Surgical Conditions of the Male Repro Tract

Question 1

Define…
1. Anechoic.
2. Balanoposthitis.
3. BPH.
4. Cryptorchid.
5. Dysuria.
6. Echogenicity.
7. Epididymitis.
8. Feminising syndrome.

Answer 1

1. Absence of the echo waves / black on ultrasound.
2. Inflammation/infection of both glans penis and prepuce.
3. Benign prostatic hyperplasia.
4. Undescended testicle(s).
5. Difficulties urinating.
6. How much ultrasound echoes are produced by an organ/tissue.
7. Inflammation/infection of the epididymis.
8. Associated w/ oestrogen secretion from Sertoli cell tumours of testicles.

Question 2

Define…
1. Galactorrhoea.
2. Gynaecomastia.
3. Haematuria.
4. Hyperplasia.
5. Hyperechoic.
6. Hypoechoic.
7. Hypospadia.
8. Iatrogenic.

Answer 2

1. Inappropriate milk production.
2. Mammary gland development in the male.
3. Blood in urine.
4. Increased number of cells in organ/tissue.
5. Higher number of echo waves / light grey on ultrasound.
6. Lower number of echo waves / dark grey on ultrasound.
7. Congenital failure of urethral closure.
8. Caused by a vet.

Question 3

Define…
1. Idiopathic.
2. Loculations.
3. Omentalisation.
4. Omental release.
5. Orchitis.
6. Paraphimosis.
7. Paraprostatic.
8. Parenchyma.

Answer 3

1. Unknown cause.
2. Compartmentalisation of a fluid-filled cavity into smaller spaces.
3. Filling a cavity w/ omentum.
4. Surgical procedure that allows omentum to be placed in more distant places.
5. Inflammation/infection of the testicle(s).
6. Inability to retract penis into prepuce.
7. Next to the prostate.
8. The functional tissue of an organ.

Question 4

Define…
1. Phimosis.
2. Pre-scrotal incision.
3. Priapism.
4. Prostate.
5. Prostatectomy.
6. Prostatic marsupialisation.
7. Prostatomegaly.
8. Prostrate.

Answer 4

1. Inability to extrude penis from prepuce.
2. Incision cranial to scrotum.
3. Persistent erection of the penis.
4. Sex gland.
5. Removal of prostate.
6. Creation of a stoma between prostate and external body wall.
7. Enlargement of prostate.
8. Lying flat on the ground.

Question 5

Define…
1. Retention cysts.
2. Scrotal ablation.
3. Scrotal flap.
4. Stranguria.
5. Torsion.
6. Transmissible Venereal Tumour.

Answer 5

1. Acquired cyst due to obstruction of gland ductules.
2. Removing scrotal skin surgically.
3. Using scrotal skin as an axial pattern flap (w/ castration).
4. Painful, frequent urination.
5. Twisting of testicle around its blood supply.
6. Sexually transmitted disease, not in UK.

Question 6

DAMNIT-V

Answer 6

D = Degenerative / developmental.
A = Auto-immune / anatomical / anomalous.
M = Metabolic.
N = Nutritional / neoplastic.
I = Infectious / inflammatory / idiopathic / immune-mediated / iatrogenic.
T = Toxic / traumatic.
V = Vascular.

Question 7

Clinical signs of prostatic disease.

Answer 7

• Dysuria / stranguria.
• Urinary incontinence.
• Haematuria.
• Straining to pass faeces.
• Abnormally shaped faeces.
• Abdominal pain.
• Pyrexia.

Question 8

Prostatic investigation.

Answer 8

CE.
- Rectal exam.
- Size, shape, symmetry and pain.
- Enlargement not always symmetrical.
- Dorsal enlargement may cause rectal compression which will change shape of faeces.
- Very large prostates can weigh down into the abdomen and take the bladder with them.
- Abdominal palpation.
Imaging.
- Radiography (Prostate should not be >1/2 width of pelvic inlet).
- Ultrasound (typically homogenous parenchyma, no pockets of fluid / difference in echogenicity).
Sampling.
- Prostatic wash – catheter tip in location of gland and simultaneous massage of gland.
- FNA under ultrasound guidance.
- Tru-cut biopsy under ultrasound guidance.

Question 9

Surgical conditions of the prostate.

