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Urology Lecture Review: Reproductive and Male Genitourinary Conditions

Hypospadias and Epispadias

  • Context: congenital malformations of the urethral opening.
  • Hypospadias vs epispadias (epaspadias in transcript):
    • Hypospadias: urethral meatus on the ventral (underside) of the penis.
    • Epispadias: urethral meatus on the dorsal (top) of the penis; the transcript shows a mild hypospadias on the left and a significant epispadias on the right.
  • Pregnancy/IVF note in transcript: complications can include difficulty directing urinary stream; severe cases may be associated with infertility and incontinence.
  • Management:
    • Many cases require surgical correction, especially if function or aesthetics are affected.
    • Mild cases may be observed or corrected based on function and family preference.

Peyronie’s Disease

  • Definition: painful bend/deformity of an erect penis; not painful in flaccid state.
  • Epidemiology: occurs in middle-aged and older men; time for fibrous plaque to thicken in tunica albuginea.
  • Associations: Dupuytren’s contracture; trauma.
  • Functional impact: can prevent normal sexual function if deformation is severe.
  • Disease course: progressive if untreated.
  • Treatments mentioned:
    • Oral phosphodiesterase inhibitors (PDE5 inhibitors) – described as preventing deposition of collagen in the plaque (note: mechanism in practice varies; included as per transcript).
    • Intracavernosal or penile injections into the penis.

Erectile Dysfunction (ED)

  • Prevalence: >50% of men over age 40 are affected.
  • Definition: persistent inability to achieve/maintain an erection rigid enough for sexual activity.
  • Differential causes to consider:
    • Diabetes, cardiovascular disease, neurologic disorders, pelvic surgery, prostate cancer treatment
    • Thyroid/adrenal/pituitary disorders, history of radiation therapy, groin trauma
    • Drugs/medications
  • Nocturnal erections:
    • Presence during sleep suggests a psychogenic rather than organic cause.
    • Nocturnal penile tumescence test monitors nighttime erections to differentiate organic vs psychogenic etiologies.
  • Physical exam: vitals, secondary sexual characteristics, thorough general exam.
  • Labs: guided by suspected underlying cause (diabetes screening; testosterone/androgen deficiency; if pituitary-brain axis concern, check prolactin and LH).
  • Vascular workup: vascular ultrasound and/or angiography if a vascular cause suspected.
  • Treatments:
    • Lifestyle modification for medical causes.
    • PDE5 inhibitors: sildenafil (Viagra), vardenafil (Levitra), tadalafil (Cialis).
    • Adverse effects: headache, dyspepsia, flushing, hypotension, visual disturbances, priapism.
    • Contraindications: nitrates due to dangerous BP drop.
    • Cautions: recent stroke, MI, arrhythmias, cardiovascular disease, aortic stenosis, sickle cell disease.
    • Specialty management: behavioral therapy; endocrine replacement when indicated (check PSA before testosterone replacement).
    • Mechanical/medical options: vacuum erection devices; intra-penile injections; intra-urethral alprostadil (urethral suppositories).
    • Surgical: vascular reconstruction or penile implant (for refractory cases).

Phimosis, Paraphimosis, and Circumcision

  • Phimosis: difficulty retracting foreskin (not total inability).
  • Paraphimosis: emergency condition where foreskin is trapped behind the glans in retraced state; can cause tourniquet effect, pain, swelling, arterial occlusion, necrosis.
    • Management: manual reduction if possible; provide adequate block and sedation; dorsal slit while awaiting circumcision.
  • Circumcision: often indicated after infection resolves.
  • Balanitis and balanitis xerotica obliterans (circumcision implications):
    • Balanitis (balanitis) can be bacterial or candidal; consider STI work-up and squamous cell carcinoma risk.
    • Candidal infection treated with antifungal cream; bacterial infection treated with topical antibiotics (e.g., mupirocin) for hygiene-related balanitis; STI-related balanitis treated with systemic antibiotics.

Urethral Conditions and Prolapse

  • Urethral prolapse: mucosa inverted around the meatus; common in premenopausal women.
    • Treatment: topical estrogen cream daily for 2 weeks, then twice weekly for 2–3 months.
  • Urethral structures/strictures: caused by trauma or instrumentation.
    • Symptoms: obstructive voiding, recurrent UTIs, urethral spray, ejaculatory dysfunction.
    • Diagnosis: voiding cystourethrogram (VCUG).
    • Management: if
  • Bladder prolapse (cystocele): pelvic floor weakness leading to bladder protrusion into vagina.
    • Symptoms: vaginal pressure/pain, dyspareunia, frequency/UTIs/incontinence.
    • Treatment: physical therapy vs surgical correction depending on severity.

