CAM II - Urology

erectile dysfunction

inability to achieve or maintain an erection; mainly affects men age 40-70; RFs: age, smoking, HTN, hyperlipidemia, DM, depression

psychogenic

ED caused by performance anxiety, anxiety, depression, stress, low self-esteem, and other psychologic disorders

neurogenic

ED caused by brain pathologies such as temporal lobe epilepsy, Parkinson's, spinal cord injuries, multiple sclerosis, spina bifida, herniated discs, and peripheral nerve dysfunction such as DM, scleroderma, SLE, pelvic trauma/surgery

endocrine

ED caused by hypogonadism or hyperprolactinemia

hypogonadism

serum testosterone <300 ng/dL

hyperprolactinemia

causes low circulating levels of testosterone due to the inhibition of GnRH secretion due to elevated prolactin levels

vasculogenic

ED associated with CVD, impaired relaxation of cavernosal tissue

antihypertensives, psychotropic drugs

common classes of drugs that can cause erectile dysfunction

testosterone replacement therapy

only indicated for patients with low serum testosterone level and clinically symptomatic; may cause acne, gynecomastia, erythrocytosis, dyslipidemia, temporary infertility

PDE-5 inhibitors

first line medical therapy for erectile dysfunction

nitrates

contraindication with PDE-5 inhibitors

alprostadil

intraurethral suppository that can be used to treat erectile dysfunction

intracavernosal injections

Trimis, Bimix; typically used to treat erectile dysfunction when oral medications have failed; side effects: local pain, hematoma, priapism

vacuum erection device

external negative pressure created by a vacuum pump pulling blood into the penis, can be used in combination with other therapies

penile prosthesis

surgical treatment for erectile dysfunction -- inflatable or semirigid

hypospadias

urethral meatus appears on the ventral surface of the glans, shaft, or at penosacral junction; occurs in 1/300 live births, can also be acquired from chronic pressure from foley catheter; associated findings: inguinal hernia, undescended testes

surgery

treatment for hypospadias and epispadias

epispadias

urethral meatus opens dorsally on the glans, shaft, or at penosacral junction; occurs in 1/100000 life births; associated findings: bladder exstrophy

priapism

prolonged erection lasting >4 hours, 50% idiopathic, can be complication of ED meds, alcohol/cocaine use; sickle cell is a RF

phenylephrine, surgery

treatments for priapism

phimosis

inability to retract foreskin over the glans penis secondary to narrowing, constriction, or adhesions; typically resolves spontaneously in first few years of life; complications: balanitis, posthitis, paraphimosis, voiding issues and increased risk of penile carcinoma; presentation: erythema, itching, discharge, pain with intercourse, urinary issues; treated with hygiene, steroid cream +/- antifungals

candida

MC infectious cause of phimosis

paraphimosis

retracted foreskin is trapped proximal to glans penis; presents with edema, inflammation, and pain; treated with firm compression to penis with manual reduction of foreskin

peyronie's disease

acquired penile deformity that presents as curvature, indentation, hourglass deformity, or shortening with erections; affects 5% of men; may be painful; possible genetic component; results from minor, buckling penile trauma followed by inflammation

colchicine, potassium aminobenzoate, intralesional injections, surgery

treatment options for peyronie's disease

penile fracture

rupture of tunica albuginea classically as a result of excessive torquing of erect penis; detumescence with subsequent development of a hematoma; 10% occur with urethral injury; blood at meatus suggests urethral injury

scrotal injury

typically a result of blunt mechanism; injury to testis, epididymis, and spermatic cord

hydrocele

collection of fluid between the layers of tunica vaginalis; fluid in scrotal sac transilluminates; presents with hemiscrotal swelling, usually non-tender; treat conservatively, with drainage & sclerosis, or hydrocelectomy

scrotal ultrasound

recommended diagnostic for hydrocele and varicocele

varicocele

engorgement of the internal spermatic veins above the testis; MC on the left side due to venous drainage patterns of spermatic veins; should diminish in size with patient in supine position; "bag of worms" on palpation, typically non-tender, more pronounced when bearing down

retroperitoneal malignancy

suspect with sudden onset of right varicocele

NSAIDs, scrotal support, ice

conservative treatment for varicocele

testicular torsion

twisting of spermatic cord leads to ischemia, typically in 10-20 year olds; presents with acute onset pain/swelling, N/V, painful testis resides higher in scrotum, "blue dot sign", absent cremasteric reflex

6 hours

timeframe for surgery in testicular torsion

ultrasound

diagnostic of choice for testicular torsion

manual detorsion, surgery

treatment for testicular torsion

bell-clapper deformity

the condition in which the patient lacks the normal posterior fixation of the testis and epididymis to the scrotal wall; RF for torsion

orchiopexy

surgical fixation of a testicle, treatment option in torsion and cryptorchidism

orchiectomy

surgical removal of a testis

cryptorchidism

undescended testis, higher risk of developing germ cell cancer, risk of spermatogenic failure and infertility

squamous cell

MC type of penile cancer

HPV 16, 18

high risk HPV strands -- risk of penile cancer

biopsy

diagnostic for penile cancer

seminoma

MC type of testicular tumor

non-seminoma

more aggressive form of testicular cancer -- embryonal carcinoma, teratoma, choriocarcinoma

testicular cancer

most are derived from germ cells; present with painless testicular mass, "sensation of heaviness", delayed presentation

hCG

elevated in both seminoma and non-seminoma

AFP

only elevated in non-seminoma

radical inguinal orchiectomy

surgical removal of the affected testes, spermatic cord, and regional lymph node; treatment for testicular cancer

male infertility

inability of a couple to conceive a child after 1 year of unprotected sexual intercourse; RFs: prior testicular injury, prior infection, certain meds, alcohol/tobacco/drug use, obesity, CV/liver/thyroid disease, DM, radical pelvic or retroperitoneal surgery

