Clin Med III (Urology) - FINAL

Delayed Puberty:

No clinical signs of puberty by age ____ in boys - first signs of puberty in males are testicular __________ and ________ of the scrotal skin

14, enlargement, thinning

In 95% of delayed puberty cases, this is a physiologic delay, aka __________ delay

constitutional

adolescents with high FSH and LH levels require a ________ to rule out genetic causes (________syndrome) and those with low levels need _________ imaging to rule out __________ or other CNS tumor

karyotype, klinefelter, cranial, pituitary

Defined as sexual maturation before age 9 in boys

precocious puberty

Precocious Puberty:

•Causes can be central/GnRH _________ or peripheral/GnRH ___________

May be classified as…

•__________: early onset and progression of all male pubertal features

•__________: early partial development of male secondary sex characteristics

•__________: boy developing some secondary sex characteristics of females (feminization associated with estrogen-producing tumors, exogenous estrogens or increased peripheral conversion of androgens to estrogens)

dependent, independent, complete, partial, mixed

causes premature closure of the epiphysis of long bones, which results in shorter stature

precocious puberty

•Fibrotic narrowing of urethra caused by scarring

•Scars may be congenital but more commonly due to trauma, urologic instrumentation, or untreated infections

urethral strictures

Clinical manifestations are caused by bladder outlet obstruction, ranging from diminished force and caliber of stream to acute urinary retention

urethral strictures

Inability to retract foreskin back over the glans (distal to proximal)

phimosis

Phimosis is normal in infancy due to congenital __________ - these separate naturally with penile erections during first _____ years and are not an indication for circumcision

adhesions, 3

Inability to replace or cover the glans with the foreskin (proximal to distal); can constrict the penis, causing edema of the glans

paraphymosis

•Slow development of fibrous thickening of fascia in erectile tissue of the corpus cavernosa

•Usually affects middle-aged men and is associated with painful erections and painful intercourse for both partners; there is no pain when the penis is flaccid

peyronie disease

•Exact cause is unknown but a local vasculitis-like reaction occurs; decreased oxygenation results in fibrosis and calcification

•Has been associated with Dupuytren contracture, diabetes, tendency to develop keloids and, in rare cases, use of beta-blockers

peyronie disease

MCC priapism

ED injection

Considered an urologic emergency as treatment within hours is effective and prevents impotence

priapism

Inflammation of the glans penis; usually occurs in conjunction with prepuce (foreskin) inflammation

balanitis

•Associated with poor hygiene and phimosis; but, also with certain skin disorders like lichen planus, eczema, psoriasis, and candidiasis infection

•Seen most commonly in males with poorly controlled DM and candidiasis

balanitis

__________ can prevent recurrences of balanitis and can be considered after inflammation has subsided

circumcision

penile cancer:

•Major risk factors include ______ infection (mainly serotypes 16 and 18), _______, and psoriasis treated with combination involving the drug psoralen and ______ light

•Males __________ at birth have less than half the chance of getting penile cancer compared to those who are not

HPV, smoking, UV, circumcised

MC penile cancer

SCC

An abnormal dilation of the vein within the spermatic cord; may be painful and tender; often described as a bag of worms

varicocele

•Caused by inadequate or congenitally absent valves in the spermatic veins

•Results in decreased blood flow through the testis, potentially interfering with spermatogenesis and causing infertility

varicocele

MC side of varicocele

left

varicocele dx

doppler us

Collection of clear, yellow fluid within the tunica vaginalis; ranging in size from slightly larger than the testis to the size of a grapefruit; may be flaccid or tense

hydrocele

Most common cause of scrotal swelling - occurs in 6% of male newborns and often resolves spontaneously in the first year of life

hydrocele

Painless extra-testicular mass that easily transilluminates

hydrocele

AKA epidermal cysts

spermatocele

Benign cystic collections of milky fluid containing sperm; located between the head of the epididymis and the testis

spermatocele

Condition of testicular maldescent; arrested descent with unilateral arrest occurring more often than bilateral

cryptorchidism

Adult male with testicular ectopy or bilateral cryptorchidism may be _______ and will be at increased risk for _________ cancer (risk 35- 50 times greater)

infertile, testicular

cryptorchidism tx

orchiopexy

•Testis has strayed from normal pathway of descent

•Caused by abnormal connection at the distal end of the gubernaculum testis that leads the gonad to the abnormal position - usually at the superficial inguinal site

testicular ectopy

•Acute inflammation of the testis

•Uncommon except as complication of a systemic disease or an extension of epididymitis

orchitis

Orchitis is occasionally seen in middle age males; a non-infectious inflammatory process occurs (__________ orchitis) that seems to be an autoimmune disease

granulomatous

Testicular cancer:

