the first lecture of this semester-- male genitalia. some diagnostic notes: besides palpating all the obvious structures of the male genitalia for structural abnormalities, discharge, masses, it is also useful to palpate the lower abdominal area for hernias. if there is a mass, transillumination is useful to determine whether the mass is solid or liquid. a prostate exam is indicated if benign prostatic hypertrophy or cancer is suspected, and will elicit the sensation of needing to pee if performed correctly.
urethritis is inflammation of the urethra generally caused by infection: potentially from the bladder, kidneys, or prostate. in young patients it is more likely to be STI derived and the microorganisms most commonly implicated are GC, trich, ecoli, and ureaplasma. GC causes a thick yellow/green discharge while other types can cause a whitish mucoid discharge. a positive diagnosis for urethritis due to GC necessitates treatment via antibiotics and reporting to public health agencies due to the risk of infecting others. cystitis can present similarly to urethritis in that both have urinary frequency, urgency, and pain. it is most commonly caused by recurring chronic bacterial prostatitis and is diagnosed via dipstick and a 3 part urinalysis (3 parts to roughly determine whether the source of infection is the bladder, kidney, prostate).
lower urinary tract infections are often related to congenital structural anomalies of the genitalia that might predispose to infection via urinary stasis or aiding in incubation of bacteria. hypospadias and epispadias are abnormal openings of the urethral meatus on the underside and topside of the penis, respectively, and can both lead to greater chance of lower urinary tract infection. balanopasthitis is inflammation of the glans penis and foreskin and occurs more frequently in uncircumscribed men. phimosis is an inability to retract the foreskin of the penis.
infection from herpes simplex is a relatively common problem and is a societal challenge in that it often presents asymptomatically but is communicable via skin contact. if symptoms do appear, they can appear 3-14 days after the initial exposure to the virus and generally manifest as painful, itchy vesicles on the head or shaft of the penis, which then disappear in 3-5 days. recurrences can occur, on average 4 times a year and are much milder than the initial onset of symptoms. HSV infections are diagnosed via the TZANK smear and treated with valtrex/lysine in the allopathic world and lauric acid in the naturopathic world.
infection from HPV, in particular strains 6 and 11, can cause genital warts after a latent period of months to years. they are highly communicable via sexual contact (60% likelihood of transmission per sexual encounter) and manifest as multiple soft, raised, painless, pruritic masses in various areas.
erythroplasia of queyrat is a premalignant lesion on the glans or the corona of the penis and appears as a well circumscribed red/velvety area. the treatment is generally surgical removal. priapism is prolonged, often painful erection in the absence of sexual stimulation that may occur from certain systemic conditions such as sickle cell anemia, pelvic tumors or infections, recreational drug use. it is treated by cold compresses to reduce blood flow to the area. peyronie's disease is a distortion or deviation of the penis caused by hardening of the corpus cavernosa. the biggest concern with this disease is that it makes intercourse virtually impossible. it is treated as a connective tissue disorder.
there are a number of conditions that might produce painless scrotal masses. transillumination is a useful technique to determine whether the mass is filled with serous fluid, blood, or other substances-- a hematocele is a mass filled with blood secondary to trauma that will not transilluminate, while a hydrocele is a mass filled with serous fluid that will transilluminate. scrotal edema might occur in patients who have systemic edema as in RCHF. varicoceles of the panpiniform plexus might occur, causing a dragging sensation in the patient and feeling like a "bag of worms" upon PE.
testicular torsion is a twisting of the testes within the scrotal sac that leads to a torsion of the epididymis, leading to severe unilateral pain. it can affect young boys (10-16) as well as adults, and can be due to congenital defects, undescended testicles, sexual arousal / activity, trauma, among other factors. patients who present with this might have experienced similar pain in the past that represents torsion and detorsion of the testicle. it is diagnosed by doppler and PE, which might show a negative prehn's sign- lifting the testicle provides no relief of pain.