Answer 9

Benign prostatic hyperplasia.
Prostatitis and prostatic abscesses.
Prostatic neoplasia.
Prostatic and para-prostatic cysts.
Prostatic trauma.

Question 10

Benign prostatic hyperplasia.

Answer 10

• Hormonally driven by testosterone or by testicular oestrogen.
• Symmetrical prostatomegaly.
• Investigate w/ imaging – plain radiographs or ultrasonography.
  – Could consider sampling if anything sinister.
  – Some have cystic appearance.

Question 11

BPH treatment.

Answer 11

Medical
- Delmadinone acetate injection = anti-androgen (“Tardak”).
- Deslorelin implant = GnRH super agonist (“Suprelorin”).
- Osaterone acetate tablets = androgen receptor antagonist (“Ypozane”).
Surgical castration - permanent and curative.

Question 12

1. Prostatitis cause.
2. Prostatitis diagnosis.
3. Prostatitis treatment.
4. How is prostatitis distinguished from BPH?

Answer 12

1. Ascending bacterial infection.
2. Hx/CE.
   Prostatomegaly.
   Ultrasound.
   Cytology and culture - FNA/prostatic wash.
3. Treat underlying BPH
   ABX.
4. Pain.

Question 13

1. Prostatic abscess cause.
2. Prostatic abscess diagnosis.
3. Prostatic abscess treatment.
4. Danger of prostatic abscess.

Answer 13

1. Progression of prostatitis - untreated more likely than unresolved.
2. Unwell, pain.
   Doughy feel on palpation.
   Loculations w/in parenchyma and hyperechoic / echo-dense fluid.
3. Surgical drainage.
   - Marsupialisation.
   - Indwelling surgical drain – high rate of complications.
   - Omentalisation.
4. Can rupture and cause a peritonitis.

Question 14

Prostatic omentalisation method.

Answer 14

• Dorsal recumbency.
• Urethral catheter.
• Caudal laparotomy.
• Omental release.
• Expose prostate and isolate w/ swabs.
• Stab incision into lateral aspect of prostate.
• Digit exploration of cavities and flush.
• Forceps draw omentum into ventral prostate.
• Wrap omentum around urethra.
• Secure w/ absorbable monofilament sutures.

Question 15

1. Cause of prostatic cysts.
2. Diagnosis of prostatic cysts.

Answer 15

1. Retention cysts.
   Para-prostatic cysts.
   Associated w/ BPH / prostatitis / neoplasia.
2. Hx / CE.
   Ultrasound.
   Biopsy – rule out neoplasia.
   Non-painful, more chronic.
   Cysts may contain urine.

Question 16

Prostatic cyst treatment.

Answer 16

Medical
- Ultrasound-guided drainage – typically refill.
Surgical
- Castration – if parenchymal and small.
- +/- partial or complete resection of cyst.
- Omentalisation for incomplete resection.

Question 17

How can a para-prostatic cyst be differentiated from the urinary bladder?

Answer 17

Contrast study.

Question 18

Prostatic cyst resection and omentalisation.

Answer 18

• Dorsal recumbency.
• Urethral catheter.
• Caudal laparotomy.
• Omental release.
• Expose prostatic cyst.
• Isolate w/ moistened lap swabs.
• Resect as much of the cyst and capsule as possible.
• Secure omentum to remaining capsule.
  *take samples for culture, cytology and histopathology.

Question 19

Diagnosis of prostatic neoplasia.

Answer 19

• Hx / CE.
  – Uncommon dogs / rare in cats.
  – More common in castrated dogs.
  – Prostatic signs and cancer signs.
  – Asymmetrical prostatomegaly.
• Ultrasound.
• Radiographs.
  – 70-80% metastatic.
  – Sometimes to bone of pelvis / lumbar spine.
• Suction biopsy not FNA.
• Almost always adenocarcinoma, sometimes transitional cell carcinoma spread from urethra.

Question 20

Prostatic neoplasia clinical signs.

Answer 20

• Straining to pass faeces.
• Abnormally shaped faeces.
• Abdominal pain.
• Pyrexia.
• Caudal abdominal mass.
• Weight loss.

Question 21

Prostatic neoplasia.

Answer 21

Medical.
- NSAIDs via COX-2 inhibition – meloxicam.
Surgical.
- Palliative relief of urethral obstruction.
– Cystostomy tube or urethral stenting increases median survival to 6.9 months.
- Prostatectomy – increases median survival to 9 months.
*both can result in urinary incontinence.
* Prognosis guarded, most euthanised w/in a few months.

