S3 L1 Male Urology Flashcards

1
Q

What is phimosis?

A
  • Foreskin cannot be fully retracted from around the tip of the penis
  • Normal to be non-retractable in adolescence, e.g 50% cannot be retracted at 1 year
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2
Q

What can be the consequences of phimosis?

A
  • Poor hygeine so more STDs
  • Pain
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3
Q

What is Balantis Xerotica Obliterans?

A
  • Lichen sclerosus of the male genitalia
  • A chronic, often progressive disease, which can lead to phimosis and urethral stenosis
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4
Q

What is paraphimosis and what are the most commonest causes?

A
  • Foreskin can no longer be pulled forward over the tip of the penis causing the foreskin to become swollen and stuck
  • Phimosis, Catheterisation (esp the elderly) and Penile Cancer are all causes
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5
Q

How do you treat phimosis and paraphimosis?

A

- Circumsion for phimosis (be careful if have phimosis and balantis, may have underlying cancer)

  • Needs reduction manually or dorsal slit may be necessary
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6
Q

What type of cancer is penile cancer and what are the risk factors?

A

- Squamous cell carcinoma

  • Really rare
  • Phimosis, hygeine and smegma are risk factors
  • HPV 16 and 18 are risk factors
  • Untreated most die in two years
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7
Q

Why may a male have a circumsion?

A
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8
Q

What are some of the causes of acute scrotal pain?

A
  • Testicular torsion
  • Epididymitis/Orchitis/Epididymoorchitis
  • Torsion of hyatid of Morgagni
  • Trauma
  • Ureteric calculi (referred pain, often blood in urine)
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9
Q

What can epididymitis be caused by?

A
  • UTIs
  • STIs
  • Mumps
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10
Q

How would testicular torsion present?

A
  • Younger patient
  • Sudden onset e.g wake to pain
  • Unilateral pain
  • May be vomiting and no LUTS
  • Tender testes that lie high and horizontal in scrotum

EMERGENCY SCROTAL EXPLORATION - don’t waste time with tests

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11
Q

What would you see in the history and examination of a male with epididymo-orchitis?

A
  • Gradual unilateral onset
  • Recent history of UTI, unprotected sex, mumps, catheter
  • Age 20-40 STI (Chlaymdia) and 40/50 often UTI (E.Coli)
  • Pyrexial
  • Red enlarged tender testis or epididymis
  • May have reactive hydrocoele or fluctuant areas showing an abscess
  • Fournier’s Gangrene (high mortalitiy)
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12
Q

What is Fournier’s gangrene?

A

Type of necrotizing fasciitis affecting the external genitalia as a complication of epididymitis, more common in poorly controlled diabetes

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13
Q

How do you investigate suspected epididymoorchitis and treat it?

A
  • Blood cultures and FBCs
  • Mid stream urine sample
  • Scrotal ultrasound if suspected abscess
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14
Q

What are some questions you need to ask when a male presents with a scrotal lump?

A
  • Is it painful?
  • How quickly has it occured?
  • Can I get above it? If yes it is scrotal in origin
  • Is it in the body of the testes? If yes it could be a tumour
  • Is it separate to the testis?
  • Does it fluctuate and transilluminate?
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15
Q

What are some common causes of scrotal lumps?

A

Painless:

  • Testis tumour
  • Epididymal cyst
  • Hydrocoele
  • Reducible inguino-scrotal hernia
  • Varicocoele (aching at end of day)

Painful:

  • Epididymitis
  • Epididymo-orchitis
  • Stranfulated inguino-scrotal hernia
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16
Q

What is the history of a testicular tumour and what should be the treatment plan if you suspect this?

A
  • Usually a painless lump you can get abovw
  • Usually a germ cell tumour if aged<45 and risk factor of a history of maldescended testis. In older men can be lymphoma

- Urgent 2 week referral to urology for testis tumour markers (aFP, hCG, LDH) and arrange urgent ultrasound

17
Q

What would a hydrocele appear like on history and examination?

A
  • Slow or suddent onset and can be bi/unilateral
  • Imbalance in the fluid production and resorption between tunica albuginea and tunica vaginalis
  • Testis may not be palpable separately

- Transilluminates

  • Can get above
18
Q

How does an epididymal cyst present on examination?

A
  • Usually painless
  • Separate from the testis
  • Can get above the mass
  • Transilluminates
19
Q

How does a varicocele present?

