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283 Cards in this Set

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What are the USPSTF screening recommendations for bladder cancer?
do not screen (grade D)

*encourage smoking cessation since 50% of all bladder cancer occurs in current or former smokers
USPSTF Handbook 2009
Discuss the appraoch to the patient with a renal disorder.
Kidney disease may be found:
1. incidentally on routine exam
2. signs/symptoms may indicated kidney dysfunction
-nausea
-HTN
-edema
-hematuria

Approach → assess cause and severity:
1. acute vs chronic
2. H&P
3. UA
4. GFR
Current ch22
Define oliguria.
abnormally low urine output
Define proteinuria.
excessive protein excretion in the urine
What patient population is usually affected by orthostatic proteinuria and how is it measured?
<30y/o
measures 8-hour overnight urinary protein secretion
shoud be <50mL
What are the USPSTF screening recommendations for penile cancer?
no recommendations
USPSTF Handbook 2009
Define hematuria.
blood in the urine
Gross hematuria is considered a sign of malignancy until proven otherwise, true or false?
True!
Describe the etiology, location and character of renal pain.
location → ipsilateral CVA
radiation → umbilicus
referred pain → ispsilateral testicle in men or labium in women

ETIOLOGY & ASSOCIATED CHARACTER:
infection → constant
obstruction → intermittent
intraperitoneal disorder → lie motionless to avoid pain
kidney disorder → move about to find comfortable position
Current ch23
Define hematospermia.
blood in the semen
Define pneumaturia.
air or gas in the urine
Define nocturia.
need to get up at night to urinate
Define urgency.
urgent need to urinate
What is uremic frost.
manifestation of chronic renal failure; urea accumulates in sweat; fine white power remains after sweat evaporates
What are the risk factors for bladder cancer?
smoking
environmental exposure to solvents or dyes
Current ch39
Define frequency.
frequent need to urinate
What is the clinical presentation of bladder cancer?
hematuria
irritative voiding symptoms → frequency, urgency
Current ch39
Describe the etiology, location and character of ureteral pain.
typically acute and due to obstruction
site of pain often correlates with site of obstruction
distension of ureter → dull ache
hyperperistalsis/spasm of ureter → colic
if upper ureter, may refer to scrotum of male or labium of female
if mid-ureter, may refer to ipsilateral lower abdominal quadrant
(do not confuse with appendicitis on RT side or diverticulitis on LT side)
if lower ureter, may cause vesicle irritability
What is the diagnostic workup of bladder cancer?
UA → hematuria
cytology
US, CT, or MRI → filling defects
biopsy → staging
Current ch39
Describe the etiology, location, and character of vesicle pain.
acute urinary retention → severe suprapubic discomfort
chronic urinary retention → painless
acute cystitis → pain referred to distal urethra + associated with urination