Question 22

1. Cause of prostatic trauma.

Answer 22

1. Cryptorchidectomy.

Question 23

Conditions of the scrotum and testicles.

Answer 23

• Anorchism / monorchism.
• Testicular hypoplasia.
• Cryptorchidism.

Question 24

1. Clinical exam of scrotal and testicular neoplasia.
2. Staging of scrotal and testicular cancer.
3. Treatment of scrotal and testicular cancer.

Answer 24

1. Asymmetrical enlargement / difference in architecture or texture.
   +/- male feminising syndrome.
   Cryptorchid - ~10X risk for neoplasia.
2. Abdominal imaging.
   Met check = metastasise late.
3. Closed castration aiming for good margin of healthy cord +/- scrotal ablation.
   Chemotherapy for the few cases w/ metastasis.

Question 25

Sertoli cell tumours.

Answer 25

- Arise from Sertoli cells in seminiferous tubules. - Typically slow growing, non-invasive. -- ~10% metastasis. - 16-39% feminising syndrome due to oestrogen secretion (Alopecia, gynaecomastia, galactorrhoea, pendulous prepuce, attractive to males). - Bone marrow hypoplasia and pancytopenia can occur --> bad.

Question 26

Interstitial cell tumours.

Answer 26

- Derived from Leydig cells. - Small and non-palpable -- 43% bilateral. - Incidental finding, always benign.

Question 27

Seminomas

Answer 27

- Arise from spermatogenic cells of seminiferous tubules. - Although normally benign, can metastasise. - Androgen secretion more common.

Question 28

1. Infectious / inflammatory conditions of the scrotum and testicles. 2. Traumatic conditions of the scrotum and testicles. 3. Vascular condition of the scrotum and testicles.

Answer 28

1. Orchitis / epididymitis. 2. - Fighting rabbits. - Jumping dogs. 3. Torsion.

Question 29

Orchitis / epididymitis.

Answer 29

- Usually ascending infection (prostatitis, UTI), but can also be secondary to bites and/or via haematogenous spread. - Bacterial -- E. coli, staphylococcus, streptococcus, mycoplasma, brucella canis. - Also possible but v rare = Distemper, Ehrlichiosis. - Acute pain and swelling. - Can result in abscess (testes/scrotum). - Medical stabilisation and castration for treatment.

Question 30

Treatment of trauma to testicles and/or scrotum.

Answer 30

- Typically debride to remove damaged / necrotic tissue. - Castration if testicle exposed. - Convert a 'messy' wound to a surgical wound for closure.

Question 31

Torsion.

Answer 31

- Associated w/ enlarged, neoplastic, abdominal testicles. - Can also be scrotal.

Question 32

1. Wound classification for scrotal surgical wound. 2. Surgical options for the scrotum.

Answer 32

1. Clean / contaminated. 2. - Pre-scrotal incision for castration. - Scrotal incision for castration. - Scrotal ablation. - Scrotal flap -- for reconstruction of inguinal/perineal skin defects in uncastrated dog (when combined w/ castration!)

Question 33

Congenital abnormalities of the penis and prepuce.

Answer 33

- Intersex -- anatomical elements of both genders (Yorkies and cockers). - Hypospadia. - Persistent penile frenulum. - Congenital phimosis. - Congenital paraphimosis. - Preputial agenesis.

Question 34

1. Neoplasia of the prepuce and penis. 2. Infection / inflammation of the prepuce and penis. 3. Trauma of the penis and prepuce. 4. Ischaemic necrosis of the penis and prepuce.

Answer 34

1. - Skin. - Mucosa. - Os penis. 2. - Balanoposthitis. - Acquired phimosis. - Acquired paraphimosis. 3. Self-inflicted or non self-inflicted. - RTA, bites, malicious behaviour, hypersexuality. - Gives rise to secondary issues: -- vascular compromise of the penis itself. -- urethral prolapse. -- phimosis. -- paraphimosis. 4. - Drug-related thrombosis.

Question 35

Hypospadia.

Answer 35

- congenital. - failure of the urogenital folds to fuse and incomplete formation of penile urethra. - abnormal termination of urethra. - UTI, urine scalding, incontinence. - Treatment only if clinical.