Vesicoureteral Reflux (VUR)

  • Definition: urine reflux from bladder toward ureter/kidney with variable severity.
  • Diagnostics: VCUG is the key diagnostic test; other imaging includes ultrasound, cystourethrograms, contrast-enhanced voiding ultrasound, radionucleotide cystograms.
  • Management by severity:
    • Severe reflux: daily prophylactic antibiotics to prevent pyelonephritis.
    • Reflux may require surgical correction in severe cases.

Interstitial Cystitis and UTI Spectrum

  • Interstitial cystitis (IC): chronic, diagnosis of exclusion; more common in females.
    • Symptoms: bladder pressure/pain; frequent urge to urinate without UTI.
    • Treatment: bladder training, physical therapy; amitriptyline; pentosan polysulfate (Elmiron) to help restore bladder epithelium.
  • Acute cystitis: ascending bladder infection; common organism: E. coli.
    • Symptoms: dysuria, urgency, frequency; patients usually not systemically ill.
    • UA findings: leukocytes; may have hematuria and nitrates depending on organism.
    • Important: urine culture for recurrent infections, pregnancy, boys, men, diabetes, or immunocompromised patients.
    • Prevention/treatment:
    • Increase fluids; avoid bladder irritants; phenazopyridine (Pyridium) for symptomatic relief.
    • Antibiotics: nitrofurantoin, TMP-SMX, ciprofloxacin (reserve for pyelonephritis), cephalexin (Keflex) – culture-guided therapy when possible.
    • Prophylaxis for >3 UTIs/year (e.g., Bactrim or nitrofurantoin around the time of sex).

Benign Prostatic Hyperplasia (BPH) and Prostate Cancer Care

  • Benign prostatic hyperplasia (BPH): common in aging males; increased stromal and glandular components cause nodularity.
  • Symptoms (with hyperplasia plus hypertrophy): increased urinary frequency, nocturia, hesitancy, urgency, weak stream.
  • Diagnosis: not solely size-based; symptom scores used:
    • AUA Symptom Index (American Urological Association)
    • IPSS (International Prostate Symptom Score)
  • Physical exam: DRE; urinalysis to exclude other conditions; PSA not routinely required for all.
  • Imaging/biopsy: not routinely indicated in mild cases; used selectively.
  • PSA considerations: normal PSA commonly cited as < 4 (board reference); factors that influence PSA include prostatitis, BPH, recent ejaculation, 5α-reductase inhibitors, recent procedures.
  • Management by symptom severity:
    • Mild symptoms: lifestyle modifications.
    • Moderate symptoms: uroselective alpha-adrenergic blockers (e.g., tamsulosin) – adverse effects include dizziness, hypotension, retrograde ejaculation; caution in patients with hypertension or cataracts/glaucoma surgery.
    • PDE5 inhibitors (e.g., tadalafil) approved for BPH symptoms but do not reliably improve flow; not superior to alpha blockers and not typically combined to show added benefit with alpha blockers or 5-ARIs.
    • 5-ARIs (dutasteride, finasteride): reduce conversion of testosterone to dihydrotestosterone (DHT); slow progression; do not primarily treat symptoms; can be combined with alpha blockers.
    • Combination therapy: alpha blocker + 5-ARI recommended in certain patients.
  • Surgical indications: refractory urinary retention, recurrent UTIs, large bladder diverticula, bladder stones, recurrent gross hematuria, renal insufficiency.
  • Acute bacterial prostatitis: infectious/inflammatory prostate; systemic signs; avoid DRE initially; fever, leukocytosis; UA with pyuria, bacteriuria, hematuria; culture; treat with antibiotics (outpatient: ciprofloxacin, levofloxacin, or TMP-SMX; inpatient if ill): IV antibiotics if needed; treat STIs accordingly.
  • Chronic bacterial prostatitis: often in younger/middle-aged men; back pain/perineal pain; variable prostate exam; organisms often gram-negative rods (E. coli, Pseudomonas, Proteus, Klebsiella);
    • Diagnosis: urine culture; no prosthetic massage; empiric antibiotics for >3 months if chronic; fluoroquinolones 4–12 weeks; alternatives include Bactrim, doxycycline, azithro, or clarithro if fluoroquinolones unsuitable.