*suprapubic pain unrelated to urination is rarely vesicular
What is the pattern of metastasis for bladder cancer?
liver → hepatomegaly
lymph → LE lymphedema
Current ch39
What is the management of bladder cancer?
1. if superficial → resection +/-local chemotherapy
2. if invasive but localized → cystectomy, irradiation, chemotherapy
3. if invasive → systemic chemotherapy followed by cystectomy
Current ch39
What is the most likely cause of pneumaturia?
fistula between urinary bladder and colon
Define azoospermia.
absence of sperm in semen
Define aspermia.
absence of semen
Define impotence (AKA erectile dysfunction).
consistent inability to attain or maintain an erection
What is uremic frost.
powdery deposits of urea and uric acid salts on the skin due to excretion of nitrogenous waste in the sweat
Stedmans
What is the pattern of metastasis of testicular cancer?
lymph
retroperitoneal
lung
brain
What is the ddx for uremic frost?
chronic renal disease
chronic renal failure
uremia
What are the risk factors of penile cancer?
5th or 6th decade
uncircumsized
smoking
balanitis
uremic frost
What is the clinical presentation of penile cancer?
non-tender ulcer or warty growth under foreskin
itchy or burning sensation beneath foreskin
hidden behind erythematous phimosis
What is the normal range for sodium?
136-145 mEq/L
Interpreting Laboratory Data p120
What is the most abundant cation in extracellular fluid?
sodium
Interpreting Laboratory Data p120
What is the management of penile cancer?
1. circumcision
2. resection
3. radiation if young male + noninvasive cancer, resection refused, metastasis
4. chemotherapy if metastasis
What is another name for vasopressin?
antidiuretic hormone (ADH)
What is the pattern of metastasis of penile cancer?
lymph
What is the major regulating factor of body fluid balance?
sodium
Interpreting Laboratory Data p120
What is the best treatment for metastatic prostate cancer?
decreasing testosterone
What is hyponatremia?
abnormally low serum sodium
<136 mEq/L
Interpreting Laboratory Data p122
List 12 signs/symptoms of hyponatremia.
lethargy
apathy
agitation
disorientation
hypothermia
Cheyne-Stokes respiration
nausea
anorexia
muscle cramps
abnormal sensor
depressed DTRs
seizures
Interpreting Laboratory Data p122
Does hyponatremia occur in presence of low, normal, or high total body sodium?
all
Interpreting Laboratory Data p122
What are the two main categories of hyponatremia?
1. sodium depletion due to fluid loss (e.g. dehydration)
2. sodium dilution due to fluid intake greater than fluid loss
Interpreting Laboratory Data p122
List 9 signs/symptoms of hypernatremia?
lethargy
irritability
restlessness
thirst
muscle twitching
hyperflexia
seizures
coma
death
Interpreting Laboratory Data p125
What should be considered when assessing natremic status?
serum sodium
renal function
hydration status
fluid intake/output
Interpreting Laboratory Data p122
What is the normal range for potassium?
3.5-5.0 mmol/L
Interpreting Laboratory Data p130
What is the ddx for hyperkalemia?
renal failure
renal failure + increased potassium intake
glomerulonephritis
problem with proximal or distal convoluted tubule
obstructive disease of urinary tract (urolithiasis)
↓ aldosterone secretion (Addison's)
acidemia
meds:
-ACE inhibitors
-ARBs
-K-sparing diuretics
surgery:
-transplant rejection
What tests are in an electrolyte panel?
sodium
potassium
chloride
total CO2
Antrim
What is the range for normal serum osmolality?
280-295 mOsm/kg H2O
Interpreting Laboratory Data p120
Where is ADH secreted from?
magnocellular neurons in supraoptic and paraventricular nuclei of hypothalamus
Interpreting Laboratory Data p120
Names 4 causes for stimulation of ADH secretion.
1. thirst
2. hypovolemia (detected by baroreceptors)
3. increased serum osmolality
4. angiotensin II
Interpreting Laboratory Data p120
Define dysuria.
difficult or painful urination
Define urinary urgency.
strong desire to void
What drug turns urine blue-green?
amitriptyline
Interpreting Laboratory Data p10
What drugs turn urine orange-red?
phenazopyridine
rifampin
Interpreting Laboratory Data p10
How does renal dysfunction affect lab results?
↑ K (hyperkalemia)
↑ PHOS (hyperphosphatemia)
↓ creatinine clearance
Interpreting Laboratory Data p11
What drugs are nephrotoxic?
prolonged course of high-dose aminoglycosides
Interpreting Laboratory Data p39
How do nephrotoxic drugs affect lab results?
↑ CREAT
↑ aminoglycoside trough
Interpreting Laboratory Data p39
What is the generic name of LASIX
furosemide
What kind of medication is furosemide?
loop diuretic
What is the risk of treating a patient with CHF with digoxin and furosemide?
furosemide decreases serum K+
hypokalemia increases risk of digoxin cardiac toxicity
so treat patient acutely with K+ supplementation
Interpreting Laboratory Data p41
Which is more accurate in assessing renal function, serum creatinine or urine output + urine creatinine?
urine output + urine creatinine
Interpreting Laboratory Data p42
How can cefoxitin affect lab results?
may falsely elevate serum CREAT
if true renal failure, both BUN and CREAT would be elevated
Interpreting Laboratory Data p42
What is the ddx for high protein in urine?
glomerulonephritis
cystitis
pyelonephritis
HTN
HF
Describe direct inguinal hernia, indirect inguinal hernia, and femoral hernia.
What penile structure surrounds the male urethra?
corpus spongiosum
What is the function of the penis?
1. excretion of urine
2. introduction of semen into vagina
Mosbys p641
What is the function of the testicles?
synthesis of spermatozoa and testosterone
Mosbys p641
Define cryptorchordism.
undescended testicle(s)
What is the function of the epididymis?
storage, maturation, and transit of sperm
Mosbys p641
Describe the pathway of the vas deferens.
begins at tail of epididymis
ascends spermatic cord
travels through inguinal canal
unites with seminal vesicle
What is the function of the vas deferens?
transportation of sperm from epididymis to ejaculatory ducts in anticipation of ejaculation
What is the function of the seminal vesicles?
secrete seminal fluid (part of semen)
-alkaline
-helps neutralize acidity of vagina → protecting sperm
What is the cremasteric muscle and its function?
muscle covering the testis that raises and lowers the scrotum to regulate the temperature of the testis and promote spermatogenesis
List possible genitourinary complaints.
erectile dysfunction
persistent erections unrelated to sexual stimulation
prolonged erection
difficulty with ejaculation
penile discharge
penile lesions
penile mass
testicular mass
testicular pain
infertility
hernia
Define hypospadias.
congenital abnormality where urethral meatus is located on ventral surface of glans penis, shaft of penis, or base of penis
hypospadias
Describe the procedure for performing a male genitourinary exam.
1. introduce self
2. explain purpose of exam
3. wash hands
ask about self exams
4. ask patient to raise gown
5. inspect skin and hair distribution around pubic hair, penis, and testicles
retract foreskin if necessary
6. palpate shaft of penis down front and sides - size, shape/contour, lesions, induration (hardness), masses, tenderness
7. palpate glans penis and urethral meatus - inflammation, discharge
8. palpate scrotum (hold testicle in hand and palpate with other hands) - size, shape/contour, mass
-palpate each testis
-palpate each epididymis and spermatic cord
-check for inguinal hernias
-feel one side and watch opposite side
9. palpate femoral pulse
palpate inguinal and femoral lymph nodes
inspect and palpate for femoral hernias by placing hand over femoral area, asking patient to cough, feel on one side and look at other side
12. inspect perianal area, feel coccyx
ask patient to bear down - hemorrhoids
lubricate finger
ask patient to bear down
insert finger while patient relaxes
-palpate prostate - identify lobes and median sulcus, assess size, consistency
-sweep finger over all 4 walls
-crook finger and sweep again
-ask patient to bear down to assess sphincter tone
-give patient tissues
What is the ddx for penile discharge?
urethritis
balanitis
STIs
-trichomonas
-gonorrhea
-chlamydia
-herpes
penile cancer
foreign body
Which testicle is often lower, left or right?
left
Mosbys p649
Describe how to perform a genital self-examination.
perform once a month
perform in warm shower
1. hold penis in hand
2. examine head for lesions or discharge
3. examine shaft for lesions, masses
-make sure to examine underside
4. examine skin beneath pubic hair for lesions
5. examine scrotum for tenderness, swelling, masses
6. purpose is to have idea of what is normal so notice when something changes
Mosbys p651
What is the ddx for enlarged penis without enlargment of the testes?
precocious puberty
adrenal hyperplasia
CNS lesion
Mosbys p654
How do you elicit the cremasteric reflex?
stroke medial thigh with a tongue blade → cremasteric muscle should contract and scrotum should rise
*notes on genitourinary and rectal exam
1. focus on 1 testicle at a time
2. cup testicle with one hand while examine with other
3. can find epididymis easier if start with spermatic cord
4. when checking for inguinal hernias, feel on one side and look at opposite side (not all hernias are palpable, but may be visible!)
5. check for femoral hernia by placing hand flat over femoral area and having patient cough
(feel on one side and look at opposite side)
6. during rectal, feel coccyx area for induration
7. put finger against anus and ask patient to bear down and then insert
8. touching prostate makes patient feel like they have to urinate
9. boggy prostate might indicate infection??
10. remember to curl knuckle
What equipment is needed for the male genitourinary and rectal examination?
gloves
lubrication
fecal occult card and developer
penlight for transillumination
Where does a femoral hernia occur?
fossa ovalis where femoral artery exits abdomen
Mosbys p656
Are femoral hernias more common in males or females?
females
Mosbys p656
Describe condyloma acuminatum lesions.
soft, reddish lesions
Mosbys p659
What is another name for foreskin?
prepuce
Mosbys p659
What are the complications of condyloma acuminatum?
squamous cell carcinoma
Mosbys p659
What is condyloma acuminatum commonly known as?
genital warts
Describe molluscum contagiousum lesions.
pearly gray, smooth, dome-shaped, umbilicated, with discrete margins
usually located on glans penis
Mosbys p660
What is Valsalva maneuver?
forcible exhalation against closed airway (i.e. when closing your mouth and pinching your nose)
Define pyuria.
urine that contains pus
Define epispadias.
congenital abnormality where urethral meatus is located along dorsal shaft of penis
Hypospadias increases the risk of what disorder?
cryptochordism
Mosbys p657
What is the treatment for hemorrhoids?
increase water intake
increase fiber intake
NSAIDs for pain
surgery if non-responsive to above treatment
What are the physical exam findings of external hemorroids?
rectal pain, pruritus, bleeding with defecation, often visible while straining, may become thrombosed
What are the physical exam findings of internal hemorroids?
no rectal pain unless thrombosed, prolapsed or infected; bleeding with or without defecation; not palpable; not visible unless prolapsed through anus
epispadias
chancre of 1° syphilis
What is the etiology of nephrolithiasis?
stones may be composed of:
calcium oxalate (70-80%)
calcium phosphate (5-10%)
uric acid (5-10%)
struvite (5-10%)
cystine (1-5%)

