clin med gu exam 6

allybrown271

In females, the Mullerian ducts give rise to the...___________.

fallopian tubes, uterus, and upper vagina

Wolffian ducts in women_________

regress over time

In males, the genital tubercle becomes the....

glans penis, the genital swellings fuse to become the scrotum, and the genital folds elongate and fuse to for the shaft of the penis and the penile urethra.

What is cryptorchidism?

undescended testes

At what age is cryptorchidism concerning?

four months old

An absent testis may be due to...

agenesis or atrophy secondary to intrauterine vascular compromise

What is the name for bilaterally absent testes?

anorchia

What is the definition of undescended testes?

testes have stopped short along their normal path of descent into the scrotum. They may remain in the abdominal cavity or they may be palpable in the inguinal canal (intracanalicular) or just outside the external ring (suprascrotal)

Define retractile testes.

normal testes that have been pulled into a suprascrotal position by the cremasteric reflex. These testes can be brought into a dependent scrotal position and will remain there if the cremasteric reflex is overcome

What are ascending testes?

Ascending testes are noted to be in a scrotal position in early childhood and then to "ascend" and become undescended (i.e., acquired undescended testes)

What are ectopic testes?

testes descend normally through the external ring but then are diverted to an aberrant position

What are the four steps of testicular decent?

1) Testes appear on the urogenital ridge (2nd month).

2) Coelemic cavity evaginates into the scrotal swelling where it forms the processus vaginalis (mid 3rd month)

3)Testes begins descent into the scrotum guided by the gubernaculum (7th month).

4) Processus vaginalis obliterates spontaneously (shortly after birth).

What is the principal determining factor for undescended testes at birth to age one year, independent of the length of gestation?

birth weight

______ percent of premature male infants have cryptorchidism?

30%

What two things are patients with cryptorchidism at risk for?

infertility and 10-fold increased risk of testicular cancer

Approximately __________ % of undescended testes are palpable.

80%

Palpable testes may be ....

undescended, ectopic, or retractile

Nonpalpable testes may be....

intra-abdominal or absent

What are the three possible locations of undescended testes and which one is the most common?

-Abdomen

-Inguinal Canal (SC)

-Suprascrotal (prepubic) regions (MC)

What are the four possible locations for ectopic testes?

-Suprapubic (penile) region

-Femoral region

-Perineal region

-Contralateral hemiscrotum

What are some complications of undescended testes (but not retractile or absent testes)?

- inguinal hernia

- testicular torsion

- testicular trauma (for intracanalicular testis - from compression against the pubic bone)

- subfertility

- malignant transformation

For unilateral or bilateral undescended testes with hypospadias or bilateral nonpalpable testes, what tests should be ordered?

- Testing to rule out intersex condition (mandatory; genetic)

- 17-hydroxylase progesterone

- Testosterone (normal - unilateral; decreased-bilateral)

- Luteinizing hormone (LH) (elevated)

- Follicle-stimulating hormone (FSH) (elevated)

What treatment option of cryptorchidism decreases the risk of cancer when performed prior to age 19?

orchiopexy

How often do we give hCG in patients with cryptorchidism?

twice a week for 5 weeks

What does GnRH do and how is it administered?

stimulates the release of the pituitary gonadotropins, LH and FSH, resulting in a temporary increase of gonadal steroidogenesis

available as a nasal spray

When do we treat cryptorchidism in term boys?

NET 4 months

When do we treat cryptorchidism in preemies?

NET 6 months

When should cryptorchidism be corrected and why?

between 9-15 months (reduces risk of infertility)

What is a hydrocele?

a fluid accumulation between the parietal and visceral layers of the tunica vaginalis

What side is more likely to have a hydrocele?

right

What test can help us diagnose a hydrocele?

transillumination

What are the common causes of a hydrocele in infants?