a positive prehn's sign would indicate epididymitis, inflammation of the epididymis due to reflux of urine or infection via lymphatics (again, source of infection is from kidneys, prostate, bladders). patients with acute epididymitis present with severe scrotal pain and tenderness that can radiate along the spermatic cord and to the flank. the likely infectious agent for patients under 35 is GC / chlamydia and for over 35, e. coli. a CBC might show leukocytosis and a dipstick might show bacteruria and pyuria. chronic epididymitis might result after repeated episodes of acute epididymitis, and differs in presentation from AE in that there is swelling and thickening of the scrotum but not pain.
cryptorchidism is a condition that involves undescended testicles, which can be in a variety of locations. the "true" variant is in the abdomen, "incomplete" in the inguinal canal, "ectopic" is outside of the normal course of descent", and "hypermobile" is the most common, where the testicle descends and retracts from the scrotum to the inguinal canal. if untreated, it may lead to failure of spermatogenesis from improper temperature regulation and an increased cancer risk as well. it is diagnosed by PE, with some help from valsalva to determine whether the testicle can retract or not. a common treatment given to aid in the normal descent of the testes is HCG.
tumors can also develop in the scrotum, generally of the types seminoma, mixed cell, teratoma, and embryonal carcinoma. they will present as a firm, smooth, non tender mass that does not transilluminate. labs might show increased AFP, HCG, LDH. those with cryptorchidism have a much greater chance to develop scrotal tumors, and blacks/asians have a lower chance.
some notes on diagnosis of prostate conditions: normal size is 4cm by 4cm and normal consistency is rubbery. palpation is done by a digital rectal exam, which is contraindicated in acute prostatitis due to risk of spreading infection. if the medial sulcus is absent upon palpation, this indicates prostatic hypertrophy. prostatic symptoms can be grouped into two categories: obstructive result from swelling of the prostate and result in difficulty urinating, and irritative result from infection or inflammation and result in urgency, dysuria, discomfort. elevated PSA levels are used to indicate damage to the prostate, although this test has a high possibility for false negatives.
acute bacterial prostatitis is an obstruction of the urethra distal to the prostate and is generally due to ecoli, klebsiella, enterococcus, or pseudomonas. it manifests with symptoms of an infection (fever, etc.) plus a host of urinary symptoms including dysuria, frequency, urgency, possibly nocturia and hematuria. it might also present with low back and perianal pain. PE would reveal a swollen, warm, firm prostate, and copious discharge would follow exam. CBC would show leukocytosis / left shift, dipstick would show leukocytes and bacteria, and culture of prostatic secretions would reveal presence of bacteria. chronic bacterial prostatitis presents similarly, but slightly more "toned down"-- but more urgent that urethritis, according to dr. thom. it is diagnosed by prostatic secretion (presence of WBC, bacterial culture), and the three glass method.
benign prostatic hypertrophy is an enlargement of the periurethral glands and stroma that results in obstructive symptoms such as frequency, urgency, nocturia. if obstruction is severe enough, it can eventually lead to renal failure. PE might result in an enlarged, boggy prostate with an absence of a median furrow. labs might show increased BUN/creatinine levels, leukocytosis, and increased PSA, although these might be elevated falsely due to the manual exam itself. conventionally, hypertrophied prostate may be alleviated by surgical removal of hypertrophied parts, although this is generally only a short term solution. dr. thom advocates the use of hot/cold hydrotherapy as an effective treatment for most prostate conditions.
finally, adenocarcinoma is cancer of the prostate which is more likely to occur with old age, african american race, obesity, increased testosterone levels. it can be asymptomatic, or have gradually developing obstructive symptoms- as well as bone pain from metastasis, commonly to the hip. diagnosis is by palpation of a stony, hard mass with irregular nodules, and can be confirmed with biopsy. elevated total PSA levels can aid in diagnosis and higher proportion of free PSA level is an indicator of better prognosis. alk phos and acid phosphatase levels may also be elevated.
questions
physical exam...
1. what are the structures that require palpation in a male genitalia exam?
2. what is a useful diagnostic technique for determining the structure of abnormal masses in the male genital region?
