hot bath) and then retract up into the inguinal canal
PE: palpate the testicles, if unpalpable, have pt squat or valsalva and repeat palpation
with cryptorchidism there is a risk of developing which two conditions later in life?
infertility
testicular cancer
what is the most common solid cancer in males 15-34 yo?
testicular cancer
what are the two types of testicular cancer and from where do they originate?
Seminomas (40%) - arising in seminiferous tubules)
Non-seminoma germ cell tumor - Embryonal (24%), Teratoma (5%), mixed (26%)
What are the SSX of testicular cancer?
painless testicular nodule, usually smooth enlargement, firm and non-tender, increases in size over time, may get dull ache, sensation of heaviness/weight, mass does not transilluminate (bc solid tumor)
What is the appropriate work-up for testicular cancer?
Scrotal US, Pelvic CT (esp if have concerns its METS)
5 yr survival of seminoma is > 80% with tx
what portion of the prostate is palpable? what is the normal size and consistency of the prostate?
portion of the prostate that is palpable is the peripheral zone, the transition zone is not palpable
normal size of the prostate is 4 cm in length and width
normal consistency is tip of nose
what are abnormal consistencies for the prostate and what are their corresponding conditions?
rubbery- BPH
boggy - congested
indurated - nodules
hard - consider tumor in absence of WBCs & infxn
labs to consider for prostate problems?
serum prostate-specific antigen (PSA)
serum PSA levels increase if the barrier between the epithelium and the bloodstream is damaged (barrier damaged due to cancer, bacterial infxn, and infarction)
Draw serum PSA before doing a DRE and obviously before prostate bx
Using PSA as a reliable screen for prostate cancer is currently under great scrutiny.
Other measures:
a) PSA velocity (how quickly it is elevating)
b) Free/bound PSA ratio (less amts of free with cancer)
can you think of any reasons for the rise in PSA levels?
DRE (do blood draw before!) Ejaculation, recent sexual activity BPH Prostate cancer Cystitis Acute & Chronic prostatitis Prostate bx exercise involving perineal pressure (biking)
can you think of any reasons for the fall in PSA levels?
Finasteride Saw palmetto Radical prostatectomy Withdrawal from anti-androgen drugs Regular prostatic massage Green tea
What is occurring physiologically with benign prostatic hyperplasia (BPH)?
hyperplasia of cells within the transition zone, resulting in formation of large, fairly discrete nodules in the periurethral region. The lumen of prostatic urethra narrows leading to urine outflow obstruction.
what is the incidence of BPH?
Increases with age, at age 40 there is a 8% chance and by age 80 there is an 80% likelihood of developing it
what are the SSX of BPH?
progressive urinary frequency, urgency, nocturia due to incomplete emptying and rapid filling of bladder, hesitancy, intermittency of urinatioin, decreased force of stream (forked stream)
What are the possible complications of BPH?
UTI from urine stasis
Urolithiasis from urine stasis
Straining to urinate may cause rupture of veins, hemorrhoids and hernias to name a few
What PE should be completed for BPH? What are the anticipated findings?
DRE: enlarged rubbery consistency
Abdominal exam: possible distended bladder
Which labs should be ordered for suspected BPH?
BUN (incrs)
UA and urine culture (to r/o causative or concomitant infxn)
PSA (mod. incrs)
Procedures for BPH?
Uroflowmetry (to check urine flow rate and post-void residual volume)
TRUS or prostate bx (to r/o cancer)
What condition can coexist with BPH?
Prostate cancer
Prostatitis
Inflammation of the prostate
may be infectious or noninfectious
what buggers cause Acute Bacterial Prostatitis?
Urinary pathogens: E. Coli, Klebsiella, Proteus, Pseudamonos, Enterobacter, Chlamydia
SSX of Acute Bacterial Prostatitis?
Sudden onset of spiking fever, chills, malaise, arthralgia, myalgia
LUTS: dysuria, nocturia, urgency and frequency (can have concomitant cystitis)
May see acute urinary retention (inability to void, abdominal fullness)
Low back/perineal/rectal pain
PE for Acute Bacterial Prostatitis?