men:women 3:1
3rd-4th decades
high temperature and humidity (SW united states)
sedentary occupation
decreased water intake
genetics
What is the clinical presentation of nephrolithiasis?
nausea and vomiting
flank pain
colic pain → sudden, severe, intermittent, radiation to anterior abdomen, ipsilateral testis or labium, patient constantly moving
irritative voiding symptoms if stone lodged lower down → frequency, urgency
What is the diagnostic workup of nephrolithiasis?
UA → hematuria, +/- infection
stone analysis
CT first line
also KUB, US, IVP
if first stone → electrolytes, calcium, phosphate, uric acid
if recurrence → 24 hour urine, PTH
What is management of nephrolithiasis?
1. double fluid intake → during meals, 2 hours after meals, before going to sleep, during night
2. calcium stone
absorptive disorder → type I, II, or III; cellulose phosphate, dietary calcium restriction, or orthophosphates respectively
resorptive disorder → secondary to hyperparathyroidism → surgery
renal disorder → thiazide diuretics
3. uric acid stone → potassium citrate to break up stone, dietary purine restriction, allopurinol
4. struvate stone → associated with UTI → antibiotics
5. cystine stone → difficult to treat → increase fluid intake, alkalinize urine, etc.
What is the patient education for nephrolithiasis?
stay hydrated
restrict sodium to 100 mEq/d
restrict protein to 1g/kg/d
Which kidney stones are radiopaque and which are radiolucent?
RADIOPAQUE:
calcium oxalate
calcium phosphate
struvite

RADIOLUCENT:
uric acid (unless mixed with calcium oxalate)
cystine
Smooth edged ground glass appearance is characteristic of what type of kidney stone?
cystine
Which kidney stones have urinary pH <5.5 and which have urinary pH >7.2?
pH <5.5 = uric acid, cystine
pH >7.2 = struvite
calcium oxalate kidney stone
What is the etiology of interstitial cystitis?
unknown

associated with:
severe allergies
IBS
IBD

diagnosis of exclusion → URNC negative, cytology negative, no vaginitis, urethral diverticulum, genital herpes, chemical/radiotion cystitis

18-40y/o
white Jewish women
hx of childhood bladder problems
What is the clinical presentation of intestitial cystitis?
pain with bladder filling that is releived by emptying
irritative voiding symptoms → frequency, urgency, nocturia
What is the diagnostic workup of interstitial cystitis?
UA/URNC → negative for infection
cytology → negative for malignancy
urodynamic eval → excludes detrusor instability
cystoscopy → +/- submucosal petechiae or hemorrhage
biospy
What is the management of interstitial cystitis?
1. symptomatic relief only
2. hydrodistension
3. amitryptiline etc.
What is the etiology of acute cystitis?
infection of bladder
most commonly due to coliform bacteria (E. coli)
occasionally due to gram-pos bacteria (enterococci)

associated with sexual activity in women
rare in men
What is the clinical presentation of acute cystitis?
usually afebrile
irritative voiding symptoms
+/- gross hematuria
suprapubic tendernes otherwise physical exam unremarkable
What is the diagnostic workup of acute cystitis?
UA → pyruria, bacteriuria, +/- hematuria
URNC → positive
What is the management of acute cystitis?
single dose therapy or 3 day regimen
fluoroquinolones ( or nitrofurantoin
What is the prevention of acute cystitis?
if women + >3 episodes per year:
1. prophylactic antibiotics → TMP-SMX, nitrofurantoin, or cephalexin
2. take single dose at bedtime or before sexual activity

