clin med II GU #2 exam #6

cryptorchidism

a testis that is not within the scrotum and does not descend spontaneously into the scrotum by 4 mo old. can be absent or undescended

ascending testes

Noted to be in a scrotal position in early childhood and then to "ascend" and become undescended (move back into groin region)

cryptorchidism patho

- malpositioned along descent pathway

- genetic syndromes

- disorders of sexual development

- birth weight is principal determining factor

- prematurity

most common GU disorder of childhood

cryptorchidism

cryptorchidism physical findings

- asymptomatic, noted on screening exam

- testis impalpable or palpable in other location

- infertility and 2 to 8 fold increased in testicular cancer

cryptorchidism management

- immediate: ultrasound or MRI to exclude genital ambiguity

- medium term: observation, orchiopexy, hormonal treatment

- long term: manage infertility and testicular cancer risk

lab studies for unilateral or bilateral undescended testes with hypospadias or bilateral nonpalpable testes

- testing to rule out intersex condition

- 17 hydroxylase progesterone

- testosterone (decreased in bilateral)

- elevated LH and FSH

-

cryptorchidism treatment

- hormonal: hCG (2x wk for 5 wks), GnRH, both (controversial)

- orchiopexy before 19 yo

- term boys: 4 mo

- preterm: 6 mo

- should be by age 9 to 15 mos

hydrocele

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

noncommunicating hydrocele

no connection between the hydrocele and the peritoneum, the fluid comes from the mesothelial lining of the tunica vaginalis

hydrocele causes

- infants: incomplete closure of vaginalis from peritoneum, peritoneal fluid that hasn't been reabsorbed

- trauma, ischemia, infection

- testicular tumor

- increased intra abdominal pressure

hydrocele signs/symptoms

- typically not painful unless acute onset

- sensation of heaviness

- diffuse scrotal swelling

- not usually reducible unless hernia

- transilluminates

- bluish coloration

- preserved cremasteric

hydrocele diagnosis

- UA and culture

- ultrasound, color flow doppler

- urethral swab

- nuclear scanning

hydrocele acute treatment

- congenital noncommunicating: conservative for first 1 to 2 years of life, after = surgery

- communicating in infants: elective surgical repair with exploration on contralateral side

- benign: none unless discomfort or impairment of activities

- secondary: surgery during primary issue surgery

- needle aspiration for symptoms but returns

- sclerosis (older men), supportive devices

varicocele

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

varicocele patho

left renal vein pressure causes increased pressure in the left gonadal vein causing dilation and valve incompetence, resulting in dilation of the scrotal venous complex

varicocele signs/symptoms

- bag of worms appearance and or feel

- chronic, nontender mass that does not transilluminate

- worse when upright or with valsalva

- 80% affects left testicle

- most asymptomatic but can cause pain, dragging, or heavy feeling

- infertility, atrophy

varicocele diagnosis

- clinical

- testicular atrophy: semen analyses

- infertile: FSH level and semen

- doppler for venous incompetence

- scrotal US to confirm extent

- CT for right sided or do not compress in recumbent position

- spermatic venography, scrotal thermography, radionuclide scanning

varicocele acute treatment

- usually done if there is progressive atrophy, pain, investigated infertility, increase in size, or lack of decompression

- open surgical repair

- laparoscope, sclerotherapy, percutaneous embolization

testicular torsion causes

- tunica vaginalis overly large, inserts high on spermatic cord and can dangle within scrotum

- 10 times more likely in undescended

- inadequate fixation of the lower pole of the testis to the tunica vaginalis

- trauma or spontaneous

testicular torsion peak incidence times

first year of life and early puberty

testicular torsion signs/symptoms

- profound testicular swelling

- reactive hydrocele, redness, firmness of scrotum

- extreme pain in scrotum, inguinal, or lower abdomen

- nausea, vomiting

- high riding testes

- cremasteric reflex absent on affected side

testicular torsion diagnosis

doppler ultrasound imaging of choice

testicular torsion treatment

- immediate urology surgeon consult

- attempt to detorse while waiting for surgeon

- orchiectomy if nonviable testis

- orchiopexy for unaffected testis

- avoiding contact sports

appendix testis

small appendage of normal tissue that is usually located on the upper portion of testis. vestigial remnant of mullerian duct