GENTLE DRE: exquisitely tender prostate, swollen, firm and warm
Contraindication- do not perform prostatic massage with acutely inflamed gland! May lead to bacteremia, septicemia
Labs for Acute Bacterial Prostatitis?
CBC shows leukocytosis with left shift
UA shows many WBC’s (cloudy), bacteria, possible hematuria
Culture of prostatic secretions (semen culture may be more accurate!) reveals
increased bacteria
sequelae to Acute Bacterial Prostatitis?
chronic bacterial prostatitis
only 5-10% of cases are found to have bacteria (possible sequestered infection)
SSX of Chronic Bacterial Prostatitis?
Recurrent UTIs (intermittent/relapsing) Fatigue Chronic pain (perineal, lower abdominal, testicular, penile) Sexual dysfunction, ejaculatory pain Milky urethral d/c
PE for Chronic Bacterial Prostatitis?
DRE: moderate tenderness, boggy, soft, enlarged
Labs for Chronic Bacterial Prostatitis?
Post-massage urine culture and sensitivity, EPS culture, semen culture
Chronic Prostatitis/Chronic Pelvic Pain Syndrome (“Prostadynia”)
Poorly understood condition. Somatic syndrome with biopsychosocial effects
Criteria for diagnosing Chronic Prostatitis/Chronic Pelvic Pain Syndrome
1) no objective cause is found to explain symptoms 2) symptoms relate to anatomical area around prostate, 3) refractory to treatment
SSX for Chronic Prostatitis
Pain in pelvic region >3mos
disability out of proportion to PE/lab findings!
Dysuria, urgency
Low back/perineal pain referred to tip of penis
Sense of rectal fullness after unsuccessful defecation
Sexual dysfunction, post-ejaculation pain, decreased libido
Possible hemospermia
Fatigue, stress
May also have concurrent IBS or Chronic Fatigue Syndrome
PE for Chronic Prostatitis
DRE: mildly tender (variable), boggy, enlarged (rarely)
Assess tenderness of pelvic floor and sidewalls
Also examine for hernia, testicular masses and hemorrhoids
Lab for Chronic Prostatitis
UA, Urine C&S, EPS cell count and culture, CBC
May need to rule out Chlamydia trachomatis and Neisseria gonorrhea if neg
Urine cytology indicated if hematuria
Assymptomatic Inflammatory Prostatitis
Found incidentally
No subjective symptoms but, WBCs are found in prostate secretions or in prostate bx
Prostate Cancer (CaP)
Most commonly adenocarcinoma
most common male cancer in men >50yrs
Lifetime risk 1 in 6 white men; 1 in 5 black men
More men die WITH prostate cancer that FROM it!!
What are the risk factors for prostate cancer?
Increasing age
Ethnicity- African- American 35% higher incidence
Family hx- primary relatives
Hormones- increased androgen exposure
Diet- high fat, low fiber, alcohol, coffee
Obesity
Vasectomy- perhaps a potential risk factor- controversial
Occupational exposures- increased in farmers, mechanics, plumbers, welding, rubber
Manufacturers, battery manufacturers (Cd)
Smoking- perhaps increased risk
Meds—statins, NSAIDs
SSX of prostate cancer?
EARLY: often none, slowly progressive depending on where tumor is growing, sexual dysfunction, incontinence, irritative or obstructive sx
LATE: bladder outlet obstruction, ureteral obstruction, hematuria, pyuria, metastasis to pelvis, ribs, vert. may create bone pain
tumor enlargement may lead to cord compression and neuropathy
unintended weight loss
PE of prostate cancer?
feeling a hard edge
DRE–variable size, asymmetrical, non-tender prostate
firm, stony hard, irregular nodule(s) is pathognomonic
Labs for prostate cancer?
Total PSA: 4-10 ng/ml likelihood of CaP is 25%; >10 ng/ml likelihood of CaP is >50%
PSA Velocity: inc of >0.75 ng/ml/year or higher (based on 3 PSA measurements over 18-24 mos) when the PSA is 4-10 ng/ml is suspicious for CaP
Free to total PSA ratio: <25% (reduced) in CaP
Dx for prostate cancer?
TRUS w/ bx (for GRADING)
Axial CT or MRI (for STAGING)
