Author: Renu Maurya

Acute Prostatitis

ACUTE PROSTATITIS


ACUTE PROSTATITIS

  • Inflammation of prostate can be Acute or Chronic.

ETIOLOGY-

  • MC organism- E. Coli > staphylococcus aureus > staphylococcus albus
  • Instrumentation
  • Ascending and descending infection from below and above into infected urine into prostatic ducts
  • Haematogenous

CLINICAL FEATURES-

  • High grade fever, chills and rigors
  • Retention of urine
  • Perineal heaviness, pain on defaecation and micturition
  • Enlarged, tender and boggy protate- rectal examination
  • Catherization and prostatic massage is contraindicated  

INVESTIGATIONS-

  • USG abdomen 

TREATMENT-

  • IV fluids, antipyretics
  • Antibiotics- TMP- SMX, ciprofloxacin or norfloxacin (2- 3 weeks)
COMPLICATIONS
  • Seminal vasculitis

Exam Important

ETIOLOGY-

  • MC organism- E. Coli > staphylococcus aureus > staphylococcus albus
  • Instrumentation
  • Ascending and descending infection from below and above into infected urine into prostatic ducts
COMPLICATIONS
  • Seminal vasculitis
Don’t Forget to Solve all the previous Year Question asked on ACUTE PROSTATITIS

Module Below Start Quiz

Acute Prostatitis

Acute Prostatitis

Q. 1 Complication which commonly accompanies acute prostatitis –

 A

Epididymitis

 B

Orchitis

 C

Seminal vesiculitis

 D

Sterility

Q. 1

Complication which commonly accompanies acute prostatitis –

 A

Epididymitis

 B

Orchitis

 C

Seminal vesiculitis

 D

Sterility

Ans. C

Explanation:

Ans. is ‘c’ i.e., Seminal vesiculitis 

Quiz In Between



Carcinoma Of Prostate

CARCINOMA OF PROSTATE


CARCINOMA OF PROSTATE

  • Carcinoma of prostate is the MC malignant tumour in men over 65 years.
  • MC cause of bone secondaries
  • Carcinoma of prostate occurs in peripheral zone in prostatic gland proper (commonly in posterior lobe)

RISK FACTORS-

  • Advancing age + increase fat intake
  • Genetic alterations is hypermethylation of glutathione transferase (GSTP-1) located on chromosome 11

PATHOLOGY-

  • Adenocarcinoma of prostate is the MC form of cancer in males
  • They are multifocal and heterogenous

SPREAD-

1. Local spread-

  • Upward- seminal vesicles, bladder neck, trigone
  • Downward- distal sphincter

2. Blood spread-

  • Bones- pelvic bones, lumbar vertebrae, femoral head, ribs and skull
  • MC site of origin- for skeletal metastases

3. Lymphatic spread-

  • Obturator lymph nodes

CLINICAL FEATURES-

  • Bladder outlet obstruction
  • Haematuria
  • Commonly asymptomatic
  • Pelvic pain, back pain, arthritic pain
  • Renal failure
  • Perineural invasion
  • Rectal examination- prostate feels hard, nodular, irregular and obliteration of medial sulcus

STAGING-  

INVESTIGATIONS-

1. Hb%

  • Anemia
  • Thrombocytopenia
  • DIC

2. Plain X-ray, KUB-

  • Shows sclerotic metastases in lumbar vertebrae and pelvic bones

3. Serum acid phosphatase-

  • Responsible for acidic pH in the prostatic urethra and normally drained in urine
  • Increase acid phosphatase

4. Serum alkaline phosphatase-

  • Increase in extensive liver metastasis or bone metastasis

5. Prostate specific antigen(PSA)

  • It is a glycoprotein, serine protease elaborated by columnar prostatic acinar epithelial cells.
  • Free- 10- 40%, complexed to antiprotease- 60 to 90%
  • Formed in prostate and secreted in seminal fluid
  • Causes liquefaction of seminal coagulum
  • More than 4nmol/ml- carcinoma detected
  • 10 nmol/ml- prostatic carcinoma
  • 35 nmol/ ml- disseminated carcinoma
  • Prostate specific, but not prostate cancer specific
  • Most efficient test and for staging and assessing