if catheter-related:
1. use catheter only when necessary
2. use proper insertion technique
3. remove catheter when no longer necessary
3. antimicrobial catheters in high-risk patients
4. external collection devices for men
5. postvoid residual
What is acute cystitis?
infection of the bladder
Acute cystitis is common in men, true or false?
false!!!
think infected stone, prostatitis, or chronic urinary retention!
What is the diagnostic workup for UTI in men?
figure out underlying problem
think infected stone, prostatits, chronic urinary retention
abdominal US
cytoscopy
CT if anatomic abnormality, pyelonephritis, recurrent infection
What is a post-void residual?
measure of urine remaining in bladder after attempt to empty it completely
measured via US
no risk or adverse effects
What organism is the most common cause of uncomplicated UTI?
E. coli
What is the etiology of pyelonephritis?
commonly gram-negative bacteria (E. coli, proteus, klebsiella, enterobacter, pseudomonas)

less commonly gram-positive bacteria (enterococcus faecalis, staph aureus)
What is the clinical presentation of pyelonephritis?
fever and chills
nausea and vomiting
flank pain → constant
irritative voiding symptoms → dysuria, frequency, urgency
tachycardia
CVA tenderness
What is the diagnostic workup of pyelonephritis?
CBC → leukocytosis, left shift
BMP → kidney function
UA → pyuria, WBCs, WBC casts, bacteriuria, +/- hematuria
URNC → positive
BC → +/- positive if sepsis
What is the management of pyleonephritis?
1. if young, uncomplicated → treat as outpatient:
fluorquinolone (ciprofloxacin x 21 days) or nitrofurantoin

2. if elderly, living alone, complicated (severe, signs of sepsis) → hospitalize:
IV ampicillin + IV gentamicin (aminoglycoside)
narrow-spectrum antibiotics based on BC results
Discuss recurrent UTI.
consider drug resistance or anatomical abnormality
Define significant bacteriuria.
presence of any bacteria (>1 bacterium/oil power field) on gram-stain of uncentrifuged urine

if asymptomatic 100,000 CFUs/mL urine
if symptomatic 1000-10,000 CFUs/mL urine
What patient populations are commonly affected by asymptomatic bacteriuria.
pregnancy
elderly
DM
spinal cord injury
What are the treatment guidelines for asymptomatic bacteriuria?
treat pregnant women

do not treat elderly, diabetics, spinal cord injury, catheters
Define asymptomatic bacteriuria.
CLEAN-CATCH SPECIMEN:
1. for women → 2 specimens, isolation of same organism, >100,000 CFUs per mL of urine
2. for men → 1 specimen, isolation of 1 organism, >100,000 CFUs per mL urine

CATHETER SPECIMEN:
women or men, one specimen, one organism isolated, >100 CFUs per mL of urine

*CFU = colony forming unit
Define incontinence.
involuntary loss of urine
Define total incontinence.
loss of urine at all times and all positions
Define stress incontinence.
loss of urine associated with activities that increase intra-abdominal pressure (coughing, sneezing, laughing, standing up, lifting, exercising)
Define urge incontinence.
strong urge to void followed by involuntary loss of urine
Defue overflow incontinence.
chronic urinary retention resulting in involuntary loss of urine
What are the 4 categories of incontinence?
total
stress
urge
overflow
What is the etiology of total, stress, urge, overflow, and mixed incontinence?
TOTAL:
often due to urinary fistula → due to trauma, radiation, surgery
treat with foley catheter or surgery

STRESS:
common in women
impaired urethral spincter tone → due to childbirth, decreased estrogen, gyn surgery
treat with pelvic muscle exercises or surgery

URGE:
common in elderly
detrusor overactivity → uninhibited bladder contractions → due to idiopathic, CNS lesion (stroke), stone, infection, tumor
associated with frequency and nocturia

OVERFLOW:
common in men
chronic urinary retention → due to bladder outlet obstruction or atonic bladder → urethral stricture, BPH, or prostate cancer if male; cystocele if female
associated with urge, straining, post-void dribbling

MIXED:
urge + stress
common in women
combination of detrusor overactivity + impaired urethral sphincter function
What are the indications for a post-void residual?
incontinence
Define mixed incontinence.
stress + urge incontinence
What is bladder outlet obstruction (BOO)?
blockage at base of bladder that prevents flow of urine
What is the etiology of BOO?
urethral stricture
bladder stone
BPH
tumor (uterus, cervix, prostate, rectum)
What is the clinical presentation of BOO?
unable to void
weak stream
feeling of incomplete void
palpable bladder
+/- abdominal pain
What is the diagnostic workup of BOO?
foley catheter
US
KUB
CT
Define hydrocele.
cyst due to fluid accumulation in tunica vaginalis of scrotum
Define paraphimosis.
inability to return foreskin to normal position after retracting it behind glans penis
Mosbys p657
What is the clinical presentation of a hydrocele?
smooth, firm, nontender scrotal mass that transilluminates