Urethritis, Epididymo- and Orchitis

  • Urethritis: urethral inflammation with dysuria and urethral discharge; sometimes discharge absent in chlamydia.
  • Reiter’s syndrome: reactive arthritis with urethritis; treat STIs (gonorrhea and chlamydia).
  • Epididymitis: common cause of adult scrotal pain; tender epididymis; more common in younger patients due to STIs; older patients often non-STI causes (e.g., E. coli).
    • Examination: begin at the inferior aspect of the testis and move upward; epididymis tenderness at the tail; cremasteric reflex intact; Prehn’s sign positive (relief with scrotal elevation).
    • Management: treat underlying STI when present; non-STI organisms managed with levofloxacin or TMP-SMX (though local antibiotic resistance patterns apply).
  • Orchitis: inflammation of the testis; can be bacterial or viral (mumps); cremasteric reflex may be absent when severe; testicular torsion and orchitis share potential lack of cremasteric reflex in advanced disease.
    • Evaluation: U/A and culture; scrotal ultrasound; empiric treatment with levofloxacin + TMP-SMX pending culture; NSAIDs and scrotal elevation; ice; avoid prosthetic manipulation.

Testicular Torsion and Acute Scrotal Conditions

  • Testicular torsion: twisting of the testis and spermatic cord causing ischemia; medical emergency.
  • Epidemiology: more common in neonates and post-pubertal boys; can occur spontaneously or after strenuous activity.
  • Presentation: acute scrotal/testicular pain with swelling; nausea/vomiting possible; abnormal lie of testicle.
  • Key signs:
    • Horizontal testicle position; bell clapper deformity; reduced/absent cremasteric reflex; acute onset.
  • Management: emergent Doppler ultrasound to assess blood flow; analgesia/sedation for detorsion attempts; urgent surgical detorsion and fixation (orchidopexy).

Urinary Incontinence: Transient, Urge, Stress, and Overflow

  • Transient incontinence: often due to reversible/acute factors
    • Delirium, infection, atrophic urethritis/vaginitis, diuretics, psychological factors, excessive fluid intake, diabetes insipidus, heart failure, hyperglycemia, cirrhosis, restricted mobility, stool impaction.
    • Approach: history, exam; diagnostic studies tailored to suspected cause (labs, post-void residuals, ultrasound, imaging as needed).
  • Urge incontinence (overactive bladder): uninhibited bladder contractions causing leakage
    • Common in elderly; may be inflammatory or neurogenic.
    • Management: behavioral therapies, bladder irritant avoidance, bladder training, fluid management, pelvic floor physical therapy (Kegels, biofeedback).
    • Medications: muscarinic antagonists (anticholinergics) like oxybutynin.
  • Stress incontinence: urethral incompetence; common in women due to pelvic floor laxity after pregnancy; in men after radical prostatectomy
    • Leakage with activities increasing intraabdominal pressure (coughing, sneezing, lifting, exercising).
    • Management: pelvic floor physical therapy; antispasmodics; surgical correction with urethral sling if conservative measures fail.
  • Urethral obstruction incontinence spectrum: dribbling after voiding, overactivity, overflow incontinence due to urinary retention
    • Common causes: BPH, urethral structures, prostate cancer.
    • Management: alpha blockers ± 5-ARI; consider urethral dilatation/structures; urinary catheterization if needed.
  • Overflow incontinence: detrusor underactivity with chronic urinary retention; bladder overflows with small leaks
    • Management: teach double-voiding, suprapubic pressure techniques; intermittent or indwelling catheters.

Urethral Prolapse and Bladder Prolapse (Cystocele)

  • Urethral prolapse: urethral mucosa protruding around the meatus; common in premenopausal women.
    • Treatment: topical estrogen therapy (daily for 2 weeks, then twice weekly for 2–3 months).
  • Cystocele (bladder prolapse): pelvic floor weakness allows bladder to prolapse into vagina.
    • Symptoms: vaginal pressure/pain, dyspareunia, frequent urination, UTIs, incontinence; bladder may be visible externally depending on severity.
    • Management: physical therapy or surgical repair depending on severity.

Vesicoureteral Reflux (VUR) and Related Imaging

  • Reflux of urine from bladder into ureter/kidney; severity varies on imaging.
  • Diagnostic imaging options:
    • VCUG (voiding cystourethrogram) – gold standard mentioned for reflux evaluation.
    • Ultrasound, cystourethrograms, contrast-enhanced voiding ultrasound, radionucleotide cystography.
  • Management: severe reflux may require daily prophylactic antibiotics to prevent pyelonephritis; surgery if indicated.

Interstitial Cystitis (IC)

  • Chronic condition; diagnosis of exclusion; more common in females.
  • Symptoms: bladder pressure, urge to urinate frequently; no UTI.
  • Management: bladder training; physical therapy; amitriptyline; pentosan polysulfate (Elmiron) to help bladder epithelium.

Acute and Recurrent UTIs; Prevention

  • Acute cystitis overview included above under UTI spectrum.
  • Prevention strategies:
    • Increase fluids; urinate before and after sex (women).
    • Prophylactic antibiotics for women with >3 UTIs/year around the time of sex (e.g., Bactrim or nitrofurantoin).
    • If patient already on prophylaxis, switch to a different agent for treatment if a UTI occurs while on prophylaxis.

