Urology - Lecture #1

Describe the mechanism of an erection?

Sexual stimulation that releases nitric oxide by cavernous nerves into neuromuscular junction, NO activates enzyme guanylyl cyclase, guanylyl cyclase converts GTP into GMP, cGMP activates protein kinase G enzyme, protein kinase G enzyme activates protein kinase but decreased intracellular calcium, decreased smooth muscle calcium causes neuromuscular relaxation and cavernosal artery dilation. This results in increased blood flow and penile erection occurs. Venous outflow mediates erectile detumescence.

What is hyperprolactinemia?

Causes low circulating levels of testosterone due to inhibition of gonadotropin-releasing hormone secretion due to the elevated prolactin levels.

What is hypogonadism?

Serum total testosterone level less then 300 ng/dL

Which type of erectile dysfunction impairs relaxation of the cavernosal tissue?

Vasculogenic

ED in men < _____________ years old is associated with a significant risk of future cardiac events

60

What labs should you order for erectile dysfunction?

Fasting lipid profile

Total and free testosterone level

Blood glucose

A 52-year-old man presents to the clinic complaining of decreased libido, fatigue, and difficulty maintaining erections for the past 6 months. He denies depression or recent stressors. His past medical history includes hypertension and dyslipidemia, both well controlled with medications. He does not smoke or drink alcohol.

Physical exam is unremarkable. Lab results reveal:

Total serum testosterone: 180 ng/dL (normal: 300-1000 ng/dL)

PSA: 0.8 ng/mL

CBC: Hemoglobin 14.5 g/dL, Hematocrit 43%

Lipid panel: Total cholesterol 220 mg/dL

LFTs: Within normal limits

The patient asks about possible treatments for his symptoms.

What medication should you give this patient?

What is a side effect of this medication?

1.) Begin testosterone replacement therapy

2.) Side Effects - Acne, gynecomastia, erythrocytosis, dyslipidemia, infertility

What is a first line medication for ED?

PDE 5 inhibitors

A 60-year-old man presents to the clinic reporting ongoing difficulty achieving and maintaining an erection. He has a history of type 2 diabetes mellitus and hypertension. He previously tried oral phosphodiesterase-5 inhibitors with minimal improvement and experienced bothersome headaches as a side effect.

He is interested in trying a different form of treatment. After discussing available options, he chooses a locally acting medication that avoids systemic effects and is administered directly into the urethra.

Two weeks later, he returns complaining of a burning sensation in the penis and a small amount of blood noted after administration. He denies fever, urinary retention, or penile curvature.

Which of the following medications is this patient most likely using?

A) Sildenafil

B) Testosterone gel

C) Alprostadil (MUSE)

D) Tadalafil

C) Alprostadil (MUSE)

What are the side effects of Alprostadil (MUSE), an intraurethral suppository for ED?

SEs - Penile pain, urethral bleeding, hypotension, dizziness, priapism

When are intracavernosal injections for ED used?

Used when oral medications fail

A 66-year-old man presents to the urology clinic for follow-up regarding his erectile dysfunction. He has tried oral PDE5 inhibitors, including sildenafil and tadalafil, without adequate response. He reports that the medications gave him facial flushing and headaches but no significant improvement in erections. He is now being considered for alternative therapy.

The urologist initiates a treatment that involves injection directly into the corpora cavernosa. After two weeks, the patient presents to urgent care complaining of persistent penile erection lasting over 5 hours. He also reports mild pain at the injection site and bruising but no fever or urinary symptoms.

Which of the following is the most likely treatment he is receiving?

A) Testosterone gel

B) Alprostadil intraurethral suppository

C) Trimix injection

D) Penile prosthesis implantation

C) Trimix injection

How does a vacuum erection device work?

External negative pressure created by a vacuum pump pulling blood into the penis. There is a constricting ring applied to the base of the penis to maintain erection.

Urethra meatus that appears on the ventral surface of the penis. What is this condition and how do you treat it?