3. what are the two most common prostate problems requiring a prostate exam?
4. what sensation will the patient feel if the prostate is properly palpated?
urethritis...
5. what are 3 potential sources of infection that may cause urethritis?
6. describe the typical presentation of a patient with urethritis.
7. what is the most likely etiology of urethritis for a young and old patient?
8. if the etiology is infection, what are the most likely microorganisms for urethritis?
9. what is the quality of the discharge in urethritis?
10. what are some ddx's for urethritis?
11. what is the treatment for infectious urethritis?
cystitis...
12. what is the most common cause of cystitis?
13. what are the symptoms of cystitis?
14. how is cystitis diagnosed?
lower urinary infections and congenital anomalies...
15. what is epispadias?
16. what is a common complication of epispadias and why?
17. what is hypospadias?
18. what is balanopasthitis?
19. what is a predisposing factor for balanopasthitis?
20. what is phimosis?
herpes simplex infections...
21. when do symptoms of HSV infections appear?
22. what is the typical presentation for symptomatic HSV infections?
23. compare the severity of recurrence of HSV infections vs. the original infection.
24. on average, how many recurrences a year do patients with HSV infection have?
25. how are HSV infections diagnosed?
26. what are the allopathic and naturopathic treatments for HSV?
genital warts...
27. what is the most common cause of genital warts?
28. what is the variant of [question 27] that causes most cases of genital warts?
29. describe the pathogenesis of genital warts.
30. describe the symptom picture of a patient with genital warts.
31. how long after exposure to [question 27] does it take for symptoms to appear?
erythroplasia of queyrat...
32. what is erythroplasia of queyrat?
33. what is the appearance of erythroplasia of queyrat?
34. what is the treatment for erythroplasia of queyrat?
priapism...
35. what is priapism?
36. what is the etiology of priapism?
37. what is the treatment goal for priapism?
peyronie's disease...
38. what is peyronie's disease?
39. what is the biggest concern with peyronie's disease?
40. what is the treatment strategy for peyronie's disease?
painless scrotal masses...
41. what is a hematocele? how is it diagnosed?
42. what is a hydrocele and how is it diagnosed?
43. what are acute hydroceles from and when do they usually occur?
44. when do chronic hydroceles usually occur?
45. when might one see scrotal edema?
46. what is the diagnostic sign for varicoceles?
47. what is the sensation for a patient with varicoceles?
48. what is a spermatocele?
testicular torsion...
49. what is the typical age for testicular torsion?
50. what are some etiologies for testicular torsion?
51. describe the typical symptom picture for testicular torsion.
52. what is a common finding for the history of a patient with testicular torsion?
53. what are some concomitant symptoms in testicular torsion?
54. what is a PE test useful to diagnose testicular torsion?
55. diagnosis of testicular torsion...
epididymitis...
56. what is the mechanism for pathogenesis of acute epididymitis?
57. what is the most likely etiology of acute epididymitis for patients under and over 35?
58. what are some factors that can trigger the onset of symptoms for AE?
59. what are the signs and symptoms of AE?
60. what are the labs used to diagnose AE and what are their findings?
cryptorchidism...
61. what are the different variants of cryptorchidism? which is the most common?
62. if untreated, cryptorchidism may lead to...
63. what is a PE test that can differentiate between types of cryptorchidism?
64. what is one hormonal treatment for cryptorchidism?
65. what is the treatment for retractile cryptorchidism for pre-pubescent boys?
scrotal tumors...
66. what are the most common types of scrotal tumors?
67. which demographic groups have a lower incidence of scrotal tumors?
68. what is a factor that increases the risk for scrotal tumors?
69. what are the signs and symptoms for scrotal tumors?
70. labs for ST's might show...
71. what is the prognosis for a seminoma?
prostate conditions diagnosis...
72. describe "obstructive symptoms" related to prostate.
73. how might obstructive symptoms be related to low energy?
74. what are "irritative symptoms" and what are they caused by?
75. which conditions can result in both irritative and obstructive symptoms?