appendix testis torsion signs/symptoms

- hard to differentiate

- ultrasound shows blood flow

- cremasteric reflex preserved

- blue dot sign: hard, tender, bluish nodule

phimosis

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

paraphimosis

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

common causes of phimosis

- present at birth

- recurrent infection or irritation of the foreskin tissue

- poor hygiene, diabetes, frequent diaper rash

common causes of paraphimosis

when the foreskin is not drawn back into place after being retracted

phimosis signs/symptoms

- may have pain on erection

- may produce urinary obstruction with ballooning of foreskin

- unretractable foreskin with superimposed balanitis

- typically resolves in children by 5 yo

paraphimosis signs/symptoms

- penile pain

- drainage, ulceration, swelling

phimosis treatment

- treatment not required in absence of complications

- betamethasone cream 0.05% BID to TID to tip of foreskin for 3 mo

- stretching foreskin gently over erect penis for 2 to 3 wk

- circumcision in procedure of choice

- dorsal slit procedure if need to catheterize emergently

paraphimosis treatment

- emergency

- reduction of foreskin under sedation

hypospadias

- urethral meatus opens on the ventral side of the penis

- results when fusion of the urethral folds is incomplete (estrogens and progestins given during pregnancy)

- evidence of feminization

hypospadias symptoms

- newborns and young children: none

- older children and adults: difficulty directing the urinary stream, stream spraying

- curvature of the penis due to chordee

- infertility

- abnormal hooded appearance of penis

- undescended testes

hypospadias diagnostic findings

- buccal smear and karyotyping to establish genetic sex

- urethroscopy and cystoscopy to see if sex organs are normally developed

- excretory urography for anomalies of kidneys and ureters

hypospadias treatment

- repair before patient reaches school age

- foreskin island flaps, buccal mucosal grafts

- removal of chordee

epispadias

urethra is displaced dorsally

epispadias symptoms

- urinary incontinence most common

- bladder exstrophy

- dorsal chordee

epispadias treatment

- chordee excision

- urethroplasty

- bladder augmentation when incontinence is not corrected

urethral prolapse

circumferential protrusion of the distal urethra through the external urethral meatus due to increased intra-abdominal pressure, loss of estrogen, and poor nutrition or hygiene

prepubertal urethral prolapse symptoms

- often asymptomatic

- vaginal bleeding, bloody spotting due to periurethral mass

- pain if large, thrombosed, or necrotic

- acute urinary retention

- pinkish orange, ulcerated, painful or tender congested mass at urethral meatus

postmenopausal urethral prolapse symptoms

- vaginal bleeding and voiding symptoms common

- hematuria

- pain if large, strangulation, thrombosed, or necrotic

- UTI

- red inflamed donut shaped mucosa protruding from urethral meatus

urethral prolapse diagnosis

- verifying that a central opening is present within the tissue

- children: observation during voiding or catheterization of central opening

- adults: urethral catheterization or cystourethroscopy

- uncertain: surgical excision and examination of tissue

- MRI

urethral prolapse treatment

- hygiene and local therapy w/ sitz baths

- topical hormones

- postmenopausal with mild: topical estrogen cream applied to site 2 to 3 x daily for 2 wks w/ sitz baths

- abx for infection

- surgical excision for failed therapy, strangulation, thrombosis, necrosis, or bleeding

urethral stricture patho

- inflammatory, ischemic, or traumatic processes lead to scar tissue formation

- anterior: scarring in spongy erectile tissue of corpus spongiosum

- posterior: fibrotic process that narrows the bladder neck

- congenital: inadequate fusion of the anterior and posterior urethra

urethral stricture causes

most common is traumatic, iatrogenic or self inflicted. less common is infectious, foreign bodies, malignancy, and congenital

urethral stricture symptoms

- decreased force of stream

- incomplete emptying of bladder

- urinary terminal dribbling

- urinary intermittency

- urinary retention

- urinary tract infections

- progressive in many patients

urethral stricture diagnosis

- cystourethroscopy

- retrograde urethrogram or antegrade cystourethrogram helps diagnose and define extent