10% of testicular tumors associated with hydrocele
Define priapism.
prolonged erection
What is the diagnostic workup of hydrocele?
positive transillumination
Define phimosis.
inability to retract foreskin
Mosbys p648
What is the treatment for a hydrocele?
usually resolves spontaneously
Define balanitis.
inflammation of the glans penis
*only occurs in uncircumsized males
Mosbys p648
In what patient population does a hydrocele most commonly occur?
infants
What is the most common etiology of balanitis?
uncircumsized male + poorly controlled DM + candidal infection
Mosbys p648
hydrocele
balanitis
What is the ddx for testicular swelling?
testicular trauma
testicular torsion
orchitis
epididymitis
hydrocele
spermatocele
varicocele
testicular tumor
hernia
What is peyronie's disease?
disorder characterized by a fibrous band in the corpus cavernosum resulting in abnormal curvature in the penis during erection
Mosbys p660
RT hydrocele
What is the etiology of peyronie's disease?
unknown

associated with dupuytren's contracture
Mosbys p660
What are the complications of peyronie's disease?
painful erection
inability to insert penis into vagina
erectile dysfunction
Mosbys p660
What is the ddx for priapism?
1. trauma
-genitourinary trauma
-spinal cord trauma
2. infection
-urethritis
-cystitis
-prostatitis
3. blood disorder
-sickle cell anemia
-thalassemia
-other hemoglobinopathy
4. cancer
-neoplasm
-leukemia
5. neurologic disorders
-multiple sclerosis
-neurosyphilis
-diabetic neuropathy
6. foreign body
7. medications
-impotence
8. cocaine
8. idopathic (most common)
What are the complications of paraphimosis?
urinary retention
impaired circulation → edema or gangrene of glans penis
How does penile squamous cell carcinoma present?
painless non-healing ulceration usually originating in foreskin or glans penis
Mosbys p660
What is the clinical presentation of peyronie's disease?
abnormal curvature of the penis during erection
painful
poor erection distal to curvature
may result in inability to insert penis into vagina
may result in erectile dysfunction
palpable fibrous plaque involving tunica albuginea (sheath surrounding corpus cavernosus penis)
What is the diagnostic workup of peyronie's disease?
if severe, radiograph may confirm ossification and calcification
What is the management of peyronie's disease?
1. refer to urologist
2. 50% resolve spontaneously
3. trial of p-aminobenzoic acid powder/tablets or vitamin E tablets x several months
4. surgery → graft or prosthetic
peyronie's disease
What is the etiology of phimosis?
normal during first few years of life

risk factors include chronic balanoposthitis
What is the etiology of paraphimosis?
often iatrogenic → foreskin retracted to insert catheter and not returned to normal
What is the clinical presentation of phimosis?
inability to retract foreskin
What is the clinical presentation of paraphimosis?
inability to return retracted foreskin to normal position
What are the complications of phimosis?
balanitis
urinary retention
What is the management of paraphimosis?
1. attempt manual reduction
-squeeze glans penis firmly for 5-10 minutes to reduce its size
-move foreskin distally while glans penis is pushed proximally
2. if manual reduction unsuccessful → make dorsal slit of foreskin
3. refer to urologist for circumcision to prevent recurrence
What is the prevention of phimosis and paraphimosis?
good hygiene
circumcision
What is the management of phimosis?
IF ASSOCIATED WITH IRRITANT BALANITIS:
1. cleansing with foreskin retracted
2. 0.5% hydrocortisone cream
3. sitz baths

IF ASSOCIATED WITH FUNGAL BALANTITIS:
1. good hygiene
2. topical antifungal cream
paraphimosis
What is the clinical presentation of balanitis?
fungal infection → malodorous, purulent, excoriated and tender glans penis

bacterial infection → erythema, warmth, and edema of foreskin, glans penis, and shaft
What is the diagnostic workup of balanitis?
wet mount for yeast?
What is the management of balantitis?
IF FUNGAL INFECTION:
1. clean with mild soap and allow appropriate drying time
2. apply topical antifungal cream → nystatin or clotrimazole
3. oral antifungal → fluconazole
4. circumcision

IF BACTERIAL INFECTION:
1. broad-spectrum antibiotic → 1st or 2nd generation cephalosporin
2. + fungal treatments

if refractory → culture or biopsy
What is the prevention of balanitis?
good hygiene
circumcision
What is the etiology of balanitis?
associated with foreskin

usually caused by poor hygiene or irritation which results in candidal infection

also may result in bacterial infection (Gardnerella, anaerobes)

if recurrent, consider DM
hydrocele
In what patient population does penile carcinoma most commonly occur?
uncircumsized men who practice poor hygiene
Mosbys p660
What is the treatment for a hydrocele?
usually resolves spontaneously
What is the ddx for orchitis?
*orchitis is uncommon
complication of mumps
complication of prostatic infection
Mosbys p662
Define varicocele.
condition where the veins of the pampiniform plexus in the spermatic cord are abnormally dilated and tortuous
Mosbys p662
What is the clinical presentation of a varicocele?
commonly on LT side
often only visible while standing → usually dimish in size or disappear when supine
"bag of worms" appearance
may be painful
Mosbys p662
What are the complications of a varicocele?
reduced fertility
Mosbys p662
LT varicocele
What is the clinical presentation of epididymitis?
ACUTE:
fever
scrotal pain → may radiate along spermatic cord or to flank
epididymis enlarged and extremely tender, distinguishable from testis early in course
scrotum erythematous and enlarged

if associated urethritis → pain at tip of penis, urethral discharge
if associated cystitis → irritative voiding symptoms
if associated prostatits → possible tenderness

positive prehn sign → elevation of scrotum above pubic symphysis provides relief (not reliable sign)
Mosbys p663
Current ch23
What is testicular torsion?
disorder characterized by twisting of the spermatic cord, reducing blood supply to scrotum
What are the physical exam findings of testicular torsion?
acute onset
nausea and vomiting
scrotal erythema, swelling, and extreme tenderness
absence of cremasteric flex on affected side
lack of voiding symptoms (compared to epididymitis)
Mosbys p663
What patient population is most commonly affected by testicular torsion?
adolescents
10-20y/o
Mosbys p663
Which is more common, indirect or direct hernia?
indirect
Mosbys p650
When palpating the testis, what should they feel like?
smooth
rubbery
free of nodules
sensitive but non-tender
Mosbys p650
If a scrotal mass is identified, how can you determine if it is cystic or solid?
perform transillumination
if light shines through → cystic
if light doesn't shine through → solid
Define orchitis.
inflammation of the testicle
Define epididymitis.
inflammation of the epididymis
Where does a direct hernia occur?
through external inguinal ring
Where does an indirect hernia occur?
internal inguinal ring
Define spermatocele.
cyst due to spermatozoa accumulation in epididymis
RT hydrocele
What is the ddx of epidiymitis?
UTI
STI
TB (if chronic epididymitis)
Mosbys p663
What are the physical exam findings of a testicular tumor?
irregular nontender mass fixed to testis that does not transilluminate
Mosbys p664
What disorders of the spermatic cord, scrotum, and testes are emergencies?
orchitis
testicular torsion
What is the etiology of epididymitis?
if acute → usually infectious
may also follow heavy lifting or trauma