-Incomplete closure of the processus vaginalis from the peritoneum

OR

-Residual peritoneal fluid that has yet to be reabsorbed after processus closure

T/F: Hydroceles are exclusively found in males.

false; newborn girls can have them in the canal of Nuck or meconium hydrocele of the labia

For adults with benign hydrocele, hydrocelectomy is not indicated unless....

there is significant discomfort or impairment of life-satisfaction issues

What is the most common cause of painless scrotal swelling?

hydrocele

What is a varicocele?

dilated, tortuous veins of the pampiniform plexus and the internal spermatic vein around the testicle

What is the most common cause of scrotal enlargement in young adults?

varicocele

Which side is more prone to developing a varicocele?

left

The________________ is one of the longest veins in the body, entering the left renal vein at a perpendicular angle.

left internal spermatic (gonadal) vein

What is a painless mass in the scrotum that feels like a bag of worms?

varicocele

If a patient has a unilateral right varicocele, what does it suggest?

inferior vena cava obstruction

In what age group are varicocele most common?

adolescence into adulthood

What can be used to feel small varicoceles on palpation?

ask patient to bare barn or use valsalva manuever

When are most varicoceles diagnosed?

fertility investigations (are associated with male infertility- need to get a semen analysis!!)

If the varicocele is of sudden onset, right-sided, and unilateral or unchanged in the supine position, what needs to be excluded? What test is used?

a retroperitoneal cause by ultrasound or CT

Following a varicocelectomy, patients should have semen analyses.......

every 3 months for the first year or until pregnancy is achieved

What test do we do to help diagnose a varicocele?

CT abdomen with contrast

A 24 year old male patient presents with unilateral severe testicular pain and swelling. On physical exam, testis is tender, slightly swollen and high-riding. What test needs to be performed and what result do you expect?

cremasteric reflex; will be absent on affected side

Testicular torsion is most common in ages....

13-17

A patient comes in with suspected testicular torsion. What is your FIRST step? And what is your SECOND step?

1) emergently contact surgery

2) try to detorse by gently rotating away from the midline (if relief of pain with detorsion indicates testicular torsion)

What is the imaging modality of choice in suspected testicular torsion?

doppler ultrasound

If a patient has testicular torsion, when should the condition be identified and corrected?

within 6 hours (testis suffer irreversible damage after 12 hours d/t ischemia)

What causes testicular torsion?

Results from inadequate fixation of the lower pole of the testis to the tunica vaginalis. Can occur after inciting event (trauma) or spontaneously.

What is the appendix testis?

a small appendage of normal tissue that is usually located on the upper portion of the testis

What is another name for the appendix testis and where is it found?

AKA hydatid of Morgagni;

a vestigial remnant of the Müllerian duct, present on the upper pole of the testis and attached to the tunica vaginalis. It is present about 90% of the time

What is the leading cause of acute scrotum in children?

torsion of the testicular appendix

How can we distinguish testicular torsion from testicular appendix torsion? (2 things)

cremasteric reflex will be preserved in testicular appendix torsion and :="blue dot sign" will likely be present

What is phimosis?

Tightness of penile foreskin that prevents it from being drawn back from over the glans

What is paraphimosis?

When the foreskin remains retracted proximal to the glans penis, causing constriction of glans penis

What is the leading cause of paraphimosis?

iatrogenic (provider or parent leaving the foreskin retracted)

T/F: phimosis is never normal and always needs to be treated.

false; normal in children and typically resolves around age 5 and does not always require treatment

2 multiple choice options

What is used to treat phimosis?

betamethasone cream 0.05% BID to TID applied to the foreskin and the area touching the glans for 3 months

What is the definitive procedure of choice in the treatment of phimosis in the nonemergency situation?

elective circumcision

What should be regarded as an emergency, because constriction leads quickly to vascular compromise and necrosis of the glans penis?

paraphimosis

What is the first-line treatment for paraphimosis?

reduction of the foreskin, usually while the patient is sedated

What is the dorsal slit procedure and when should it be performed?

the phimotic opening may need to be dilated, formally incised (performed in phimosis or paraphimosis - in ER setting)

You are discharging a new mother an her newborn son. This is her first child. What are some important patient education topics to discuss with the parents on caring for their son?