76. what is the average size of the prostate?
77. what might one notice upon palpation of a hypertrophied prostate?
78. what might a "mushy" consistency indicate?
79. what might an "indurated" consistency indicate?
80. what might a "stony hard" consistency indicate?
81. when might a digital rectal exam be contraindicated and why?
82. what do elevated PSA levels indicate?
prostatitis...
83. what is ABP and what is it generally due to?
84. what are the signs and symptoms of ABP?
85. what are the PE findings for ABP?
86. what are some labs that might aid in the diagnosis of ABP?
87. compare the presentation of chronic bacterial prostatitis with ABP and urethritis.
88. describe the symptom picture of a patient with chronic bacterial prostatitis.
89. how is CBP diagnosed?
90. what is chronic non bacterial prostatitis?
91. what is the characteristic symptom for chronic non-bacterial prostatitis?
benign prostatic hypertrophy...
92. when is BPH likely to occur?
93. what are the structures affected in BPH?
94. describe the symptom picture of a patient with BPH.
95. what is a complication of BPH?
96. what are the PE findings for BPH?
97. what are the lab findings for BPH?
98. what is an important factor to consider regarding the PSA test?
99. what is a naturopathic treatment for BPH?
adenocarcinoma of the prostate...
100. what is the prognosis for adenocarcinoma of the prostate?
101. what are some risk factors for adenocarcinoma of the prostate?
102. what are the signs / symptoms for A of P?
103. what are the PE findings for A of P?
104. how is a definitive diagnosis for A of P made?
105. what is the relationship between age of diagnosis and prognosis?
106. what is the relationship between PSA levels and prognosis?
107. what are the labs used to diagnose adenocarcinoma of the prostate?
answers
1. penis, glans, testes, lower abdominal wall, epididymis.
2. transillumination.
3. BPH and cancer.
4. the urge to pee.
5. kidneys, bladders, prostate.
6. urinary urgency, frequency, pain, discharge.
7. young: STD. old: BPH or prostate issue.
8. GC, e.coli, trich, ureaplasma.
9. yellow/green, purulent in GC. whitish mucoid in non-specific.
10. congenital anomalies or urinary tract obstruction that cause urinary stasis, or bladder cancer.
11. antibiotics because of the risk of spreading.
12. chronic bacterial prostatitis.
13. frequency, urgency, dysuria, low back pain, hematuria.
14. midstream urinalysis, dipstick, urine culture.
15. congenitally displaced urethral meatus on dorsal side of the penis.
16. infection due to urinary stasis.
17. same as urethral meatus on the ventral side of the penis.
18. inflammation of the glans penis and foreskin.
19. uncircumcision.
20. inability retract foreskin of penis.
21. 3-14 days after infection.
22. itchy and painful vesicles on the head or shaft of penis that heal in 3-5 days.
23. recurrence is generally milder and shorter.
24. four a year.
25. TZANK smear.
26. allopathic: valtrex, lysine. naturopathic: lauric acid.
27. HPV.
28. strains 6 and 11, low risk for developing cancer.
29. viral particles penetrate the skin and mucosal surfaces of the genital area via micro-abrasions acquired through sexual contact.
30. soft, raised masses that are generally painless and pruritic.
31. months to years.
32. a premalignant lesion on the glans or the corona.
33. well circumscribed red/velvet area.
34. surgical removal.
35. prolonged erection not related to sexual stimulation.
36. idiopathic in 1/3, 2/3 related to other systemic conditions (sickle cell, pelvic tumors, infections, drugs)
37. reduce blood flow to the area via cold compresses.
38. hardening of the corpus cavernosa which results in distortion or deflection of the penis.
39. inability for intercourse.
40. treat as any other connective tissue disorder.
41. blood filled mass in the scrotum from trauma that does not transilluminate.
42. serous fluid filled mass in the scrotum that transilluminates.
43. inflammation of epididymis or testes, between 2-5 years old.
44. middle aged men.
45. in patients with systemic edema: congestive heart failure, nephrotic syndrome, ascites, etc.