Hypospadius, treatment is surgical

A 2-day-old male newborn is brought to the pediatrician for a routine newborn check. On physical exam, the urethral opening is noted to be located on the ventral surface of the penile shaft, rather than at the tip of the glans penis. No chordee is observed. Both testes are descended, but a small right inguinal bulge is appreciated.

The parents ask about circumcision and the next steps in management.

Which of the following is the most appropriate next step in management?

A) Proceed with circumcision

B) Reassure the parents that no intervention is necessary

C) Refer for urologic surgical evaluation

D) Obtain karyotype testing immediately

What is the diagnosis?

C) Refer for urologic surgical evaluation

This patient has hyposadius

___________ is the maldevelopment of the meatus opening dorsally on the glans, shaft, or at the penoscrotal junction.

Epispadias

A newborn male infant is evaluated shortly after birth for genital abnormalities. On physical examination, the urethral meatus is located on the dorsal surface of the penis. The bladder is visibly protruding through the lower abdominal wall. Both testes are palpable in the scrotum.

The neonate is stable but has not yet voided since birth.

Which of the following is the most likely diagnosis?

A) Hypospadias with inguinal hernia

B) Bladder exstrophy with epispadias

C) Posterior urethral valves

D) Congenital phimosis

How do you treat this?

B) Bladder exstrophy with epispadias

1.) Consult surgery

What is priapism?

How do you treat it?

1.) Prolonged erection lasting more than 4 hours

2.) This is a medical emergency that can lead to ischemia, must be treated with injection of phenylephrine

What is phimosis?

The inability to retract the foreskin over the glans penis secondary to narrowing, constriction or adhesion

What is the most common infectious cause of phimosis?

Candida infections

A 45-year-old uncircumcised man presents to the clinic with a 1-week history of penile discomfort, itching, and difficulty retracting his foreskin. He also reports some whitish discharge and mild pain with urination. He has no fever and is otherwise healthy. Physical examination reveals erythema and inflammation of the foreskin with inability to retract it fully. A curd-like white substance is noted under the foreskin.

Which of the following is the most appropriate initial treatment?

A) Oral fluconazole

B) Elective circumcision

C) Topical corticosteroid with antifungal

D) Foley catheter placement

C) Topical corticosteroid with antifungal

This condition involves retracted foreskin trapped to the glans penis. It presents with edema, inflammation, and pain. What is this condition?

Paraphimosis

A 68-year-old uncircumcised man presents to the emergency department with penile pain and swelling that began earlier today. He had been cleaning under his foreskin in the shower when he retracted the foreskin but was unable to return it to its normal position. On exam, the glans penis is edematous and tender, and the foreskin is retracted and tightly constricting behind the glans.

Which of the following is the most appropriate next step in management?

A) Begin oral fluconazole for Candida infection

B) Apply topical corticosteroid cream

C) Manually reduce the foreskin after firm compression

D) Schedule elective circumcision in 4-6 weeks

What is this condition called?

C) Manually reduce the foreskin after firm compression, if its severe enough the elective circumcision may be considered.

1.) This is paraphimosis

This condition prevents the penis with curvature, indentation, hourglass deformity, or shortening with erections, this may be painful.

Peyronie's disease

A 57-year-old man presents to his primary care provider complaining of painful erections and noticeable curvature of the penis that developed gradually over the past 4 months. He denies trauma but recalls discomfort during intercourse several months ago. He reports difficulty with penetration and is embarrassed about the deformity. Physical exam reveals a firm, palpable plaque along the dorsal shaft of the penis, causing an upward curvature when erect.

Which of the following is the most likely diagnosis?

A) Phimosis

B) Peyronie's disease

C) Paraphimosis

D) Penile fracture

B) Peyronie's disease

___________ make up 10% of penile fractures with urethral injury,

Penile Fractures

A 34-year-old man presents to the emergency department immediately after sustaining a penile injury during intercourse. He reports hearing a "popping" sound followed by immediate loss of erection, intense pain, and rapid swelling of the penis. On exam, the penis is swollen and ecchymotic with deviation to the left side. There is no blood at the urethral meatus, and he is able to void without difficulty.

