urologic diseases and nephrolithiasis victor politi, m.d., facp medical director, st. john’s...
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Urologic Diseases and Nephrolithiasis
Victor Politi, M.D., FACPMedical Director, St. John’s University-School of Allied Health Professions, Physician Assistant Program
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Urologic Diseases
Testicular torsionEpididymitis/
orchitis
Hernias
Incontinence
Phimosis/paraphimosis
Prostatitis
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Acute Scrotum
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Testicular Torsion
Twisting of the testes and spermatic cord around a vertical axis
Leads to venous obstruction, progressive swelling, arterial compromise and eventually testicular infarct
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Must be considered initial diagnosis of scrotal pain!
Exam: reveals painful testi that may have a
high lie
Testicular Torsion
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Epidemiology: Usually young malesPresentation: Sudden onset of
scrotal pain, PMH of cryptorchidism, red, swollen scrotum, negative Prehn’s sign (relief of pain by elevation of testicles)
management: Emergent surgical detorsion
Testicular Torsion
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Epididymitis
Infection of the epididymis acquired by retrograde spread of organisms via the urethra to the ejaculatory duct, then down the vans deferens to the epididymitis
Acute infectious process associated with painful enlargement of epididymis
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Most cases of acute epididymitis are infectious
two categories sexually transmitted -typical with
C.trachomatis or N. gonorrhoeae non-sexually transmitted (typically older men)
associated with UTI prostatitis, caused by gram negative rods
tx with amiodarone has been associated with epididymitis
Epididymitis
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Symptoms may follow acute physical strain, trauma, or sexual activity, usually associated with urethritis
Fever and scrotal swelling are common
The epididymis is located posterior lateral to the testis
Epididymitis
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Presentation: coexisting UTI or prostatitis usually adult males heaviness and dull aching discomfort in
affected hemiscrotum which can radiate to flank
epididymis indistinguishable from testis erythematous scrotum positive Prehn’s sign (pain relief by elevation of
scrotum in supine patient)
Epididymitis
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Management: rule out torsion antibiotics (directed toward identified
pathogen)age < 35 chlamydia (sexual partner treated
also)age > 35 E. coli
Urine culture bed rest w/scrotal elevation in acute phase
Epididymitis
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Orchitis
Inflammation of the testes due to STD or inadequate immunization
epidemiology: manifestation of STD - gonorrhea or chlamydial infection, non STD with viral mumps or rarely filariasis
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Orchitis
Presentation: Painful testes Hx of postpubertal mumps tender, swollen testis difficult to distinguish epididymis parotid swelling (with mumps)
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Orchitis
Management: antibiotics if bacterial symptomatic if viral
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Inguinal hernias
Direct Hernia History:
men over 40large, painless
groin mass for many years
Indirect hernia History:
Most commonpainless scrotal
mass
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Direct hernia Physical Exam
Palpable mass at side of finger outside of inguinal canal
Indirect hernia Physical Exam
Palpable mass at tip of finger in inguinal canal
Large mass in scrotum
Inguinal hernias
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Inguinal Hernias
Management: Avoid strangulation or incarceration,
otherwise elective surgical repair
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Interstitial Cystitis
Pain with full bladder relieved by emptying associated with urgency and frequency.
Dx of exclusion no other cause of cystitis I.E.
radiation cystitis, chemical cyctitis (cyclophosphamide),vaginitis, urethral diverticulum
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Interstitial Cystitis
Etiology is unkown assoc with irritable bowel dz, or
inflammatory bowel dz and persons with severe allergies.
Dx made with cystoscopy after hydrodilitation to detect submucosal hemorrhage.
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Interstitial Cystitis
There is no cure for ICTx includes hydrodistention for
symptomatic reliefAmitriptyline,calcium channel
blockersDMSO, intravesical instillation of
dimethyl sulfoxide, heparin orBCGSurgery as last resort.
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Presentation: Uncircumcised male painful penis or foreskin hx of catheterization inflamed retracted foreskin erythematous, edematous glans
Phimosis/Paraphimosis
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Management: compression of the glans with forward
traction on the foreskin may reduce paraphimosis, phimosis may resolve, if not prompt circumcision required
Phimosis/Paraphimosis
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Prostatitis
Presentation: suprapubic or pudendal pain fever dysuria hematuria tender, fluctuant prostate
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Prostatitis
Management: E. Coli most common bacterial- treat
with antibiotics 30 days if acute, 6-8 weeks is chronic
Chlamydia is typical “non bacterial” agent,
also prostatic massage, diet
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Nephrolithiasis
Renal stones occur throughout the urinary tract - common causes of pain, infection, obstruction
Formed in proximal tract and pass distally, lodging at ureteropelvic junction, ureter at iliacs, and ureterovesical junction
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Nephrolithiasis
Four Basic Types: Calcium phosphate/oxalate 80% Uric acid 5% Cystine 2% Struvite <2%
Calcium stones are radiopaque, uric acid stones are radiolucent
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Nephrolithiasis
Presentation back pain and renal colic that waxes and
wanes, may awaken from sleep pain radiates to groin, testicles, suprapubic,
patients constantly moving may be asymptomatic (non obstructing
stones) hematuria, dysuria, urinary frequency diaphoresis, tachycardia, tachypnea fever and chills, hypertension, CVAT, nausea
and vomiting
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Nephrolithiasis
Evaluation: CBC w/diff, BUN/creatinine,Ca,Po4,uric acid Urinalysis, urine culture, 24hr urine Plain film of abdomen (90% radiopaque)KUB Intravenous urogram Retrograde urography Ultrasound-- CT w/o contrast best choice obtain strained urinary sediment for analysis
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Nephrolithiasis
Patients are encouraged to increase fluid intake particularly 2 hours after meals when the body is most dehydrated and before bedtime.
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Nephrolithiasis
Management: Stones< 5mm likely to pass
spontaneouslytreat as outpatient; drink
Stones > 10mm not likely to pass spontaneously and more likely to have complicationstreat as inpatient; vigorous fluids, IV
antibiotics if signs of infection, ureter stent or nephrostomy, IM analgesia
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Stones 5-10 MM less likely to pass spontaneously, should be considered for early selective intervention if no complicating factors (infection, high grade obstruction, solitary kidney)
Larger stones may require ureteroscopic stone extraction ( basket) or extracorporeal shock wave lithotripsy ESWL
Nephrolithiasis
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Nephrolithiasis
Patients with renal stones in the renal pelvis without pain, obstruction or infection need not be treated.
Larger stones that might present a future problem can be removed by percutaneous nephrolithotomy
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Questions ?