urethral, penile, testicular disorders

phimosis

inability to retract the foreskin from the glans

phimosis RF

MCC chronic infection d/t bad hygiene, DM, forceful retraction leading to scarring

phimosis CP

recurrent infection, painful erection, problems with urination, inability to retract foreskin

phimosis management

hygiene, topical steroid, abx if infection, possible circumcision

phimosis complication

RF for development of penile cancer (SCC)

paraphimosis

entrapment of retracted foreskin that cannot be reduced in (partially) uncircumcised male

paraphimosis causes

phimosis, GU procedures, sexual activity, penile trauma, plasmodium infection

paraphimosis CP

pain/swelling, dysuria, ischemia

paraphimosis tx

if s/s necrosis urology referral, manual reduction first line

forceps traction, dorsal slit procedure, glans penis aspiration, puncture technique

balanitis

inflammation of glans

balanitis cause

MC inadequate hygiene in uncircumcised, trauma, DM, obesity

balanitis CP

pain, tenderness, pruritus of glans/foreskin

balanitis PE

erythematous glans possibly with curd like exudate or foul purulent material, glans may be edematous

balanitis tx

hygiene, antifungal if candida

erectile dysfunction

male sexual dysfunction, recurrent inability to initiate or maintain an erection

erectile dysfunction causes

vascular, neurologic, local penile factors, hormonal, drugs, psychogenic

rapid onset erectile dysfunction causes

psychogenic, GU trauma

nonsustained erection erectile dysfunction cause

anxiety, venous leak

loss of nocturnal erections erectile dysfunction cause

vascular or neurologic disease

failure to initiate erectile dysfunction cause

psychogenic, endocrinologic, neurogenic

failure to fill erectile dysfunction cause

arteriogenic

failure to store blood volume erectile dysfunction cause

venous issue

erectile dysfunction diagnostics

medical, sexual, psychosocial hx w/PE

A1c, FPG, CBC,CMP, lipids, TSH, hormones (AM testosterone)

erectile dysfunction tx

PDE5 inhibitors

PDE5 inhibitor D2D

nitro

priapism

prolonged erection, urological emergency

priapism causes

sexual arousal, sickle cell, medications, illicit drugs

priapism pathophys

compartment syndrome causing risk for irreversible damage (ischemia → fibrosis → permanent ED)

priapism tx

emergent urology consult

intracavernosal injection with phenylephrine

peyronie’s disease

acquired localized fibrotic disorder of penile shaft leading to deformity, mass, pain, ED

peyronie’s disease pathophys

fibrous plaques occur possibly d/t xs collagen or fibroblastic proliferation

peyronie’s disease CP

penile pain, deformity (curvature, nodule, indentation), shortening during erection, sexual dysfunction

peyronie’s disease tx

urology referral, NSAIDs, pentoxifylline

intralesional drug therapy (CCH)

peyronie’s disease surgery indication

sexual dysfunction, sx >12mos, refractory to medical therapy

urethral prolapse

urethra falls and is visible at urethral meatus

urethral prolapse population

prepubertal Black females and post menopausal white women

urethral prolapse CP

asymptomatic

pain, bleeding, urinary symptoms

protrusion of distal urethra with donut shaped mass

urethral prolapse tx

if asymptomatic - sitz baths, topical estrogen, abx, steroids

surgery if sx

if strangulated emergent urology consult

urethral stricture

fibrotic narrowing d/t dense collagen and fibroblasts causing restriction of urine flow

urethral stricture complications

urinary retention, prostatitis, UTIs, urethral carcinoma, renal failure

urethral stricture causes

idiopathic/trauma MC, iatrogenic, penile fracture, infection, hypospadias, lichen sclerosis, radiation

urethral stricture CP

weak urinary stream, incomplete emptying, spraying stream, dysuria

urethral stricture imaging

cytourethroscopy, retrograde urethrogram, voiding cystourethrogram

urethral stricture tx

urethral dilation/urethrotomy, perineal urethrostomy, urethroplasty

single dose cefazolin pre-op

hydrocele

collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis (scrotum)

hydrocele CP

painless scrotal mass that transilluminates

hydrocele diagnostics

u/s

hydrocele classifications

communicating, noncommunicating, reactive (from infection, injury)

communicating hydrocele

d/t patent processus vaginalis (channel btn peritoneum and tunica vaginalis)

communicating hydrocele CP

fluctuating mass, possible hernia and inguinal swelling

communicating hydrocele tx

surgical repair if not spontaneously resolved

noncommunicating hydrocele

segmental obliteration of processus vaginalis resulting in fluid sac btn parietal and visceral tunica vaginalis w/no communication to peritoneum