Prostate and Male Reproductive Cancers

  • Prostate cancer: second most common cancer in men; risk factors include age, African American ethnicity, family history, BRCA mutations, high dietary fat intake.

  • Presentation: early disease often asymptomatic; metastasis common to the back (bone) causing back pain.

  • Screening: PSA testing starting at age 50 for average risk; start at age 40 for high-risk individuals; PSA thresholds affected by prostatitis, BPH, recent ejaculation, 5-ARI use, recent procedures.

  • PSA interpretation: target < 4 for board purposes; PSA improves cancer detection vs DRE in many cases; most cancers detected via PSA elevation.

  • Diagnostic workup: prostate biopsy via transrectal ultrasound guidance.

  • Bone metastasis signs: elevated alkaline phosphatase or hypercalcemia.

  • Treatments: radical prostatectomy (risk of erectile dysfunction and urinary incontinence); radiation therapy; chemotherapy; androgen deprivation therapy; combination strategies for metastatic disease.

  • Bladder cancer (transitional cell carcinoma): the most common bladder cancer; risk factors include smoking and exposure to industrial dyes/solvents.

    • Presentation: painless hematuria.
    • Evaluation: UA and culture; cystoscopy with biopsy for grading/staging.
    • Treatment: transurethral resection (TURBT), radiation, intravesical therapy (chemotherapy or BCG immunotherapy).

  • Penile cancer: presents as a painless ulcer on the penis; consider differential with syphilis.

    • Risk factors: tobacco use, HPV, HIV, circumcision status; most tumors are epithelial squamous cell carcinomas; relatively rare in the U.S.; more common in areas with low circumcision.
    • Treatment: varied, from topical chemotherapy, laser ablation, radiation, chemotherapy, to surgery; circumcision prior to treatment may improve outcomes.

  • Testicular cancer (germ cell tumors)

    • Demographics: most common cancer in men aged 15–35; germ cell tumors predominate.
    • Risk factor: cryptorchidism increases risk; history of cryptorchidism is a notable risk.
    • Presentation: painless testicular nodule or heaviness; may have hydrocele.
    • Markers: hCG, alpha-fetoprotein (AFP), LDH.
    • Evaluation: testicular ultrasound; CT and PET for metastasis assessment.
    • Treatment: orchiectomy; chemotherapy; overall excellent prognosis with modern therapy (approximate survival ~95%).

Cryptorchidism (Undescended Testes)

  • Prevalence: ~20% in preterm/low birth weight infants; 3–6% in full-term infants; ~1% by age 1.
  • Risks: increased lifetime risk of testicular cancer; infertility risk if not corrected early.
  • Management: surgical correction (orchiopexy) ideally before 1 year of age to reduce infertility risk.
  • Diagnosis: physical exam sufficient; imaging not routinely required.

Testicular Torsion (recap emphasis)

  • Emergency condition with ischemia from twisting of testis and spermatic cord.
  • Urgent Doppler ultrasound to assess blood flow; if torsion suspected, proceed to surgical detorsion and fixation.

Best-Answer Tip from Transcript

  • Question example: best imaging study to evaluate vesicoureteral reflux is VCUG (voiding cystourethrogram); other options may be plausible but VCUG is the best choice for VUR evaluation.

Quick Reference: Key Formulas, Thresholds, and Numbers

  • Prostate cancer screening threshold (board reference): ext{PSA} < 4
  • Erectile dysfunction prevalence reference: >50% in men aged >40
  • Cryptorchidism prevalence by age (transcript data):
    • Preterm/low birth weight: 20\%
    • Full term infant: 3\text{-}6\%
    • Age 1 year: 1\%
  • Testicular cancer survival (germ cell tumors): about 95\%.
  • Basic testing modalities to remember: VCUG for VUR; Doppler ultrasound for torsion; scrotal ultrasound for suspicious testes; transrectal ultrasound-guided biopsy for prostate cancer; cystoscopy with biopsy for bladder cancer.

Real-World and Practical Notes

  • ED discussions require emphasis on safe intercourse and vascular health; PDA guidelines and patient safety with nitrates.
  • Incontinence approaches emphasize non-pharmacologic strategies first (behavioral, pelvic floor therapy) before surgical options.
  • When evaluating scrotal pain, distinguish epididymitis (often STI-related in younger patients) from torsion (urological emergency); Prehn sign and cremasteric reflex are clinical clues but do not substitute imaging.
  • For prostate cancer, PSA is a more sensitive indicator than DRE for many cancers; treat metastatic disease with androgen deprivation therapy and consider combination therapies.
  • For bladder/prostate cancer, be mindful of risk factors (smoking, toxins) and ensure appropriate workups including imaging and biopsy to guide treatment.