STI:
<40 y/o
associated urethritis
gonorrhea or chlamydia

Non-STI:
older men
associated UTI or prostatitis
gram-negative rods

Route → via urethra to ejaculatory duct, then down vas deferens to epididymis
What is the diagnostic workup of epididymitis?
CBC → leukocytosis, shift to the left

if STI:
URNC
GCCHDNA → positive

if non-STI:
UA → puria, bacteriuria, +/- hematuria
URNC → positive
What is the management of epidiymitis?
1. best rest with scrotal elevation
2. if STI → antibiotics x 10-21 days; treat partner
3. if non-STI → antibiotics x 21-28 days
What is the prognosis for epididmyitis?
if prompt treatment → outcome favorable
if delayed treatment → possible orchitis, abscess formation, or decreased fertility
What is the etiology of orchitis?
associated with mumps (viral)
associated with epididymitis (bacterial)
What is the clinical presentation of orchitis?
mild or severe scrotal pain

MUMPS:
fatigue, fever, HA, myalgias
occurs 4-7 days following parotitis
testicular pain and swelling (sparing epididymis)
scrotal skin may be erythematous or edematous
70% unilateral

EPIDIDYMITIS
enlarged, tender epididymis
boggy, tender prostate
What is the diagnostic workup of orchitis?
Doppler U.S. to differentiate between mumps orchitis and testicular torsion
What is the management of orchitis?
MUMPS ORCHITIS:
1. symptomatic treatment only
2. analgesics
3. hot or cold packs
4. scrotal elevation

EPIDIDYMO-ORCHITIS:
1. treat same as epididymitis
What is the diagnostic workup of hydrocele?
positive transillumination
Which type of inguinal hernia may descend into the scrotum, direct or indirect?
indirect
List conditions related to the prostate.
prostatodynia
non-bacterial prostatitis
acute bacterial prostatitis
chronic bacterial prostatitis
benign prostatic hypertrophy (BPH)
prostate cancer
Define prostatodynia.
prostatic pain
What is the clinical presentation of acute bacterial prostatitis?
high fever
irritative voiding symptoms
+/- obstructive voiding symptoms
suprapubic, sacral, or perineal pain
warm and EXQUISITELY tender prostate
What is the diagnostic workup of acute bacterial prostatitis?
CBCDP → leukocytosis, shift to the left
UAC → pyuria, bacteriuria, +/- hematuria
URNC → positive
What is the etiology of acute bacterial prostatitis?
Infection via:
ascent up urethra
reflux of infected urine into prostatic ducts
hematogenous (rare)
lymphatic (rare)

Possible organsims:
usually gram-neg rods (E coli, pseudomonas)
rarely gram-pos cocci (enterococci)
List irritative voiding symptoms.
dysuria
frequency
urgency
nocturia
List obstructive voiding symptoms.
hesistancy
decreased force of stream
intermittency
post void dribbling
What is the management of acute bacterial prostatits?
OUTPATIENT: ??

refer if chronic prostatitis or urinary retention
admit if sepsis or urinary drainage required
HOSPITALIZATION:
1. order BC
2. treat empirically with IV ampicillin + IV gentamicin until BC results available, then switch to narrow-spectrum antibiotics
3. if afrebrile 24-48 hours → oral antibiotics → quinolones x 4-6 weeks
4. after therapy complete → order URNC and examine prostatic secretions
3.
What are the complications of acute bacterial prostatits?
sepsis

*prostatic massage is contraindicated
What is the etiology of chronic bacterial prostatitis?
may result from acute bacterial prostatitis, but many men have no history of acute infection

history of UTI

routes same as acute
organisms same as acute
What is the clinical presentation of chronic bacterial prostatitis?
asymptomatic
irritative voiding symptoms
suprapubic, sacral, and perineal discomfort → dull, poorly localized
physical exam often unremarkable
normal, boggy, or indurated prostate
What is the diagnostic workup of chronic bacterial prostatitis?
CBC
UAC → normal
URNC → positive
prostatic secretions → leukocytosis
What is the management of chronic bacteiral prostatitis?
1. trimethoprim-sulfamethoxazole x 6-12 weeks
2. symptomatic relief with NSAIDs (ibuprofen, indomethacin), hot sitz baths
3. difficult to cure
4. refer if persistent
What is the etiology of non-bacterial prostatitis?
unknown

most common form of prostatitis
What is the clinical presentation of non-bacterial prostatitis?
irritative voiding symptoms
suprapubic or perineal discomfort
positive expressed prostatic excretions