- ultrasonography of male urethra used to evaluate stricture length and degree, depth of spongiofibrosis

urethral stricture treatment

- urethral dilation: stretch scar without producing more

- internal urethrotomy

- permanent urethral stents

- primary repair: completely remove urethral segment

- UTI should be treated and malignancy should be ruled out beforehand

prostate cancer patho

- 95% are adenocarcinomas developing in the acini of prostatic ducts

- 70% in peripheral zone, 20% in transition zone

- risk: genetic (BRCA I and II), black, high dietary fat, environmental, NOT smoking

prostate cancer signs/symptoms

- often none until advanced

- nonuniformly enlarged prostate of DRE, loss of median sulcus

- BPH can occur with this so prostate can be smooth

- urinary outflow obstruction most common

- lower urinary tract symptoms

- advanced: bone pain, enlarged hard prostate, neuropathic pain, hypercalcemia, weight loss, pelvic lymph node metastases, lymphedema, spinal cord compression

prostate cancer diagnosis

- digital rectal exam

- PSA: 4.1 to 10, 18 to 30% have cancer; >10, 50 yo 70% will have cancer; >20, metastatic disease

- elevated BUN/Cr, alkaline phosphate, hypercalcemia, DIC

- UA, C&S

- needle bx with transrectal US (gold standard)

- MRI guided needle bx

gleason staging

- primary grade applied to architectural pattern of malignant glands occupying largest area of specimen

- secondary pattern assigned to next largest area of cancer

- adding score of both gives gleason score

prostate cancer acute treatment

- radical prostatectomy, can cause urinary incontinence or ED

- radiation therapy

- active surveillance for older pts, those with health problems, very small and well differentiated cancers

- cryosurgery

- locally and regionally advanced: prostectomy vs radiation, neoadjuvant androgen deprivation, external beam radiation

- metastatic: prostectomy, androgen deprivation, estrogen

testicular cancer patho

- primary germ cell tumors 95%: seminomas and non seminomas (much more aggressive and occur earlier)

- unknown cause

- risk: cryptorchidism, testicular atrophy, estrogen increases

testicular cancer signs/symptoms

- painless intratesticular mass that does not transilluminate

- fullness, dull ache, pain, infertility

- 20% have metastatic symptoms: neck mass, spinal cord compression, leg swelling, regional lymph nodes, abd mass, N/V, weight loss

testicular cancer lab studies

- AFP: not elevated in seminomas

- BhCG: greater elevation in non seminomas than seminomas

- LDH: less specific marker for GCTs but can correlate with overall tumor burden

- elevated AFP and 13-hCG are diagnostic for nonseminomatous GCTs

testicular cancer imaging studies

- scrotal US initially

- CT scan of abd and pelvis w/ contrast for staging

- chest x ray for pulm metastasis

- need orchiectomy for definitive dx

testicular cancer treatment

- radical orchiectomy first

- seminoma is sensitive to radiotherapy

- bleomycin, etoposide, cisplatin most common chemotherapies used

penile cancer patho

- SCC and its variants 95%

- melonoma, kaposi, BCC, lymphoma

- risk: less developed areas of africa, asia, SA, phimosis, genital warts, HIV, penile tear, tobacco, uncircumcised

penile cancer symptoms

- skin abnormality or palpable lesion

- painless lump or ulcer (mostly nodular or wart like with secondary infection)

- rash, bleeding, balanitis

inguinal adenopathy

penile cancer diagnosis

biopsy

penile cancer treatment

- small, noninfiltrating: fluorouracil cream, external beam radiation, laser therapy

- larger but not deep: partial penile amputation at least 2 cm proximal to lesion

- deeply infiltrating and proximal: total penectomy with perineal urethrostomy

- prophylactic node dissection

bladder cancer patho

- >90% transitional cell carcinoma

- developing countries: schistosoma haematobium infection

- genes: ras family, p21 ras oncogene, p53, Rb on 13q, chromosome 9

- TCC: chemical exposure mostly to aromatic amines, occupational link, smoking

- adenocarcinoma: neurogenic bladder, metastases, urachal remnant

bladder cancer symptoms

- most present with painless gross hematuria

- anorexia, weight loss, bony pain, lower edema, flank pain in advanced

- irritative bladder symptoms

- abdominal mass

- anemia

bladder cancer diagnosis

- UA, culture

- CBC, BUN/Cr

- voided urinary cytology

- CT scan of abd and pelvis pre and post infusion

- MRI, IVP, renal US

- cystoscopy with bx is definitive

- BTA, NMP-22 urine marker

bladder cancer treatment

- TCC: resection, in multiple or recur bacile calmette guerin is choice. some may need cystectomy

- muscle invasive: radical cystectomy. if cant or do not want use tumor resection and chemo

- metastatic: combination chemo such as methotrexate, vinblastine, doxorubicin, and cisplatin

- SCC: radical cystectomy, preop radiotherapy

- adenocarcinoma: radical cystectomy, resistant to others