•90% are ______ cell tumors arising from male gametes – classified as either______________ (the most common and least aggressive, 35% of testicular cancers), _______________ (60% of testicular cancers and include embryonal, teratomas and choriocarcinomas) or mixed

•10% are _________ cell tumors involving either Leydig cells, Sertoli cells, granulosa cell and theca cell tumors (<10%)

germ, seminoas, nonseminoas, non germ

•Painless testicular enlargement is usually first sign - may be accompanied by sense of heaviness or dull ache in lower abdomen

•Risk factors include history or cryptorchidism, HIV and AIDS, Klinefelter syndrome, family history

testicular cancer

•Inflammation of the epididymis

•Common in sexually active young men with the cause being a sexually transmitted microorganism

epididymitis

_____________ epididymitis can also result from reflux of sterile urine from the bladder into the vas deferens and epididymis (caused by lifting or straining)

chemical

systemic signs and positive urine culture; ascending infection of the urinary tract

acute bacterial prostatitis

no pathogenic bacteria localized to the prostate; subtypes are inflammatory with increased WBC and non-inflammatory with no WBCs

chronic pelvic pain syndrome

bacteria or WBCs localized to prostate but no symptoms

asymptomatic prostatitis

80 -90% of prostatic testosterone is converted to the more active ______ by the enzyme _____________; once synthesized, DHT acts in a ________ fashion on androgen-dependent epithelial cells and promotes growth

DHT, 5A reductase, paracrine

Prostatic levels of DHT remain ________ with aging even though peripheral levels of testosterone __________ - the decrease in plasma androgen levels are further amplified by an age-related increase in plasma ________ level, resulting in relatively greater decreases in free testosterone than in total testosterone levels

high, decrease, SHBG

Nonmalignant growth of the prostate stroma and epithelial glands (alone or in combination) causes the enlargement; the prostate grows slowly over decades and can eventually reach up to 10 times the normal adult prostate size in severe cases

BPH

Development of obstructive symptoms in BPH are related to the presence of a__________ around the prostate

capsule

Most common non-skin cancer in males in the US but the incidence varies greatly worldwide; lifetime risk in US estimated at 15.9%

prostate cancer

95% of prostate neoplasms are __________ and most occur in the ___________ of the prostate

adenocarcinoma, periphery

predominant androgen in prostate

DHT

epidemiological studies suggest total fat intake, animal and saturated fat, red meat and dairy products are associated with increased risk

prostate cancer

Prostate Cancer develops in androgen-__________ epithelium and is usually androgen ____________

dependent, sensitive

Testosterone is synthesized in the testes but also in the prostate gland itself, in a process called __________________ where _______ produced by the adrenal glands is converted to ___________ and then into DHT in the prostate

intraprostatic, DHEA, testosterone

_________ is normally expressed in normal and benign stroma and is involved in the conversion of androgen (such as testosterone) to estrogen (such as potent estradiol-17β)

aromatase

With prostate cancer, aromatase is expressed in tumor cells and in stromal cells leading to increased levels of __________ and abnormal receptor signaling that promotes a ___________ feedback cycle (with more and more inflammation)

estrogen, positive

Multi-factorial hypothesis of prostate carcinogenesis:

•___________ act as strong tumor promoters

•Alterations in autocrine/paracrine growth-stimulating and growth-inhibiting factors between tumor cells and the _____________ influence cancer pathogenesis

•Possibly unknown environmental-lifestyle _____________ may contribute to prostate cancer

•*All of these factors may be modulated by ________ and ________ determinants

androgens, microenvironment, carcinogens, diet, genetic

________ disorders prevent erection

vascular

Endocrine disorders that reduce ___________ production affect sexual function and ________ - inadequate gonadotropins, feminizing tumors, estrogen therapy, testicular atrophy

testosterone, libido

__________ disorders can interfere with neural mechanisms required for erection, emission and ejaculation

neurologic

Spermatogenesis requires adequate secretions of FSH and LH from the ________, sufficient secretion of testosterone by the ________ cells, sufficient function of the ________ cells and adequate spermatogonia

pituitary, leydig, sertoli

Impaired _______________ also caused by genetic disorders ( i.e. Klinefelter syndrome), myotonic dystrophy, testicular trauma, systemic illness, exposure to gonadotoxins (chemotherapy, radiation), varicocele, cryptorchidism

spermatogenesis

Sperm count under _____ million per milliliter of semen has been suggested as the minimum for fertility (average fertile man has _______ million sperm per milliliter