identical to presentation of chronic bacterial prostatitis except no history of UTIs
What is the diagnostic workup of non-bacterial prostatits?
CBC
UAC
URNC → negative
prostatic secretions → leukocytosis
What is the management of non-bacterial prostatitis?
1. trial of antibiotics → erythromycin x 14 days
2. continue x 3-6 weeks if favorable response, otherwise discontinue
3. symptomatic relief with NSAIDS and sitz baths
4. recurrence common but no serious sequelae
What is the clinical presentation of BPH?
obstructive voiding symptoms → straining, hesitancy, decreased force of stream, post-void dribbling, double voiding (voiding a second time within 2 hours), sensation of incomplete bladder emptying
irritative voiding symptoms → frequency, urgency, nocturia
+/- enlarged prostate → smooth, firm, elastic
What is the prevalence of BPH based on age?
41-50y/o → 20%
51-60 y/o → 50%
>80 y/o → 90%
What is BPH?
benign tumor of the prostate
What is the ddx for obstructive voiding symptoms in men?
BPH
UTI
urethral stricture
neurogenic bladder
prostate cancer
bladder cancer
What is the diagnostic workup of BPH?
UA → to exclude infection and hematuria
PSA → controversial
Define prostatitis.
inflammation of the prostate
Define premature ejaculation.
peristent or recurrent ejaculation with minimal stimulation before a person desires (associated with distress)
Define retrograde ejaculation.
ejaculation of semen into urinary bladder instead of out through urethra
What is the prevalence of erectile dysfunction?
affects 30 million American men
affects 52% of men 40-70y/o
What is the etiology of male infertility?
1. decreased/absent sperm count → ejaculatory duct obstruction, retrograde ejaculation, androgen insufficiency
2. abnormal sperm motility → abnormal flagella, partial ejaculatory duct obstruction, varicocele, antisperm antibodies, infection
3. abnormal morphology → varicocele, infection, environmental exposure
Current ch23
What is the intial workup of suspected male infertility?
WORKUP IF >6 MONTHS UNPROTECTED SEX

HISTORY:
1. testicular insults (trauma, torsion, cryptochordism)
2. testicular infections (mumps orchitis, epididymitis)
3. environmental exposures (excessive heat, pesticides, chemotherapy, radiation)
4. medications (anabolic steroids etc)
5. drugs (alcohol, tobacco, marijuana)
6. sexual habits (frequency and timing of sex, use of lubricants)
7. both partners previous fertility experiences
8. PHM (thyroid disease, liver disease, diabetic neuropathy, pituitary tumor, hernia repair, retroperitoneal or pelvic surgery)

PHYSICAL EXAM:
1. features of hypogonadism (body habitus, diminished male hair pattern, gynecomastia, underdeveloped secondary sexual characteristics)
2. estimate testicular size
3. evaluate scrotal contents
4. palpate epididymis, vas deferens, prostate
5. varicoceles?

DIAGNOSTIC WORKUP:
1. semen analysis on 2 separate occasions
-must be collected after 2-3 of no ejaculation
-must be evaluated within 1 hour
2. endocrine evaluation if low sperm count
-initially order FSH and testosterone
-if FSH or testosterone abnormal, order LH and prolactin
3. other possibilites include urine (for suspected retrograde ejaculation), genetic testing, imaging
Current ch23
Define azotemia.
retention of BUN and CREAT
Define oligospermia.
low concentration of sperm in the semen
Define vasectomy.
method of contraception where vas deferens is surgically cut and tied to prevent sperm from entering ejaculatory stream
Define impotence.
inability to achieve or maintain an erection during sexual performance
List the methods of male birth control.
CONDOMS:
worn on penis
made of latex or animal membrane
prevents pregnancy 98% of time with perfect use
prevents STIs including HIV
temporary
cost ranges from free to $1

VASECTOMY:
outpatient surgical procedure
vas deferens severed and sealed through scrotal incision under local anesthesia
azoospermia may take 2-6 months
other forms of contraception must be used until 2 sperm-free ejaculations confirm sterility
complications rare and generally due to infection
100% effective
cost $350-1000
permanent but can be reversed

WITHDRAWAL METHOD:
pulling out
75-95% effective

PILL may be coming soon!
What is the etiology of priapism?
60% idiopathic

penile trauma
spinal cord trauma
pelvic infection
pelvic tumor
sickle cell disease
leukemia
medications → sildenafil citrate, tadalafil, alprostadil
What is the clinical presentation fo priapism?
erection >4hr
corpus cavernosum engorged while corpus spongiosum and glans penis flaccid
What is the diagnostic workup of priapism?
none
What is the management of priapism?
if reversible cause:
1. terbutaline PO or IM
2. aspiration of blood from corpus cavernosum + compression dressing
3. if due to alprostadil → aspirate + inject alpha-adrenergic agent (phenylephrine)
4. if traumatic or refractory → urologic consult
5. can lead to ischemia
6. commonly results in erectile dysfunction
What is the prevention of priapism?
discontinue offending medications
What is the etiology of male sexual dysfunction?
LOSS OF LIBIDO:
androgen deficiency

LOSS OF ERECTION:
arterial
venous
neurogenic
medications → anti-hypertensives, antidepressants
psychogenic
Discuss the physiology of an erection.
Normal male erection is a neurovascular phenomenon relying on an intact autonomic and somatic nerve supply to the penis, smooth and striated musculature of the corpora cavernosa and pelvic floor, and arterial blood flow supplied by the paired pudendal arteries. Erection is caused and maintained by an increase in arterial flow, active relaxation of the smooth muscle elements of the sinusoids within the paired corpora cavernosa of the penis, and an increase in venous resistance. Contraction of the bulbocavernosus and ischiocavernosus muscles results in further rigidity of the penis with intracavernosal pressures far exceeding systolic blood pressure. Nitric oxide is a pivotal neurotransmitter that initiates and sustains erections; however, other molecules contribute, including acetylcholine, prostaglandins, and vasoactive intestinal peptide.
What is the initial workup of male sexual dysfunction?
1. distinguish between problems of erection, libido, orgasm, ejaculation, and deformity
2. erection during sleep or in morning?
if yes → psychogenic cause
if no → organic cause
3. gradual loss of erection?
if yes → likely organic cause
4. severity of ED → achieving vs maintaining; situational, intermittent, chronic
5. associated disease → pelvic trauma, peyronie's disease, HTN, hyperlipidemia, cardiovascular disease, peripheral vascular disease, CKD, DM, endocrine disorder, neurogenic disorder, depression, alcohol, tobacco, drugs, chemotherapy, radiation therapy
6. CBC, GLUC, LIPID, testosterone, prolactin
7. if testosterone or prolactin abnormal → FSH, LH
What is the management of erectile dysfunction?
1. oral medications → sildenafil citrate, tadalofil
2. injectable medications → alprostadil
3. vacuum erection device
4. penile prosthetic
5. if arterial disorder → vascular reconstruction
6. if hormonal disorder → hormone replacement
Sildenafil Citrate (Viagra): indications, contraindications, patient education
INDICATIONS:
erectile dysfunction
pulmonary arterial HTN