6. Abdominal and transrectal USG- staging of the disease

7. CT scan or MRI scan

  • Staging of the disease
  • MRI is ideal for most accurate for local staging

8. Bone scan-

  • Increased ALP
  • Increased PSA (>20nmol/ml)
  • For diagnosing metastasis

TREATMENT-

I) Early malignancy

a) T1 a-

  • Well differentiated associated with very slow growth rate
  • Regular follow up with DRE and PSA

b) T1b T1c, T2

  • Radical prostactectomy or radiotherapy
  • External beam radiotherapy- T1 or low T2 disease
  • Branchytherapy- low T1 disease

II) Late malignancy (T3, T4 or any metastasis)

  • Androgen ablation is the first line of treatment followed by antiandrogenic measure
  • Orchiectomy + flutamide or LHRH + flutamide
  • Palliative radiotherapy

Exam Important

  • Carcinoma of prostate is the MC malignant tumour in men over 65 years.
  • MC cause of bone secondaries
  • Carcinoma of prostate occurs in peripheral zone in prostatic gland proper (commonly in posterior lobe)

CLINICAL FEATURES-

  • Bladder outlet obstruction
  • Haematuria
  • Commonly asymptomatic
  • Pelvic pain, back pain, arthritic pain
  • Renal failure
  • Perineural invasion
  • Rectal examination- prostate feels hard, nodular, irregular and obliteration of medial sulcus

INVESTIGATIONS-

1. Hb%

  • Anemia
  • Thrombocytopenia
  • DIC

2. Plain X-ray, KUB-

  • Shows sclerotic metastases in lumbar vertebrae and pelvic bones

3. Serum acid phosphatase-

  • Responsible for acidic pH in the prostatic urethra and normally drained in urine
  • Increase acid phosphatase

4. Serum alkaline phosphatase-

  • Increase in extensive liver metastasis or bone metastasis

5. Prostate specific antigen(PSA)

  • It is a glycoprotein, serine protease elaborated by columnar prostatic acinar epithelial cells.
  • Free- 10- 40%, complexed to antiprotease- 60 to 90%
  • Formed in prostate and secreted in seminal fluid
  • Causes liquefaction of seminal coagulum
  • More than 4nmol/ml- carcinoma detected
  • 10 nmol/ml- prostatic carcinoma
  • 35 nmol/ ml- disseminated carcinoma
  • Prostate specific, but not prostate cancer specific
  • Most efficient test and for staging and assessing

6. Abdominal and transrectal USG- staging of the disease

7. CT scan or MRI scan

  • Staging of the disease
  • MRI is ideal for most accurate for local staging

8. Bone scan-

  • Increased ALP
  • Increased PSA (>20nmol/ml)
  • For diagnosing metastasis

TREATMENT-

I) Early malignancy

a) T1 a-

  • Well differentiated associated with very slow growth rate
  • Regular follow up with DRE and PSA

b) T1b T1c, T2

  • Radical prostactectomy or radiotherapy
  • External beam radiotherapy- T1 or low T2 disease
  • Branchytherapy- low T1 disease

II) Late malignancy (T3, T4 or any metastasis)

  • Androgen ablation is the first line of treatment followed by antiandrogenic measure
  • Orchiectomy + flutamide or LHRH + flutamide
  • Palliative radiotherapy
Don’t Forget to Solve all the previous Year Question asked on CARCINOMA OF PROSTATE

Module Below Start Quiz

Carcinoma Of Prostate

Carcinoma of prostate

Q. 1 Which is the most common site of carcinoma prostate?

 A

Peripheral

 B

Centre

 C

Verumontum

 D

None of the above

Q. 1

Which is the most common site of carcinoma prostate?

 A

Peripheral

 B

Centre

 C

Verumontum

 D

None of the above

Ans. A

Explanation:

85% of prostate carcinoma arise from the peripheral zone.
Ninety five percent of tumors are adenocarcinoma.
Prostate carcinoma rarely occur before the age of 40 years, and the incidence increases with age. 

