Nephrology: Genitourinary Part 1

What is Epispadias?

An embryonic malformation typically characterized by an exposed urethra on the dorsal penis.

What is Hypospadias?

A common congenital malformation in which the urethral meatus is incorrectly positioned (either along the penile shaft or on the scrotum or perineum).

Surgical repair of epi- and hypospadias should be done before which age? Circumcision should be withheld until which age?

Surgical repair before age 2. WIthhold circumcision until repair.

What is Cryptorchidism?

A failure of one or both testicles to descend to their natural position in the scrotum. It is the most common congenital anomaly of the genitourinary tract. Undescended testes can be palpable in the abdominal or inguinal region. Most undescended testicles will complete the descent within the first three to six months of life.

What are the risk factors for Cryptorchidism?

Prematurity, low birth weight, intrauterine exposure to pesticides and diethylstilbestrol.

What are the clinical features of Cryptorchidism?

Empty scrotum with or without an inguinal fullness

How is Cryptorchidism treated?

Orchiopexy before the age of 1

What are the complications of Cryptorchidism?

Inguinal hernia, testicular torsion, subfertility, testicular cancer

How are erections achieved?

Stimulation causes the smooth muscle cells of the arteries in the penis to relax. As a result, more blood flows into the sinusoids, and their volume increases. The penis becomes swollen and erect.

What are the etiologies of Erectile Dysfunction?

Neurogenic, Psychogenic, Vasculogenic, Endocrine, Drugs, Radiotherapy, Surgery, Chronic Renal Failure, Diabetes, Aging

How is ED due to hormonal imbalance treated?

Hormonal therapy, allow 2-3 months, if no improvement is noted, then add PDE5 inhibitors

How is ED due to psychogenic causes treated?

Sexuologic therapy, then PDE5 inhibitor, if no improvement is noted, switch to another PDE5 inhibitor or intraurethral injection of prostaglandins

How is ED due to organic causes treated?

PDE5 inhibitor, if no improvement is noted, switch to another PDE5 inhibitor or intraurethral injection of prostaglandins

How is ED with risk factors treated?

Cardiogenic evaluation and related therapy, if approved, add PDE5 inhibitor

What are the side effects of PDE5 inhibitors?

Headache, flushing, dyspepsia, nasal congestion, visual disturbances, priapism, sensorineural hearing loss

What are the drug interactions of PDE5 inhibitors?

Alpha blockers, nitrates, CYP3A4 inhibitors

What are the injectables that are indicated in treating ED?

Prostaglandin (Alprostadil) and Trimix (Prostaglandin, Phentolamine, Papaverine)

What are the alternatives to pharmacotherapy for ED?

Vacuum erection device, shockwave therapy, prosthesis

What is Peyronie's Disease?

An acquired fibrosis of the tunica albuginea that leads to abnormal curvature of the penis. Commonly causes pain, deformity, and erectile dysfunction.

What are the risk factors for Peyronie's Disease?

Early PDE5i use, partner on top position, androgen deficiency.

What is the prognosis for Peyronie's Disease?

60% stabilize and become painless, 30% progress and require surgical correction, 10% resolve spontaneously

What is Priapism?

Sustained painful penile erection without sexual stimulation

What is Ischemic Priapism?

Priapism in which there is low flow of blood in or out. Caused by sickle cell disease, lymphoproliferative disorders, ED drugs, and psychedelics. Causes a painful rigid penile shaft with a soft glans penis.

What is non-Ischemic Priapism?

Priapism in which there is high flow of blood in and out. Caused by spinal cord injury and penile trauma. Causes a less painful less rigid penile shaft.

How is Priapism diagnosed?

Clinical, do doppler to differentiate between ischemic and non-ischemic.

How is Priapism treated?

Cold compress, and if ischemic, aspiration, vasoconstriction injection, and surgical shunt

What is Balanitis?

Inflammation of the glans penis

What is Balanoposthitis?

Inflammation of the mucosal surface of the prepuce (foreskin)

What causes Balanitis and Balanoposthitis?

Poor hygiene and autoimmune disorders (Balanitis xerotica obliterans)

What are the clinical manifestations of Balanitis and Balanoposthitis?

Pain and preputial discharge

What are the treatments for Balanitis and Balanoposthitis?

Topical antifungals, antibacterials, and antiinflammatory drugs + hygiene

What are the complications for Balanitis and Balanoposthitis?

Preputial scarring

What is Phimosis?

A congenital or acquired constriction of the foreskin (prepuce) causing inability to retract it.

What is Paraphimosis?

Retracted foreskin in an uncircumcised male that cannot be returned to its original position

What is Urethritis?

Inflammation of the urethra.

What are the two types of Urethritis?

Gonococcal urethritis (<35yo) and Nongonococcal urethritis (>35yo)

What are the clinical features of Urethritis?

Dysuria, pruritus, discharge at the urethral meatus

How is Urethritis treated?

Ceftriaxone AND Azithromycin(or)Doxycycline

What is Urethral Stricture?

A complication of Urethritis that causes scarring in the urethra.

What is Urethral Syndrome?

A disorder in which patients have symptoms Urethritis without evidence of infection. Treated with Pyridium.

What is Epididymitis?

Inflammation of the epididymis

What are the causes of Epididymitis?

Infection (STI, UTI, prostatitis, mumps), enlarged prostate, catheterization, bike and motorcycle riding

What are the clinical manifestations of Epididymitis?

Tender pain and swelling, positive Prehn's sign, Hemospermia

How is Epididymitis diagnosed?

Urine PCR, ultrasonography

How is Epididymitis treated?

Ceftriaxone AND Doxycycline OR Levoflox OR Ofloxacin

What is Prehn's sign?

A physical examination finding in which elevation of the scrotum relieves testicular pain. A positive Prehn sign is associated with epididymitis; a negative Prehn sign is associated with testicular torsion.

What is Orchitis?

Inflammation of one or both testes.

What are the causes of Orchitis?

Infection (STI, UTI, prostatitis, mumps), urethral stricture, enlarged prostate, catheterization, bike and motorcycle riding

What are the clinical manifestations of Orchitis?

Tender pain and swelling, hemospermia

Orchitis without epididymitis should indicate which cause?

Mumps

How is Orchitis diagnosed?

Urine PCR, ultrasonography

How is Orchitis treated?

Ceftriaxone AND Doxycycline OR Levoflox OR Ofloxacin

What is Fournier's Gangrene?

Rapidly progressive necrotizing fasciitis of the scrotum and/or the perineum due to GA Streptococcus

What are the risk factors for Fournier's Gangrene?

Piercings, perineal abscess, hysterectomy, UTI, circumcision, herniorrhaphy

How is Fournier's Gangrene treated?

IV antibiotics and surgical debridement

What is Prostatitis?

Inflammation of the prostate

What are the causes of Prostatitis?

STI (MC under 35yo), UTI, prostate biopsy, instrumentation

What are the clinical manifestations of Prostatitis?

Pyrexia, prostatism, painful ejaculation, pelvic pain and heaviness

How is Prostatitis diagnosed?

Urine M/C/S and/or PCR, ultrasonography, CT/MRI

How is Prostatitis treated?

NSAIDs for pain, Alpha blockade for prostatism, if under 35 yo give Ceftriaxone and Azithro(or)Doxy, if over 35yo give FLuoroquinolones for 6-12wks

What is a complication of Prostatitis?

Prostate abscess