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YEAR 3 & 5 CORE CONDITIONS > Reproductive > Flashcards

Reproductive Flashcards

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1
Q

What is testicular torsion?

A

Sudden twisting of spermatic cord within the scrotum

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2
Q

Why is testicular torsion an emergency?

A

Risk of ischaemia and infarction of the testis

Irreversible damage after 6-12hrs of torsion

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3
Q

How does testicular torsion present?

A 
Sudden onset unilateral testicular pain
May radiate to lower abdo
Swollen and tender testicle
Nausea and vomiting
Abnormal position of testicle:
- Abnormal transverse lie
- Scrotal elevation
- Possible undescended testes (predisposes to testicular torsion)
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4
Q

When is testicular torsion most common?

A 
Neonatal period (first 30 days of life)
Puberty
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5
Q

What signs may / may not be elicited in testicular torsion?

A

Absent cremasteric reflex

Prehn sign negative

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6
Q

What is Phren sign? What does it suggest?

A

A positive Prehn sign is the relief of pain during elevation of the testes and suggests epididymitis rather than torsion

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7
Q

What investigations are done for testicular torsion?

A

Clinical diagnosis

Can US or radionuclide image scrotum if atypical features

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8
Q

What may an US show in testicular torsion?

A

Twisting of spermatic cord = whirlpool sign
Reduced / absent blood flow to / from the affected testis
Heterogenous appearance of testicular parenchyma indicates testicular necrosis

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9
Q

What may a radionuclide image show in testicular torsion? How does this compare to epididymitis?

A

Areas that do not absorb radionuclide as a result of decreased blood flow to affected testis = cold spots
Asymmetric blood flow

(Epididymytis would shot hot spots due to increased blood flow in inflammation)

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10
Q

What is the management of testicular torsion?

A

Surgical emergency - within 4-6 hrs

Bilateral orchidoplexy - cord and testis untwisted and both testicles fixed to the scrotum

Analgesics
Antiemetics
NBM

If testis not visible, orchidectomy - prosthetsis can be inserted at time of surgery or later date

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11
Q

What is the epididymis?

A

The tube located at the back of the testis that stores and carries sperm

Inflammation = epididymitis

+/- inflamed testes (epididymo-orchitis)

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12
Q

How does epididymis present?

A 
Gradual onset (few days / weeks)
Painful swelling
\+/- urethral discharge
Fever
Dysura
Urinary frequency
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13
Q

What may an examination show in epididymis?

A

Very tender
Positive Phren sign
Positive cremasteric reflex

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14
Q

What may bloods and urine show in epididymis?

A

Raised inflammatory markers

Possible pyuria

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15
Q

What is the tumour marker for testicular cancer?

A

Alpha fetoprotein (AFP)

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16
Q

How may testicular cancer present?

A 
Slow progression (weeks to months)
Usually painless testicular mass - may feel dull ache / heavy sensation
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17
Q

What may an examination show in testicular cancer?

A

Palpation of solid mass
Possible manifestations of metastatic disease eg LN, chest pain, GI symptoms
Possible ipsilateral lower limb swelling = venous engorgement due to obstruction

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18
Q

What can lead to insidious onset of unilateral scrotal pain in boys aged 3-5?

A

Torsion of testicular appendage (hydatid of Morgagni)

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19
Q

Describe what happens in torsion of testicular appendage (hydatid of Morgagni)

A

The hydatid of Morgagni (appendix of testes) is an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Müllerian duct)

This has the potential to rate

Causing symptoms that resemble acute testicular torsion

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20
Q

How does infarction of the hydatid of Morgani appear through the skin?

A

“blue dot” sign

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21
Q

What is prostatitis? What are the subtypes?

A

Inflammation of the prostate gland

Infectious (5%)
- acute vs chronic bacterial

Noninfectious (95%)
- chronic pelvic pain syndrome (CPPS)

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22
Q

What is the most common cause of acute and chronic bacterial prostatitis?

A

E coli

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23
Q

What are some risk factors for acute and chronic bacterial prostatitis?

A

Other genitourinary tract infections eg urethritis, cystitis, epididymitis

Genitourinary tract interventions:

  • Indwelling catheter
  • Transurethral surgery
  • Prostate biopsy

Voiding dysfunction and bladder outlet obstruction

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24
Q

How does acute bacterial prostatitis present?