- no special care for penis besides washing

- frequent diaper changes

- avoid forcible retraction of foreskin

- Gentle retraction of the foreskin with diaper changes and bathing

- After bathing, the retracted foreskin should always be pulled down to its normal position covering the glans penis

Physiologic phimosis ism present in....

almost all newborn males

What is hypospadias and what causes it?

the urethral meatus opens on the ventral side of the penis proximal to the tip of the glans penis; Results when fusion of the urethral folds is incomplete

What is epispadias?

Urethra is displaced dorsally, and classification is based on its position in males

When does sexual differentiation and urethral development happen in utero?

8 weeks - 15 weeks

What is contraindicated in hypospadias because the preputial skin may be useful for future reconstruction?

circumcision

Why are buccal smears and karyotyping indicated in patients with hypospadias?

To help establish the genetic sex - Since children with penoscrotal and perineal hypospadias often have a bifid scrotum and ambiguous genitalia

Why might hypospadias concerning?

expression of feminization that could be a sign of larger problems/they may actually be a female internally

What tests need to be ran on patients with hypospadias to determine whether internal sex organs are appropriately developed?

urethroscopy, cystoscopy, and excretory urography

How do we treat hypospadias?

repair before the patient reaches school age ( usually before age 2)

What is penile type epispadias?

the urethral meatus, often broad and gaping, is located between the pubic symphysis and the coronal sulcus. Distal groove usually extends from the meatus through the splayed glans (incontinence in 75%)

What is penopubic type epispadias?

the urethral opening at the penopubic junction, and the entire penis has a distal dorsal groove extending through the glans (incontinence present in 95%)

What type of epispadias has the greatest risk of incontinence?

penopubic type (95%)

What is bladder exstrophy?

the bladder is formed on the outside of the body and is turned inside out (epispadias is a mild form of this)

What is chordee?

curvature/bending of the penis

What type of chordee is found in hypospadias?

ventral

3 multiple choice options

What type of chordee is found in epispadias?

dorsal

3 multiple choice options

What is urethral prolapse and what can it lead to?

Circumferential protrusion of the distal urethra through the external urethral meatus; can lead to strangulated urethral prolapse

What is the most common symptom of urethral prolapse?

vaginal bleeding

What would you suspect if you saw a doughnut-shaped protrusion mucosa obscuring urethral opening?

urethral prolapse

How do we manage a patient with urethral prolapse?

topical estrogens to conservative surgical excision if medical therapies fail

What are some possible risk factors for urethral prolapse?

-increased intra-abdominal pressure (children)

- poor nutrition and hygiene (older women)

- loss of estrogen at menopause

What is the fundamental anatomical defect seen in urethral propapse?

separation of the longitudinal and circular-oblique smooth muscle layers

What is a urethral caruncle?

A benign fleshy outgrowth of the posterior urethral meatus. It is the most common lesion of the female urethra and occurs primarily in postmenopausal women.

What is an ectopic ureterocele?

a ballooning at the end of the ureter inside the bladder. ... Outside the bladder, through the bladder neck and urethra

When should you refer a patient with a urethral prolapse?

always

3 multiple choice options

What are the most common causes of urethral strictures today?

traumatic or iatrogenic or self inflicted

What is a congenital stricture?

results from inadequate fusion of the anterior and posterior urethra, is short in length, and is not associated with an inflammatory process

What is the most clinical presentation of urethral strictures?

obstructive voiding symptoms, urinary retention, or UTIs

What imaging is used for urethral strictures?

retrograde urethrogram or anterograde cystourethrogram

When is surgery indicated for treatment of urethral strictures?

when the patient has severe voiding symptoms, bladder calculi, increased post void residual, or urinary tract infections or when conservative management fails

When is surgical treatment of urethral strictures contraindicated?

untreated UTI or malignancy

A patient comes in complaining of bone pain and unexplained weight loss. On DRE, prostatic induration is noted. What is the most likely diagnosis

prostate cancer

What is the most common nondermatological cancer?

prostate cancer