Question 36

1. Malignant penile and preputial neoplasia. 2. Benign penile and preputial neoplasia.

Answer 36

1. Haemangiosarcoma. MCT. Osteosarcoma of the os penis. Chondrosarcoma of the os penis. Squamous cell carcinoma. Transitional cell carcinoma (urethral). Transmissible venereal tumours. 2. Fibroma. Lymphoma. Osteoma of the os penis. Papilloma.

Question 37

1. Clinical signs of penile neoplasia. 2. Staging of penile neoplasia. 3. Treatment of penile neoplasia.

Answer 37

1. - Swelling / mass. - Discharge. - Prolapse. - Haematuria / dysuria. 2. Biopsy LN check Distant met check. 3. - Amputation (partial/complete). - Adjunctive therapies.

Question 38

1. Most common form of preputial neoplasia. 2. Why is surgical treatment of preputial neoplasia so difficult?

Answer 38

1. MCT. 2. Need to be able to reconstruct the skin and preputial mucosa.

Question 39

1. Clinical signs of penile laceration. 2. Treatment of penile laceration.

Answer 39

1. Haemorrhage. May have dysuria. 2. Minor lacerations heal by second intention. Minor wounds in penile urethra managed w/ catheter (7-10 days) while heals. More major trauma requires: - primary reconstruction. - partial or total penile amputation.

Question 40

1. Signalment for urethral prolapse. 2. Aetiology of urethral prolapse. 3. Clinical signs of urethral prolapse. 4. Treatment of urethral prolapse.

Answer 40

1. Brachycephalic. 2. - Sexual excitement. - UTI. 3. - Can be intermittent or permanent. - Urethral mucosa protrudes from tip of penis. - Haemorrhage. - May have dysuria. 4. Treat underlying cause and perform urethropexy.

Question 41

1. What is phimosis. 2. Aetiology of phimosis. 3. Clinical signs of phimosis. 4. Treatment of phimosis.

Answer 41

1. Inability to extrude penis from prepuce. 2. Preputial orifice too small. - Congenital or - acquired (secondary to inflammation, infection, trauma, scarring. 3. Inability to urinate normally. Impedes mating. 4. Surgical correction to enlarge orifice (fairly simple).

Question 42

1. What is paraphimosis? 2. Aetiology of paraphimosis.

Answer 42

1. Inability to retract the penis into the prepuce. 2. - Congenital -- narrowed preputial orifice and an abnormally short prepuce. - Acquired -- Trauma, balanoposthitis (inflammation of glans penis and prepuce), neoplasia, often following sexual activity, can be caused by hair entrapment post penile extrusion.

Question 43

1. Clinical signs of paraphimosis. 2. Treatment of paraphimosis.

Answer 43

1. Pain. 2. Avoid and/or treat urethral obstruction / ischaemic necrosis.

Question 44

Paraphimosis medical management.

Answer 44

Reduce size of penis and protect from trauma. - Sedatives. - Flush penis -- sugar, mannitol, cold saline. - Lubricate -- KY. Replace penis. - Remove any foreign bodies. - Draw prepuce forward. Prevent recurrence w/ temporary purse string while swelling resolves.

Question 45

Surgical management of paraphimosis.

Answer 45

Narrowing of preputial orifice (temp. or permanent). Enlargement of preputial orifice. Preputial lengthening (preputioplasty). Phallopexy. Penile amputation.

Question 46

1. What is priapism? 2. Aetiology of priapism. 3. Treatment of priapism.

Answer 46

1. Persistent erection of the penis (not associated w/ sexual excitement). 2. Parasympathetic stimulation via pelvic nerve. Typically secondary to spinal cord injury / thromboembolic occlusion / mass lesion. 3. Treat underlying cause. Not surgery unless become necrotic, in which case - amputate.

Question 47

Penile surgical options.

Answer 47

Urethropexy - for prolapsed urethra, stitch urethra back into penis. Phallopexy - for paraphimosis, permanently sutures penis to prepuce. Penile amputation - partial or complete. Vasectomy (ferrets!)

Question 48

Preputial surgery options.

Answer 48

Preputial neoplasia excision and reconstruction. Preputial orifice: - narrowing -- for paraphimosis (purse string or skin reconstruction). - widening -- for phimosis. Preputioplasty (lengthening for paraphimosis).