What is the most appropriate next step in management?

A) Reassurance and outpatient follow-up

B) Foley catheter insertion and observation

C) Emergent surgical exploration and repair

D) MRI of the penis to confirm diagnosis

C) Emergent surgical exploration and repair

A 17-year-old male presents to the emergency department after being struck in the groin during a baseball game. He immediately developed severe pain and swelling in the right testicle. He is alert, hemodynamically stable, and able to ambulate, but reports ongoing severe scrotal pain. On physical exam, there is right-sided scrotal ecchymosis and swelling with significant tenderness to palpation. A scrotal ultrasound shows a heterogeneous testicular echo pattern with irregular contour of the tunica albuginea.

What is the most appropriate next step in management?

A) Emergent surgical exploration

B) NSAIDs and ice packs with outpatient urology follow-up

C) Observation with serial exams

D) Scrotal support and repeat ultrasound in 48 hours

What is the diagnosis?

A) Emergent surgical exploration

1.) Scrotal injury

What is a hydrocele?

Collection of fluid between the layers of the tunica vaginalis

What imaging is recommended to examine a hydrocele?

Scrotal ultrasound

A 6-month-old male infant is brought to the pediatrician for evaluation of a painless swelling in the right side of the scrotum that the parents noticed about 3 weeks ago. The swelling appears to be soft, non-tender, and has gradually increased in size. The infant is feeding well and has no signs of distress. On physical exam, the right hemiscrotum is enlarged and transilluminates with light. There is no erythema, tenderness, or signs of hernia.

What is the most appropriate next step in management?

A) Immediate surgical referral

B) Trial of antibiotics

C) Observation and reassurance

D) Ultrasound to rule out testicular torsion

C) Observation and reassurance

A 54-year-old man presents to his primary care provider complaining of a gradually enlarging left scrotal swelling over the past year. He denies pain but reports a feeling of heaviness and discomfort when walking or sitting for long periods. He is otherwise healthy with no fever, urinary symptoms, or history of trauma.

On physical exam, the left hemiscrotum is enlarged, non-tender, and transilluminates with a penlight. The mass is separate from the testicle, and there is no inguinal hernia noted. Ultrasound confirms a simple hydrocele without evidence of tumor or infection.

What is the most appropriate next step in management?

A) Trial of antibiotics

B) Needle aspiration of the fluid

C) Observation and reassurance

D) Surgical hydrocelectomy

D) Surgical hydrocelectomy

How do you confirm a varicocele?

Scrotal ultrasound

How do you treat a varicocele?

NSAIDs, Scrotal support, ice

If symptomatic or concern for fertility treat with varicocelectomy

A 29-year-old man presents to the clinic with concerns about infertility after 1 year of trying to conceive with his partner. He also reports a dull ache in the left side of his scrotum that worsens with prolonged standing and improves when lying down. He denies any history of trauma, infections, or prior surgeries.

On physical exam, you palpate a soft, irregular, non-tender mass above the left testicle that feels like a "bag of worms", and it becomes more prominent with Valsalva maneuver. Scrotal ultrasound confirms a dilated pampiniform plexus.

Which of the following is the most appropriate next step in management?

A) Empiric trial of antibiotics

B) Immediate referral for varicocelectomy

C) Reassurance and conservative treatment

D) Testicular biopsy to assess spermatogenesis

What is the diagnosis?

B) Immediate referral for varicocelectomy

1.) Patient has varicocele

For Testicular torsion how long do you have to operate from the onset?

6 hours

Patient has painful testis that reside higher within the scrotum along with acute onset of severe pain and swelling, what is this?

Testicular torsion

A 15-year-old male presents to the emergency department with sudden onset of severe left testicular pain that began 2 hours ago while he was sleeping. He is visibly uncomfortable and reports associated nausea and vomiting. He denies any trauma or dysuria.