20, 50-100

gynecomastia usually involves imbalance of ________________ ratio

estrogen testosterone

All unilateral breast enlargement warrants an evaluation for __________

malignancy

Crusting and nipple discharge are common clinical manifestations

male breast cancer

MC male breast cancer

infiltrating ductal

acute cystitis pathogen

e coli

acute cystitis is an ascending infection from the ______________

urethral meatus

S/Sx:

•Classic symptoms- dysuria, frequency, urgency

•Suprapubic tenderness

acute cystitis

UA:

•Nitrites

•Leukocyte esterase (pyuria)

•+RBC +WBC on microscopy

•+ bacteria on microscopy

acute cystitis

WBC casts on microscopy indicates _____________

pyelonephritis

most specific finding of acute cystitis

leukocyte esterase (pyuria)

Obtain in.....

•suspected pyelonephritis

OR

•if the patient has recurrent symptoms within 2-4 weeks of completing treatment

OR

•the patient does not clear symptoms with treatment.

OR

•Complicated PMH, elderly patients, multiple abx allergies, pregnancy

urine culture

_________ UTI:

•Immunocompetent

•No Comorbidities

•No known urologic abnormalities

•Non-pregnant

•Premenopausal

uncomplicated

_________ UTI:

•History of childhood urinary tract infections

•Immunocompromised

•Preadolescent or postmenopausal

•Pregnant

•Underlying metabolic disorder (e.g. Diabetes mellitus)

•Urologic abnormalities (stones, stents, indwelling catheters, neurogenic bladder, polycystic kidney disease)

•Male

complicated

uncomplicated UTI tx

bactrim, fosfomycin, nitrofurantoin

uncomplicated uti tx failure:

•Most likely due not ___________ the urine during treatment

•Obtain Urine ________

•Assume infecting organism is _________ to original antibiotic used and consider _____-day regimen using different antibiotic

sterilizing, culture, resistant, 7

complicated cystitis:

•Obtain ________ at first visit

•Treat ________ days

•Consider follow-up culture within _____ days of completing treatment

culture, 7-14, 14

complicated UTI tx

cipro, levo

consider _______ to r/o prostatitis in men w cystitis

DRE

Three groups of patients with asymptomatic bacteriuria have been shown to benefit from treatment

pregnant, renal transplant, urology procedures

tx of UTI w foley

quinolones

tx of canndiduria

fluconazole

•Frequently occurs in patients with indwelling Foley

•Treat only if symptomatic

candiduria

Indwelling Foley catheter:

•Risk of bacteriuria is about ____% per day

•Represents high proportion of nosocomial infections

•Only treat patient when ____________ (fever, dysuria)

•_______ catheter before treatment

5, symptomatic, change

recurrent cystitis:

____ UTIs in _______mo OR _____ in 1yr

1, 6, 3

UTI prevention

water intake (2-3L), topical estrogen

Suspect if:

•Cystitis-like illness and accompanying flank pain

•Severe illness with fever, chills, nausea, vomiting, abdominal pain

pyelonephritis

Pyelonephritis diagnosis is _________, confirmed with:

•Dipstick urinalysis w ___________

•Microscopic urinalysis showing _____________ (not universally recommended as necessary for diagnosis)

clinical, Leukocyte esterase (pyuria), WBC casts

pyelonephritis tx

cipro

IV meds for pyelonephritis

ceph, aztreonam, quinolone, aminoglycosides

Suspect in patient with severe flank pain or the presence of hematuria

nephrolithiasis

Patients with persistent symptoms after 3 days of appropriate antimicrobial treatment of pyelonephritis should be evaluated by CT for:

•__________ abscess

•____________ with UTI

perinephric/renal, nephrolithiasis

perinephric/renal abscess dx

us, CT w contrast

perinephric/renal abscess tx

drainage

gold standard pyelonephritis dx

CT w/o con

alternatives to CT for dx of pyelonephritis

us, iv pyelogram

_________ should be considered if there is no response to a 72 hr course of antibiotic therapy in a patient with pyelonephritis

imaging

•Necrotizing fasciitis of the perineum

•Usually begins as a benign infection that results in micro thrombosis of the small subcutaneous vessels, leading to the development of gangrene of the overlying skin

•Typically immunocompromised patients like DMII

fournier's gangrene

•"Tight" foreskin that cannot be retracted to expose the glans penis

•Can be congenital

•If older child or adult, can arise from inflammatory response to infectious causes

phimosis

Retracted foreskin that cannot be returned to its normal position

paraphimosis