  • PSA is elevated in 60% of men with prostate cancer. Levels above 4ng/ml is considered abnormal.
  • Levels of PSA can be elevated with age and BPH. 
  • Falsely elevated PSA can be seen following cystoscopy, prostate biopsy, or urethral catheterization.
  • PSA is not elevated following digital rectal examination.

Ref: CURRENT Diagnosis & Treatment: Surgery, 13e, chapter 38


Q. 2

Trans rectal ultrasonogram in evaluation of carcinoma prostate most useful for:

 A

Taking guided biopsy

 B

Identifying seminal vesicle invasion

 C

Nodal sampling

 D

Measuring the extent of invasion

Q. 2

Trans rectal ultrasonogram in evaluation of carcinoma prostate most useful for:

 A

Taking guided biopsy

 B

Identifying seminal vesicle invasion

 C

Nodal sampling

 D

Measuring the extent of invasion

Ans. A

Explanation:

Ans. is ‘a’ Taking guided biopsy 

“TRUS is the imaging technique most frequently used to assess the primary tumor, but its chief use is directing prostate biopsies, not staging” – Harrison

  • Thus primary role of TRUS is guiding prostate biopsies
  • Other uses are

– assessing extent of invasion if cancer is detected.

– measurement of prostate volume which is needed in the calculation of the PSA density. – also used in performance of cryosurgery & brachytherapy.


Q. 3

Which is not used in carcinoma prostate ‑

 A

Estrogen

 B

Progesterone

 C

Cyproterone acetate

 D

Flutamide

Q. 3

Which is not used in carcinoma prostate ‑

 A

Estrogen

 B

Progesterone

 C

Cyproterone acetate

 D

Flutamide

Ans. C

Explanation:

Ans. is ‘c’ i.e., Conservative treatment 

Quiz In Between


Q. 4

In carcinoma prostate with matastasis which is raised

 A

ESR

 B

Alkaline phosphatase

 C

Acid phosphatase

 D

All

Q. 4

In carcinoma prostate with matastasis which is raised

 A

ESR

 B

Alkaline phosphatase

 C

Acid phosphatase

 D

All

Ans. B

Explanation:

Ans. is ‘b’ i.e., Alkaline phosphatase 


Q. 5

70 year old man with Ca.prostate with osteoblastic secondaries in pelvis and lumbar vertebra showed well differentiated Adeno Carcinoma prostate on needle biopsy. He is idealy treated by –

 A

Radical prostectomy

 B

TURP

 C

Radiation

 D

Hormonal manipulation

Q. 5

70 year old man with Ca.prostate with osteoblastic secondaries in pelvis and lumbar vertebra showed well differentiated Adeno Carcinoma prostate on needle biopsy. He is idealy treated by –

 A

Radical prostectomy

 B

TURP

 C

Radiation

 D

Hormonal manipulation

Ans. D

Explanation:

Ans. is ‘d’ i.e., Hormonal manipulation 

Quiz In Between



Epispadias

EPISPADIAS


EPISPADIAS

  • Urethra opens in the dorsum (upper aspect) of the penis in males.
  • In females, there is fissure in the wall of the urethra which opens above clitoris (uncommon)
  • MC site in abdominopenile junction
  • Associated with-

a) Dorsal chordee

b) Ectopia vesicae

c) Urinary incontinence

d) Separated pubic bone

CLINICAL FEATURES-

  • Males- glandular epispadias seldom have urinary incontinence
  • Incontinence in penopubic (95%) and penile epispadias (75%)
  • Females- bifid clitoris and separation of the labia
  • Most are incontinent

TREATMENT-

  • Surgery- correct incontinence, remove chordee and extend urethra to glans penis
  • Urinary diversion

Exam Important

  • Urethra opens in the dorsum (upper aspect) of the penis in males.
  • In females, there is fissure in the wall of the urethra which opens above clitoris (uncommon)
  • MC site in abdominopenile junction
  • Associated with-

a) Dorsal chordee

b) Ectopia vesicae

c) Urinary incontinence

d) Separated pubic bone

Don’t Forget to Solve all the previous Year Question asked on EPISPADIAS

Module Below Start Quiz

Epispadias

Epispadias

Q. 1 Epispadias is associated with?

 A

Bifid pubic symphysis

 B

Chordee

 C

Anal atresia

 D

Intestial obstruction

Q. 1

Epispadias is associated with?