46. feels like a "bag of worms". does not transilluminate.
47. none or a heavy, dragging sensation.
48. cystic tumor of the epididymis containing sperm.
49. 10-16.
50. congenital anomaly, undescended testicle, sexual arousal/activity, trauma.
51. spontaneous, severe, scrotal pain.
52. similar episodes in the past that resolved spontaneously.
53. N/V
abdominal pain
fever
urinary frequency
[stomach stomach hot pee]
54. the prehn sign- if lifting the testicle does not relieve the pain, it is likely testicular torsion. if it does, it is likely epididymitis.
55. doppler to assess blood flow.
56. reflux of urine into the epididymis, or infection via lymphatics.
57. under 35: GC, chlamydia. over 35: e.coli.
58. strenuous activity, sexual activity, urethral instrumentation.
59. severe scrotal pain that can radiate up spermatic cord to flank
swelling and extreme tenderness
erythematous scrotal skin that is freely movable
fever
60. CBC might show leukocytosis, UA might show bacteruria, pyuria.
61. true, incomplete, ectopic, hypermobile- most common.
62. failure of spermatogenesis and increased cancer risk.
63. asking the patient to valsalva and feel for retraction-- indicates hypermobile type.
64. HCG.
65. wait for puberty for testicle to descend fully.
66. seminomas, mixed cell types, embryonal carcinoma, teratoma.
67. blacks and asians.
68. cryptorchidism.
69. a smooth, firm, painless enlargement that does not transilluminate.
70. increased AFP, HCG, LDH.
71. 80% 5 year survival.
72. swelling of prostate leads to obstruction of urethra leads to difficulty urinating.
73. the nocturia that might result can lead to a decreased quality of sleep.
74. irritation of the prostate rather than swelling, leads to urgency, dysuria, perineal discomfort.
75. BPH, chronic prostatitis.
76. 4cm by 4cm.
77. absence of the medial sulcus palpating east-west, larger size palpating north-south.
78. congestion from lack of intercourse or infection.
79. nodules from infection.
80. tumor.
81. acute prostatitis, because it might spread the infection.
82. damage to the epithelium of the vasculature of the prostate, from cancer, infection, infarction, or trauma.
83. obstruction of the urethra distal to the prostate, generally from infection by e.coli, klebsiella, enterococcus, pseudomonas.
84. that of any infection (fever etc) plus
frequency, urgency, dysuria, nocturia
lower back and perianal pain
arthralgia / myalgia
85. warm, tender, firm, swollen prostate. copious discharge after exam.
86. CBC might show leukocytosis with left shift. dipstick might show leukocytes and bacteria. culture of prostatic secretions might show increased bacteria.
87. more urgent than urethrtitis, more toned down than ABP.
88. many of the same symptoms as ABP. may also include intense local discomfort in the scrotum, severe tenderness to palpation.
89. WBC's in prostatic secretions, "three glass method", bacterial culture.
90. inflammation of the prostate not overtly related to bacterial infection, although some connection to chlamydia might exist. more common than chronic bacterial.
91. milky white discharge.
92. over 70yo.
93. peri-urethral glands and stroma.
94. obstructive symptoms. frequency, urgency, nocturia.
95. renal failure if obstruction is severe enough.
96. enlarged, boggy, spongy, maybe lumpy. loss of median furrow.
97. increased BUN/creatinine, leukocytosis, elevation of PSA.
98. the marked increased after a manual exam.
99. hydrotherapy.
100. 97% 5 year survival.
101. old age
african american
positive family history
increased testosterone levels
high fat/low fiber diet
obesity
102. asymptomatic, or gradually developing obstructive symptoms
bone pain from metastasis
103. stony hard mass with irregular nodules.
104. biopsy.
105. the older age the diagnosis is made, the less likely it is that the patient will die from it.
106. higher free PSA levels correlate with lower chance for cancer.
107. elevated total PSA, alk phos (if spread to bone), acid phosphatase.
No comments:
Post a Comment