urology stuff

Question 1

Balanitis

Answer 1

Acute inflammation of the foreskin and glans. Associated with strep and staph infections. More common in diabetics. Often seen in young children with tight foreskins ℞: Antibiotics, circumcision, hygiene advice.

Question 2

Phimosis

Answer 2

The foreskin occludes the meatus. In young boys this causes recurrent balanitis and ballooning, but time (+ trials of gentle retraction) may obviate the need for circumcision. In adulthood presents with painful intercourse, infection, ulceration and is associated with balanitis xerotica obliterans.

Question 3

Paraphimosis

Answer 3

Occurs when a tight foreskin is retracted and becomes irreplaceable, preventing venous return leading to oedema and even ischaemia of the glans. Can occur if the foreskin is not replaced after catheterization. ℞: Ask patient to squeeze glans. Try applying a 50% glucose-soaked swab (oedema may follow osmotic gradient). Ice packs and lidocaine gel help. May require aspiration/dorsal slit/circumcision.

Question 4

prostatitis classification

Answer 4

• 1 Acute Bacterial Prostatitis
• 2 Chronic Bacterial Prostatitis
• 3 Chronic Pelvic Pain Syndromes: – a Inflammatory – b Non-inflammatory
• 4 Asymptomatic Prostatitis

Question 5

prostatitis aetiology and features

Answer 5

Usually those >35yrs. Acute prostatitis is caused mostly by S. faecalis and E. coli, also chlamydia (and previously TB).
Features: UTIS, retention, pain, haematospermia, swollen/boggy prostate on DRE.

Question 6

Lumps in the groin and srotum - differentiation

Answer 6

Testicular lump = cancer until proved otherwise.

Acute, tender enlargement of testis = torsion until proved otherwise.

Diagnosing scrotal masses
1 Can you get above it?
2 Is it separate from the testis?
3 Cystic or solid?

Question 7

Cannot get above testicular lump?

Answer 7

inguinoscrotal hernia or hydrocele extending proximally

Question 8

scrotal lump separate and cystis?

Answer 8

epididymal cyst

Question 9

scrotal lump separate and solid|?

Answer 9

epididymitis/varicocele

Question 10

scrotal lump is testicular and cystic?

Answer 10

hydrocele

Question 11

epididymal cysts are whta

Answer 11

usually develop in adulthood and contain clear or milky (spermatocele) fluid. They lie above and behind the testis. Remove if symptomatic.

Question 12

hydroceles are what?

Answer 12

fluid within the tunica vaginalis). Primary (associated with a patent processus vaginalis, which typically resolves during the 1st year of life) or secondary to testis tumour/trauma/infection. Primary hydroceles are more common, larger, and usually in younger men. Can resolve spontaneously. ℞: aspiration (may need repeating) or surgery: plicating the tunica vaginalis (Lord’s repair)/inverting the sac (Jaboulay’s repair) Is the testis normal after aspiration? If any doubt, do USS

Question 13

epididymoorchitis

Answer 13

Causes: Chlamydia (if <35yrs); E. coli; mumps; N. gonorrhoea; TB.
Features: • Painful swollen testes and epididymis • May extend up cord (fundibulitis) • Onset gradual over a few days •Dysuria •sweats/fever • O/E diffusely swollen tender testes and epididymis, hyperaemia
• Exclude torsion of testes and cancer of testes
• USS scrotum will show normal cord vascularity and hypervascularity in region of infection, it excludes abscess and canc
Warn of possible infertility and symptoms worsening before improving

Question 14

varicocele

Answer 14

Dilated veins of pampiniform plexus. Left side more commonly affected. Often visible as distended scrotal blood vessels that feel like ‘a bag of worms’. Patient may complain of dull ache. Associated with subfertility, but repair (via surgery or embolization) seems to have little effect on subsequent pregnancy rates

Question 15

haematocele

Answer 15

Blood in tunica vaginalis, follows trauma, may need drainage/excision.

Question 16

testicular tumours

epidemiology

Answer 16

The commonest malignancy in ♂ aged 15–44; 10% occur in undescended testes, even after orchidopexy. A contralateral tumour is found in 5%.

Question 17

types of testicular tumours

Answer 17

①seminoma, 55% (30–65yrs);

②non-seminomatous germ cell tumour 33% (NSGCT; previously teratoma; 20–30yrs);

③mixed germ cell tumour 12%;

④lymphoma.

Question 18

signs of testicular tumours and risk factors

Answer 18

Typically painless testis lump, found after trauma/infection ± haemospermia, secondary hydrocele, pain, dyspnoea (lung mets), abdominal mass (enlarged nodes), or effects of secreted hormones.

25% of seminomas & 50% of NSGCT present with metastases.

Risk factors: Undescended testis; infant hernia; infertility.

Question 19

tests for testicular tumour

Answer 19

(allow staging) CXR, CT, excision biopsy. α-FP(eg >3iu/mL) and β-HCG are useful tumour markers and help monitor treatment,check before & during ℞.

Question 20

treatment of testicualr tumour

Answer 20

orchidectomy (inguinal incision; occlude the spermatic cord before mobilization to ↓risk of intra-operative spread).

Options are constantly updated (surgery, radiotherapy, chemotherapy).

Seminomas are exquisitely radiosensitive. Stage 1 seminomas: orchidectomy + radiotherapy cures ∼95%.

Do close follow-up to detect relapse.

Cure of nsgct, even if metastases are present, is achieved by 3 cycles of bleomycin + etoposide + cisplatin.

Prevention of late presentation: self-examination.

5yr survival >90% in all groups.

Question 21

diagnosing groin lump from alteral to medial

Answer 21

• Psoas abscess—may present with back pain, limp and swinging pyrexia
• Neuroma of the femoral nerve
• Femoral artery aneurysm
• Saphena varix—like a hernia, it has a cough impulse
• Lymph node
• Femoral hernia
• Inguinal hernia
• Hydrocele or varicocele
• Also consider an undescended testis (cryptorchidism)

Question 22

torsion of testis features

Answer 22

Symptoms: Sudden onset of pain in one testis, which makes walking uncomfortable. Pain in the abdomen, nausea, and vomiting are common.

Signs: Inflammation of one testis—it is very tender, hot, and swollen. The testis may lie high and transversely.

Torsion may occur at any age but is most common at 11–30yrs.

With intermittent torsion the pain may have passed on presentation, but if it was severe, and the lie is horizontal, prophylactic fixing may be wise.

Question 23

ddx for testicular torsion

Answer 23

The main one is epididymo-orchitis but with this the patient tends to be older, there may be symptoms of urinary infection, and more gradual onset of pain

Also consider tumour, trauma, and an acute hydrocele.

nb: torsion of testicular or epididymal appendage (the hydatid of Morgagni—a remnant of the Müllerian duct)—usually occurs between 7–12yrs, and causes less pain. Its tiny blue nodule may be discernible under the scrotum.

Doppler USS may demonstrate lack of blood flow to testis, as may isotope scanning. Only perform if diagnosis equivocal—do not delay surgical exploration.