On exam:

The left testis is tender, swollen, and positioned higher in the scrotum compared to the right.

The cremasteric reflex is absent on the left side.

Prehn's sign is negative (lifting the testis does not relieve pain).

What is the most appropriate next step in management?

A) Scrotal ultrasound with Doppler followed by urologic consultation

B) Manual detorsion in outpatient setting with urology follow-up

C) Immediate urologic consultation for surgical exploration

D) Empiric antibiotics and outpatient follow-up in 24 hours

How do you diagnose testicular torsion?

While you wait for urology, what is something you can do in the meantime?

C) Immediate urologic consultation for surgical exploration

1.) Ultrasound

2.) Manual detorsion

What is bell-clapper deformity?

Its a congenital condition that significantly increases the risk of testicular torsion.

Which direction do most testicular torsions occur?

Turns in the medial direction

Blue dot sign

testicular torsion

What is testicular torsion?

Twisting of spermatic cord leading to ischemia

The cremasteric reflux is usually ___________ in testicular torsion but is not pathognomonic.

absent

True/False: Torsion is more prevalent in adolescence then infancy.

FALSE

A 14-year-old boy presents to the emergency department with sudden onset of severe left testicular pain that began 3 hours ago while playing video games. He reports associated nausea and vomiting but denies trauma, dysuria, or fever. He recalls a similar, less intense episode of pain a few weeks ago that resolved spontaneously.

On physical exam:

The left testis is elevated, tender, and has a horizontal lie

The cremasteric reflex is absent on the left

Prehn's sign is negative

The right testis appears normal

What is the most appropriate next step in management?

A) Begin empiric antibiotics for suspected epididymitis

B) Order scrotal ultrasound with Doppler and await results before proceeding

C) Immediate urology consultation for surgical exploration

D) Administer NSAIDs and observe for symptom resolution

C) Immediate urology consultation for surgical exploration

A 17-year-old male presents to the emergency department with 8 hours of worsening right testicular pain that began while he was sleeping. He also reports nausea and vomiting. Physical exam reveals an enlarged, firm, high-riding right testis with an absent cremasteric reflex. Scrotal Doppler ultrasound shows absent blood flow to the right testicle.

He is taken to the OR for surgical exploration. Intraoperatively, the right testicle appears dark, necrotic, and nonviable despite detorsion.

Which of the following is the most appropriate next step in surgical management?

A) Detorsion and bilateral orchiopexy

B) Right orchiectomy and left orchiectomy

C) Right orchiectomy and left orchiopexy

D) Right orchiectomy only

C) Right orchiectomy and left orchiopexy

This is testicular torsion. Unfortunately this testicle is necrotic therefore not salvageable. Therefore, it must be taken out. Orchiopexy should be performed on the opposite side to prevent torsion from occurring in opposite side to save future fertility.

A 13-year-old boy is brought to the emergency department with sudden onset of left testicular pain that began 2.5 hours ago while playing basketball. He also reports nausea, but denies fever, trauma, or urinary symptoms.

On physical exam:

The left testis is swollen, firm, high-riding, and horizontally oriented

There is no cremasteric reflex on the left side

The scrotum is diffusely tender without erythema

Scrotal ultrasound with Doppler shows reduced blood flow to the left testis. He is taken immediately to the OR for surgical exploration.

During surgery, the testicle is found to be viable.

What is the most appropriate surgical management?

A) Detorsion only

B) Detorsion with bilateral orchiectomy

C) Detorsion with ipsilateral orchiopexy only

D) Detorsion with bilateral orchiopexy

D) Detorsion with bilateral orchiopexy

This is testicular torsion with salvageable testicle.

What is cryptorchidism?

undescended testis

Babies with cryptoorchidism have a higher risk of developing __________ cancer

testicular germ cell

In cryptorchidism, unilaterally or bilaterally undescended testes are at risk for ___________ and infertility later in life.

spermatogenic failure

A baby has cryptorchidism what should occur if the right testis cannot be brought down to the scrotum?