noncommunicating hydrocele CP

nonfluctuant mass

noncommunicating hydrocele tx children

usually spontaneously resolves, surgical repair if no resolution in 1y

noncommunicating hydrocele tx adult

none if small, hydrocelectomy to remove fluid if sx or large

differentiating hernia and hydrocele

auscultation, transillumination

varicocele

collection of dilated and tortuous veins along spermatic cord (pampiniform plexus) d/t valve incompetence, often causes infertility

varicocele location

90% L side

varicocele CP

painless or dull pressure scrotal mass (“bag of worms”) more prominent upright or during valsalva, can cause atrophy of testicle

varicocele diagnostics

u/s

varicocele tx

observation if no severe sx, scrotal support, surgery (spermatic vein ligation, varicocelectomy)

nutcracker syndrome

L renal vein is compressed btn aorta and superior mesenteric artery leading to L varicocele

nutcracker syndrome complications

CKD, clots, infertility, pain

renal carcinoma red flags

sudden varicocele, single R side varicocele, supine position nonreducible varicocele

testicular torsion

urological emergency when testicle twists w/in scrotum leading to compromised blood flow

testicular torsion population

neonates, adolescents (wrestlers)

testicular torsion pathophys

lower pole of testicle not appropriately attached to tunica vaginalis

testicular torsion CP

acute severe testicular pain, high riding testicle, testicular swelling, N/V, diffuse low abd pain, negative cremasteric reflex, negative phren’s sign

prehn’s sign

exacerbation of pain with elevation of testicle

testicular torsion diagnostic

color doppler u/s of scrotum/testicles

testicular torsion tx

orchidopexy, manual detorsion, orchiectomy if necrosis

testicular torsion complications

irreversible damage, infertility

nephrolithiasis population

males, white pts, increasing age

MCC nephrolithiasis

calcium oxalate

nephrolithiasis

kidney stones

nephrolithiasis CP

asymptomatic

varying pain - flank, testicle/labia

hematuria, N/V, dysuria, urinary urgency

nephrolithiasis imaging

CT no cx, u/s if pregnant

nephrolithiasis labs

BMP, UA, urine culture

nephrolithiasis passage

≤5 mm probably pass, ≥10mm not likely to pass

nephrolithiasis types

calcium oxalate, calcium phosphate, uric acid, cystine, struvite

nephrolithiasis tx

pain control (ketorolac, ibuprofen)

passage - tamsulosin (muscle relaxer, OHoTN risk)

tx UTIs, possible urology referral, surgery

nephrolithiasis surgeries

extracorporeal shock wave lithotripsy (ESWL), ureteroscopy with laser lithotripsy (URS), percutaneous nephrolithotomy

nephrolithiasis complications

persistent obstruction, kidney damage

calcium oxalate stone prevention

maintain calcium intake but avoid supps, decrease animal protein intake, avoid vit C, limit sucrose/fructose

benign prostatic hyperplasia (BPH)

increased total number of stomal and glandular epithelial cells within transition zone of prostate gland

benign prostatic hyperplasia (BPH) complications

benign prostatic enlargement/obstruction, bladder outlet obstruction

acute urinary retention, UTIs, bladder stones, renal dysfunction

benign prostatic hyperplasia (BPH) RF

black men <65, genetics, obesity, high caffeine intake, low physical activity

benign prostatic hyperplasia (BPH) pathophys

increased smooth muscle tone/resistance, androgens, systemic/localized inflammation

UA kidney stone findings

nitrites, WBCs 3-5

benign prostatic hyperplasia (BPH) CP

asymptomatic

lower UTI sx - storage and voiding sx

on DRE - nontender enlarged prostate

benign prostatic hyperplasia (BPH) cancer

increased risk of prostate and bladder cancer

benign prostatic hyperplasia (BPH) diagnostics

DRE, UA, post void residual volume, prostate bx only if concern for cancer or high PSA

benign prostatic hyperplasia (BPH) management

urology referral, lifestyle (limit fluid before bed/diuretics, avoid constipation, regular activity, wt loss, kegels, timed voiding, double voiding)

benign prostatic hyperplasia (BPH) acute urinary retention tx

catheterization

benign prostatic hyperplasia (BPH) medication tx

alpha blocker first to relax muscle

tamsulosin, doxazosin, alfuzosin, silodosin

benign prostatic hyperplasia (BPH) surgical tx

transurethral resection of prostate, simple prostatectomy, prostatic arterial embolization