A

Spiking fever, chills, malaise

Acute dysuria, freq, urgency, cloudy urine

SEVERE perineal and pelvic pain, worse with defecation

Tender, boggy swollen prostate

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25
How does chronic bacterial prostatitis present?
Commonly no systemic fever, sometimes low grade present Chronic bladder irritation: - Dysuria, freq, urgency ED Possibly bloody semen Mild genitourinary pain worse on ejaculation Prostate may be often normal, may be enlarged and tender
26
How does CPPS present?
``` Systemic symptoms absent - no fever ED Painful ejaculation Bloody semen May have symptoms of bladder irritation Moderate genitourinary pain: - Lower abdo, perineum, scrotum or penis Prostate usually normal but may be slightly tender ```
27
How is prostatitis diagnosed?
Bacterial - urinalysis and culture CPPS - diagnosis of exclusion
28
What is the treatment of bacterial prostatitis?
14 day course of: Ciprofloxacin 500 mg PO BD or Ofloxacin 200 mg PO BD twice daily first line or if they are unsuitable trimethoprim 200 mg PO BD Analgesics Hydration Review after 48hrs Suprapubic catheterisation in cases of acute urinary retention and persistent fever
29
What is the treatment of CPPS?
Alpha blockers eg tamsulosin, doxazosin = improves urinary voiding by relaxing smooth muscles in prostate and bladder 5-alpha reductase inhibitors eg finasteride = reduce prostate size by blocking growth-inducing effect of androgen on the prostate NSAIDs Anti-inflammatory phytotherapeutic agents eg cernilton Physio - prostatic and pelvic floor masage
30
Why is finasteride is not recommended in young patients?
5-alpha-reductase inhibitors reduce semen volume
31
What are some complications of prostatitis?
Prostatic abscess Acute urinary retention Pyelonephritis and sepsis Epididymitis
32
What is balanittis?
Inflammation of the glans penis (head / tip of penis)
33
What is balanoposthitis?
Inflammation of the glans penis and the foreskin
34
What can cause balanitis and balanoposthitis?
``` Poor hygiene Contact irritants Drug reaction Bacterial infection Yeast ``` Rarely: - Pemphigus - Pemphigoid - Lichen sclerosis
35
What is lichen sclerosis of the penis called?
Balanitis xerotica obliterans
36
How does balanitis and balanoposthitis present?
Pruritis, pain, edema of glans penis Erythema and uclerated lesions of the glans or foreskin Thick penile discharge or discharge from ulcerated lesions Systemic symptoms may occur eg fever, arthralgias, malaise
37
How are balanitis and balanoposthitis diagnosed?
Usually clinical KOH (potassium hydroxide preparation )to confirm fungal Gram stain and culture for bacterial
38
What is the treatment of balanitis and balanoposthitis?
Conservative - Daily retraction of foreskin and bathing with warm saline solution - Avoid irritants - Topical antifungal eg clotrimazole if yeast - Topical bacitracin if bacterial - Topical corticosteroid and aqueous cream for irritant or drug reaction
39
What are some complications of balanitis and balanoposthitis?
Postinflammatory phimosis Urinary tract obstruction - requires bladder catheterisation Recurrent UTIs Penile cancer
40
What is phimosis?
Tight foreskin than cannot be completely retracted
41
When does phimosis occur?
Often normal in young children but may be pathological if it develops secondary to scarring Pathological phimosis most commonly occurs as a complication of balanitis and balanoposthitis
42
What is the management of phimosis?
Topical steroids and stretching exercises Surgery may be required: - Vertical incision (incision of constricting bands) or circumcision
43
What is paraphimosis?
Condition in which the foreskin has retracted and cannot be returned to its original position
44
What can cause paraphimosis?
Phimosis Sexual activity Trauma
45
What is the management of paraphimosis?
Urological emergency Pain control Manual reduction Some cases may need surgical intervention to prevent penile necrosis: - Dorsal slit reduction surgery = incision of the constricting band - Circumcision last resort
46
Define erectile dysfunction
Inability to achieve or sustain an erection sufficient in rigidity of duration for sexual intercourse which is present for a minimum of 6 months
47
List some vascular causes of ED
``` HTN DM CVD Hyperlipidemia Smoking ```
48
List some neurogenic causes of ED
``` Stroke Brain / spinal cord injury Dementia PD MS ```
49
List some endocrine causes of ED
Hypogonadism Hyperprolactinemia Thyroid disorders
50
List some medications than can cause ED
Anti HTN - beta blockers, thiazide diruetics Antidepressants - SSRIs Dopamine antagonists
51
How do dopamine antagonists cause ED?
Dopamine receptors blocked in tuberoinfundibulnar pathway, leading to an increase in prolactin secretion from the anterior pituitary This leads to a decrease in GnRH secretion from the hypothalamus (negative feedback) This leads to decreased LH secretion from the anterior pituitary which leads to decreased testosterone production from the Leydig cells This leads to hypogonadotropic hypogonadism
52
List some iatrogenic causes of ED
Radical prostatectomy | Pelvic radiation
53
List some other causes of ED
Trauma Alcohol abuse Peyronie disease - scar tissue develops on the penis and causes curved, painful erections Psychological - depression, anxiety, stress
54
What bloods are done for ED?