Since the left testicle descended normally, the right one can be removed.

A 10-month-old boy is brought to the pediatrician for a routine well-child exam. His growth and development are appropriate for age. On physical examination, the right hemiscrotum is underdeveloped, and the right testis is not palpable in the scrotum or inguinal canal. The left testis is in normal position.

What is the most appropriate next step in management?

A) Observation and repeat exam at 18 months

B) Order serum FSH, LH, and testosterone

C) Immediate exploratory surgery with possible orchiopexy

D) Refer for surgical orchiopexy at or before 12 months of age

What is the diagnosis?

D) Refer for surgical orchiopexy at or before 12 months of age

1.) Cryptochidism

A 7-month-old male infant is brought to the pediatric clinic for follow-up after an abnormal newborn genital exam. The right testis is palpable in the inguinal canal, while the left testis is in the scrotum. There are no signs of hernia or other abnormalities. The infant is otherwise healthy and meeting developmental milestones.

What is the most appropriate next step in management?

A) Continue observation and re-examine at the 1-year visit

B) Refer to pediatric urology for orchiopexy

C) Begin hormonal therapy with hCG

D) Schedule exploratory surgery to locate the testis

B) Refer to pediatric urology for orchiopexy

What is a risk factor for penile cancer?

HPV 16 or 18

Most common type of penile cancer

Squamous cell carcinoma

How do you diagnose penile cancer?

Biopsy

What percent of testis tumors are derived from germ cells?

90-95%

How to treat seminomas

Sensitive to radiation therapy and responds well to platinum-based chemotherapy

A 25-year-old man presents with a painless mass in his right testicle that he noticed about 2 weeks ago. He denies trauma, fever, or urinary symptoms. He does report a sensation of fullness in his scrotum. He has no significant past medical history.

On exam, there is a firm, non-tender nodule in the right testicle. Scrotal ultrasound confirms a hypoechoic intratesticular mass. Serum tumor markers are ordered and reveal:

AFP: elevated

β-hCG: elevated

LDH: mildly elevated

What is the most likely diagnosis?

A) Seminoma

B) Teratoma

C) Embryonal carcinoma

D) Leydig cell tumor

C) Embryonal carcinoma

What type of cancer is cryptorchidism a risk factor for?

Testicular cancer

What is the most common solid tumor in men ages 15-40 years old?

Testicular cancer

Sensation of heaviness

Testicular cancer

Painless testicular mass

Testicular cancer

A 28-year-old man presents to the clinic with a complaint of a painless lump in his right testicle that he noticed 2 months ago. He describes a feeling of heaviness in his scrotum but denies trauma, urinary symptoms, or infection. He has not sought care earlier because he thought it might go away. Recently, he has developed a persistent dry cough and mild back pain.

On physical exam, there is a firm, non-tender mass in the right testis. There is no transillumination. No inguinal lymphadenopathy is noted. Scrotal ultrasound reveals a solid intratesticular mass, and tumor markers are pending.

Which of the following is the most appropriate next step in management?

A) Needle biopsy of the testicular mass

B) Scrotal orchiectomy and staging imaging

C) Trial of antibiotics and follow-up in 1 month

D) Fine needle aspiration (FNA) of retroperitoneal lymph nodes

B) Scrotal orchiectomy and staging imaging

Remember no biopsy for testicular cancer since it can risk tumor seeding

What are some testicular cancer tumor markers to look out for?

HCG

AFP

LDH

Which tumor marker is only elevated in non-seminoma testicular cancer?

AFP

Which tumor marker is elevated in both seminoma and nonseminoma?

HCG

What is infertility defined as?

Inability of couple to conceive a child after 1 year of sexual intercourse without contraceptive use.

Elevated FSH and LH with low testosterone levels

Primary hypogonadism

Low FSH and LG with low testosterone levels

•May be due to hypothalamic or pituitary origin

Secondary hypogonadism