75 days

length of spermatogenesis

semen analysis

diagnostic for male infertility -- 2 samples on 2 separate occasions collected 2-5 days after ejaculatory abstinence and analyzed within an hour of collection

oligozoospermia

<15 million sperm/mL

azoospermia

complete absence of sperm

>1.5 mL

normal sperm volume

>39% motile

normal sperm motility

>3% normal

normal sperm morphology

elevated FSH & LH, low testosterone

lab abnormalities seen in primary hypogonadism

low FSH, LH, testosterone

lab abnormalities seen in secondary hypogonadism

cystitis

MC bacterial infection, more common in women, increased risk with age in men (due to BPH), typically caused by GN bacteria; RFs: foley catheter, sexual activity, estrogen deficiency, DM, instrumentation, pregnancy; presentation: dysuria, frequency, gross hematuria, urgency

nitrates, leukocytes

positive on urine dipstick in cystitis

Bactrim, Macrobid

antibiotics of choice for cystitis

epididymitis

inflammation of epididymis; RFs: unprotected intercourse, foley catheter, bladder outlet obstruction, recent cystoscopic procedures (especially TURP), hematogenous spread, amiodarone use; presentation: tender hemiscrotum, swollen epididymis, warm/erythematous scrotum, reactive hydrocele, heavy/dull ache radiating to ipsilateral flank, Prehn sign

prehn sign

elevation of scrotum improves pain from epididymitis, worsens pain in torsion

Bactrim or FQ

abx treatment for epididymitis and orchitis

fournier's gangrene

necrotizing fasciitis of the perineum and male genitalia, usually polymicrobial; presentation: pain, swelling, crepitus, ecchymosis

fluids, Imipenem/Meropenem, surgery

treatment for fournier's gangrene

orchitis

inflammation of a testicle; most commonly a complication from epididymitis, can be caused by mumps (4-7 days after parotid symptoms); presentation: swollen/tender testicle, erythematous scrotal skin, malaise, HA, myalgias, fever

urethritis

inflammation of the urethra, usually associated with sexual activity; symptoms: pain, urethral burning during urination, urethral discharge

ceftriaxone 250 mg IM plus 10 days doxycycline 100 mg PO QID

treatment for urethritis (assuming STI cause)

balanitis

inflammation of glans penis; MC due to inadequate hygiene in uncircumcised men; RFs: DM, trauma, obesity, edematous conditions; associated dermatologic conditions, Reiter syndrome, fixed drug eruption; presentation: pain, tenderness, pruritus, erythema, curd-like or purulent exudate, edema

hygiene, hydrocortisone cream, antifungal cream

treatments for balanitis

stress incontinence

leakage of urine upon coughing, sneezing, or standing

urge incontinence

urgency and inability to delay urination -- due to detrusor overactivity or decreased bladder compliance

overflow incontinence

common in older men due to bladder outlet obstruction, cystoceles in women, detrusor underactivity

delirium, infection, pharmaceuticals, psychological factors, excessive urinary output, restricted mobility, stool impaction

transient causes of bladder incontinence (DIAPPERS)

bladder training, lifestyle modifications, Kegel exercises, pelvic floor PT

urge incontinence treatment

lifestyle modifications, Kegel exercise, pelvic floor PT

treatment for stress incontinence

catheterization, treat obstruction

treatment for overflow incontinence

topical estrogen, anticholinergics, beta-3 adrenergic agonists

pharm treatment options for incontinence

overactive bladder

urinary urgency with/without incontinence, nocturia, urinary frequency

bladder training, pelvic floor strengthening

first line treatment for overactive bladder

anticholinergics, beta-3 adrenergic agonists

2nd line treatments for overactive bladder

vesicoureteral reflux

backflow of urine from the bladder into the ureters; occurs in 1/1000 people; genetic component; suspect in children with recurrent UTIs; can develop after kidney transplant in adults; diagnosed in adolescence when patients present with HTN & substantial proteinuria

voiding cystourethrogram

imaging procedure of the bladder and urethra produced during urination; diagnostic tool of choice for vesicoureteral reflux

monitor, abx prophylaxis, surgery

treatment for vesicoureteral reflux

interstitial cystitis

inflammation within the wall of the urinary bladder; chronic bladder pain in the absence of other explanatory etiologies; MC in women in 4th decade of life or later; presentation: increased discomfort with bladder filling, relief with emptying, pain/pressure/discomfort/spasms, aggravated by certain foods/drinks/stress/activities, urinary symptoms such as frequency, urgency, nocturia

pentosan polysulfate sodium (Elmiron)

only FDA approved oral medication for treatment of interstitial cystitis/bladder pain syndrome

iatrogenic

MC cause of ureteral injury

pelvic fracture

MC cause of bladder injury

surgery

treatment for intraperitoneal bladder injury

large bore Foley catheter drainage

treatment for extraperitoneal bladder injury

bladder cancer

2nd MC urologic malignancy; presentation: hematuria, irritative voiding symptoms (frequency, urgency, dysuria)

smoking

major risk factor for bladder cancer

UA, urovysion test, urine cytology

lab studies used in diagnosing bladder cancer

CT urogram

preferred initial imaging for bladder cancer

cystoscopy with biopsy/TURBT

only definitive diagnostic for bladder cancer

urothelial carcinoma

MC bladder cancer

T2

bladder cancer stage that has invaded detrusor muscle

carcinoma in situ

bladder cancer grade with highest risk of progression