CONTRAINDICATIONS:
hypersensitivity to sildenafil
concurrent use of nitrates

PATIENT EDUCATION:
take 1 tablet 1 hour before sexual activity
do not take >1 tablet per day
absorption delayed by consumption of food (especially high-fat)
avoid excessive alcohol consumption → may cause hypotension
do not take nitrates
may experience HA, flushing, vision changes, nasal congestion, epistaxis, dyspepsia, myalgia, insomnia
discontinue if serious side effects → erection >4hr, vision change, hearing changes
Pharmacology p341
Lexi-Comp p1368
Tadalafil (Cialis): indications, contraindications, patient education
INDICATIONS:
erectile dysfunction

CONTRAINDICATIONS:
concurrent use of nitrates

PATIENT EDUCATION:
take 1 tablet 1 hour before sexual activity
do not take >1 tablet per day
avoid excessive alcohol consumption → may cause hypotension
do not take nitrates
may experience HA, flushing, nasal congestion, dyspepsia
discontinue if serious side effects → erection >4 hours, vision changes, hearing changes
Pharmacology p341
Lexi-Comp p1422
Compare sildenafil citrate (Viagra) and tadalafil (Cialis).
SILDENAFIL CITRATE:
quicker onset (<1 hour)
shorter duration (4 hours)
absorption delayed by food consumption

TADALAFIL:
slower onset (1 hour)
longer duration (36 hours)
absorption NOT delayed by food consumption
Pharmacology p341
Alprostadil (Caverject, Muse): indications, contraindications, patient education
INDICATIONS:
erectile dysfunction

CONTRAINDICATIONS:
hypersensitivity to alprostadil
anatomical deformity of penis
conditions predisposing to priapism → sickle cell disease, multiple myeloma, leukemia
penile implant
pregnancy

PATIENT EDUCATION:
get trained on how to inject into penis or urethra
only use appropriate dose
do not use >1 time per day
do not use >3 times per week
do not reuse needles
avoid concurrent alcohol use
may experience penile pain, urethral burning or bleeding, testicular pain, HA, dizziness, HTN
discontinue if serious side effects → erection >4hr, signs of penile fibrosis (angulation, fibrosis, peyronie's disease)
Lexi-Comp p70
List drugs to treat erectile dysfunction and whether they are oral or injections.
ORAL:
sildenafil citrate
tadalafil

INJECTION:
alprostadil (may be injected into corpus carvernosum or urethra)
Describe the male sexual response cycle.
sexual stimulation → increased production of nitric oxide → increased acitivity of guanylyl cyclase → increased cGMP → increased relaxation of smooth muscle of corpus cavernosum → increased blood flow → erection
Pharmacology p342
What are the pharmacologic agents used to treat BPH?
finasteride
prazosin
terazosin
What are the pharmacologic agents used to treat prostate cancer?
treatment → flutamide
palliative treatment → leuprolide
What are the adverse effects of finasteride?
decreased libido
sexual dysfunction
What are the adverse effects of prazosin and terazosin?
vertigo
orthostatic hypotension
tachycardia
sexual dysfunction
What are the adverse effects of flutamide?
decreased libido
sexual dysfunction
gynecomastia
Flutamide: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:


INDICATIONS:
metastatic prostate cancer

CONTRAINDICATIONS:
hypersensitivity
severe hepatic impairment

ADVERSE EFFECTS:
gynecomastia
decreased libido
impotence
nausea and vomiting
increase AST and LDH


DOSING PARAMETERS:

PATIENT EDUCATIONS:
Finasteride: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:

INDICATIONS:

CONTRAINDICATIONS:

ADVERSE EFFECTS:

DOSING PARAMETERS:

PATIENT EDUCATIONS:
Prazosin: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:

INDICATIONS:

CONTRAINDICATIONS:

ADVERSE EFFECTS:

DOSING PARAMETERS:

PATIENT EDUCATIONS:
Terazosin: MOA, indications, contraindications, adverse effects, dosing parameters, patient education
MOA:

INDICATIONS:

CONTRAINDICATIONS:

ADVERSE EFFECTS:

DOSING PARAMETERS:

PATIENT EDUCATIONS:
What is a semen analysis?
includes semen volume, sperm count, sperm morphology, and sperm motility
What are the indications for ordering a semen analysis?
suspected infertility
post-vasectomy
What are the collection requirements for a semen analysis?
semen collected in urine container following masturbation and 3 days of abstinence from ejaculation

sample must be kept at room temperature and examined within 1 hour
What are the indications for ordering a PAP?
intermediate and high-risk prostate cancer
may be helpful in determining who needs more aggressive treatment
What is a PAP test?
blood test that measures an enzyme produced by the prostate called prostatic acid phosphatase
What does PAP stand for?
prostatic acid phosphatase
What is the sensitivity of PSA?
40%
PSA has a low sensitivity since it is specific for the prostate but not for prostatic carcinoma
It can be elevated by urinary retention, urethral instrumentation, prostatitis, benign prostatic hyperplasia, prostatic instrumentation (e.g. rectal exam, prostatic needle biopsy)
It cannot be relied on as the sole prostatic cancer screening method
Interpreting Laboratory Data p3-4, p42