A
  • Dull ache at the end of the day
  • Bag of worms above testis
  • Not tender
  • More common in left than right
  • Can be associated with reduced fertility or renal pathology so check for palpable abdominal mass
20
Q

How do we treat the following scrotal lumps?

  • Testicular tumour
  • Epididymal Cyst
  • Hydrocele
  • Varicocele
  • Inguino-scrotal hernia
A
21
Q

What are some of the causes of urinary retention? (more common in males than females)

A
  • Prostatic enlargement e.g BPH or prostate cancer
  • Phimosis/Urethral Stricture/Meatal stenosis
  • Constipation
  • UTI
  • Anticholinergic drugs (e.g schizophrenia drugs and drugs for overactive bladder)
  • Over distension e.g drunk too much at party
  • Following abdominal surgery (from nerve damage or the anaesthesia)
  • Neurological
22
Q

What are the three different types of urinary retention and how do we treat them?

A

Acute: TWOC after fixing the main cause e.g constipation

Chronic: intermittent self catheterisation

Acute-On-Chronic: long term catheter or surgical intervention

23
Q

When an older man presents with eneuresis what is your initial diagnosis?

A

Chronic retention with overflow incontinence until proven otherwise

24
Q

What are the two different categories of LUTS and what can be some of the causes of each category?

A

Storage: irritative (stones), overactive bladder (idiopathic or neuropathic e.g MS), low compliance of bladder from scarring (TB and schistomiasis), polyuria

Voiding: bladder outflow obstruction (e.g phimosis, BPH), lack of coordination between bladder and urinary sphincter due to upper motor neurone lesion, reduced contractility due to lower motor neurone lesion

25
Q

What are some causes of polyuria?

A

Global: uncontrolled type 2 diabetes

Nocturnal: venous stasis and sleep apnoea as ANP released causing polyuria

26
Q

What are some causes of bladder outflow obstruction?

A

Physical

  • Phimosis
  • Urethral stricture
  • BPH

Dynamic

  • High sympathetic smooth muscle tone by A1 receptors

Neurological

  • UMN lesion so lack of coordination between bladder and urinary sphincter
27
Q

How can we assess a patient’s LUTS, especially when suspecting BPH?

A

International Prostate Symptom Score (IPSS)

28
Q

Apart from filling out an IPSS what do you need to investigate when a male patient presents with LUTS?

A

Examination

  • DRE
  • Is the bladder palpable
  • Neurological exam

Investigations

  • Dipstick ?UTI or bLOOD
  • Consider PSA
29
Q

How can BPH be managed in primary care?

A

Lifestyle changes:

  • Avoid fizzy drinks
  • Reduce caffeine intake
  • Don’t drink more than 2.5L a day

Drugs:

  • Alpha Blockers
  • 5-Alpha-Reductase Inhibitors
30
Q

What is the mechanism of action of the drugs used to treat BPH and what are their side effects?

A

Alpha Blockers (Tamsulosin)

MOA: relax smooth muscle within the prostate and bladder neck (alpha-blocker - alpha-adrenoreceptor antagonist). rapid symptom relief

Side effects: postural hypotension so can cause falls in elderly, headache, dizziness, problems ejaculating

5ARIs (Finasteride or Durasteride)

MOA: shrink the prostate by preventing the conversion of testosterone to DHT. slower symptom relief but reduces the risk of retention

Side effects: ED, loss of libido, difficulty orgasming, gynaecomastia

31
Q

How is BPH managed if lifestyle changes and drugs don’t work?

A
  • Referred to secondary care and will do a flow rate study before surgery
  • Do TURP by laser to make cavity bigger
32
Q

TURP

A

Transurethral resection of the prostate is a urological operation. It is used to treat benign prostatic hyperplasia. As the name indicates, it is performed by visualising the prostate through the urethra and removing tissue by electrocautery or sharp dissection.

33
Q

What are the pros and cons of having the PSA test to test for prostate cancer?

A

3 out of 4 men with a raised PSA will not have prostate cancer and PSA will miss 15% of cancer diagnoses

+ May be reassurance if the test is normal

+ Can find early signs of cancer

  • Can miss cancer and provide false reassurance
  • Cannot tell the difference between fast and slow growing cancers and may make you worry about a slow growing cancer that would cause no harm anyway
  • May mean you have lots of tests you don’t really need
34
Q

What should a male do before having a PSA test?

A
35
Q

How would you explain to a patient what NNT means?

A

Number of patients you need to treat to prevent one additional bad outcome (e.g stroke or death)

36
Q

What is the definition of orchitis?

A

Testicular inflammation or infection