``` Testosterone levels SHBG (sex hormone binding globulin) Prolactin LH FSH TSH Fasting glucose / HbA1c Lipid profile ```
55
Other than bloods, what investigations can be done for ED?
Nocturnal penile tumescene measurement Doppler US or arteriography to identify suspected arterial inflow or venous leaks after injection of a vasodilatory agent
56
What is a nocturnal penile tumescene measurement?
Measurement of spontaneous nightly erections (usually in a a sleep lab) to differentiate between organic and psychological causes of ED Lack of nocturnal erections suggests organic cause of ED
57
What is the medical and psychological management of ED?
Psychological - Counselling - Senate focus exercises for performance anxiety = focuses on sensual experiences of touch without goal of orgasm Medical - Phosphodiesterase 5 inhibitors 1st line - Intracavernous injection therapy or prostaglandin E1 (alprostadil) 2nd line - Testosterone replacement if needed
58
How do phosphodiesterase 5 inhibitors work? Examples?
Slidenafil (viagra), tadalafil, vardenafil Inhibit PDE 5 enzyme that normally breaks down cyclic GMP, thus sustaining cyclic GMP levels and increasing intracavernosal NO induced vasodilation
59
What are some considerations for prescribing phosphodiesterase 5 inhibitors?
Contraindicated in patients taking nitrites due to profound hypotension May cause orthostatos hypotension in those taking alpha-adrenergic antagonist eg for BPH, take 4 hrs apart
60
How do nitrites work? Examples
Increase the release of nitric oxide (NO) in vascular smooth muscle cells, which leads to smooth muscle relaxation and subsequent vasodilation Eg nitroglycerin, sodium nitroprusside, isosorbide mononitrate
61
What is the mechanical management of ED?
Vacuum pump - hollow cylinder that is placed onto the penis with a penis ring (outflow obstruction of the existing erection) The suctioning function of the vacuum pump leads to stiffening of the penis (the blood is literally sucked into the penis). As the erection regresses again after releasing the vacuum (detumescence), an elastic penis ring is usually fixed to the base of the penis. The ring prevents the return of blood via constriction and provides a durable, sufficient erection
62
What is the surgical management of ED?
Implantation of penile prosthesis Last resort
63
What are the most common causes of urethritis?
Gonococcal urethritis - neisseria gonorrhoea Nongonococcal: - Chlamydia trachomatis - Mycoplasma genitalium - Trichomonas vaginalis - HS1 and 2 - Adenovirus
64
How doe urethritis present?
``` Dysuria Burning or itching of urethral meatus Uthehral discharge - purulent, cloudy, blood tinged or clear Initial haematuria Asymptomatic (esp nongonococcal) ```
65
How is urethritis investigated?
Urine dip of first void urine Urethral smear Swab NAAT
66
What are some risk factors for testicular cancer?
Cryptorchidism Klinefelter syndrome Down syndrome Hypospadia
67
How are testicular tumours classified?
Germ cell (95%) - Seminoma - Non seminoma Non germ cells (5%) - Leydig - Sertoli - Secondary eg lymphoma
68
List some types of nonseminoma germ cell tumours of the testis
``` Embryonal carcinoma Teratoma Testicular choriocarcinoma Yolk sac tumour Mixed germ cell tumour (most common) ```
69
How does testicular cancer present?
``` Painless testicular nodule or swelling Negative transillumination test Dull lower abdo or scrotal discomfort (more common than acute scrotal pain) Metastatic disease: - Cough, SOB, chest pain - Lower back or bone pain ``` Gynaecomastia Paraneoplastic hyperthyroidism
70
What can cause gynaecomastia in testicular cancer?
HCG overproduction or excess estrogen
71
Which is the most aggressive testicular tumour?
Testicular choriocarcinoma Highly malignant Early mets to lungs or brain
72
What are testicular cancer tumour markers?
Alpha fetoprotein (AFP) HCG LDH
73
What investigations are done for testicular tumours?
``` Tumour markers US CT abdo pelvis chest Cranial CT / MRI if mets suspected Histopathology following radical inguinal orchidectomy ```
74
Describe US findings of: Seminoma Nonseminoma Microlithiasis
Seminoma: - Hypoechoeic (more dense) - Homogenous - Sharp margins Nonseminoma: - Variable echogenicity - Inhomogenous - May be calcified or cystic Microlithiasis: - Disseminated calcification as a possible precursor of carcinoma = starry sky appearance
75
Why is it important that the testis are removed and sent to pathology when investigating a suspected testicular tumour, rather than performing a transscortal biopsy?
Do not perform a transcrotal biopsy because of the risk fo tumour seeding
76
Ddx of testicular swelling
Hydrocele Varicoele Spermatocele Scrotal hernia
77
Describe a hydrocele vs varicoele
Hydrocele is a swelling caused by fluid around the testicle - Fluctuant swelling - +ve transillumination Varicocele is a swelling caused by dilated or enlarged veins within the testicles - "Bag of worms" - Reduced when lying supine - -ve transillumination
78
What is the management of testicular cancer?
Sperm cryopreservation before surgery Radial inguinal orchiectomy Radiation / chemo
79
What is the prognosis of testicular cancer?
Excellent - high cure rate and >95% 5 yr survival Often curable in advanced and metastatic stages Better prognosis in seminomas but both still good survival rates

YEAR 3 & 5 CORE CONDITIONS (30 decks)

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