 A

Bifid pubic symphysis

 B

Chordee

 C

Anal atresia

 D

Intestial obstruction

Ans. B

Explanation:

Ans is b i.e. chordee 

  • An epispadias is a rare type of congenital malformation in which the urethra opens on the dorsum (the upper aspect) of the penis. It is often part of the condition termed Epispadias-exstrophy of the bladder. Epispadias is a mild form of bladder exstrophy, and in severe cases, exstrophy and epispadias coexist.
  • The extent of the defect can vary from a mild glandular defect to complete defects as are observed in bladder exstrophy, diastasis of the pubic bones, or both.

–  In glandular epispadias, the urethra opens on the dorsal aspect of the glans, which is broad and flattened.

– In the penile type, the urethral meatus, which is broad and gaping, is located between the pubic symphysis and the coronal sulcus. A distal groove usually extends from the meatus through the splayed glans.

–  The penopubic type has the urethral opening at the penopubic junction, and the entire penis has a distal dorsal groove extending through the glans.

  • All types of epispadias are associated with varying degrees of dorsal chordee.
  • Females with epispadias have a bifid clitoris and separation of the labia.
  • Male to female ratio of epispadias is 3: 1.
  • Incontinence due to maldevelopment of urinary sphincters is commonly associated with most epispadias except for the glandular type.
  • Other associated anomaly is pubic diastasis as in exstrophy.
  • Surgery is required to correct the incontinence, remove the chordee to straighten the penis, and extend the urethra out onto the glans penis.

Note that pubic diastasis (i.e. separation of pubic bones) is not synonymous with bifid pubic symphysis.


Q. 2 Epispadias in relation to hypospadias ‑

 A

Is more common

 B

Less common

 C

Occures with the same frequency

 D

Is difficult to treat

Q. 2

Epispadias in relation to hypospadias ‑

 A

Is more common

 B

Less common

 C

Occures with the same frequency

 D

Is difficult to treat

Ans. B

Explanation:

Ans. is ‘b’ i.e., Less common 

Quiz In Between



Phimosis

PHIMOSIS


PHIMOSIS

  • Inability to retract the preprucial skin over the glans.

ETIOLOGY-

  1. Congenital (MC)
  2. Balanitis (inflammation of the glans) & Balanoposthitis (inflammation of glans, prepuce and sac). Both are common in diabetics
  3. Chancre
  4. Carcinoma of penis

CLINICAL FEATURES-

  • Difficuluty in micturition
  • In children, ballooning of prepuce
  • Edema, erythema, tenderness of prepuce

TREATMENT-

  • Circumcision (especially recurrent infection >16- 18 years)
  • Local steroid cream (4- 6 weeks)
  • If phimosis is associated with considerable infection, it should be treated with broad-spectrum antimicrobial drugs. The dorsal slit of foreskin, if improved drainage is necessary.
  • Circumcision for phimosis should be avoided in children requiring general anesthesia; except in cases with recurrent infections.
  • The procedure should be postponed until the child reaches an age when local anesthesia can be used.

COMPLICATIONS-

  • Balanoposthitis, hydronephrosis
  • Prepucial calculi, carcinoma under foreskin or penis

Exam Important

TREATMENT-

  • Circumcision (especially recurrent infection >16- 18 years)
  • Local steroid cream (4- 6 weeks)
  • If phimosis is associated with considerable infection, it should be treated with broad-spectrum antimicrobial drugs. The dorsal slit of foreskin, if improved drainage is necessary.
  • Circumcision for phimosis should be avoided in children requiring general anesthesia; except in cases with recurrent infections.
  • The procedure should be postponed until the child reaches an age when local anesthesia can be used.
Don’t Forget to Solve all the previous Year Question asked on PHIMOSIS

Module Below Start Quiz

Phimosis

Phimosis

Q. 1 The recommended treatment for preputial adhesions producing ballooning of prepuce during micturition in a 5  years old boy is:
(AIIMS June 2003)

 A

 Wait and watch policy

 B

Circumcision

 C

 Dorsal slit

 D

Preputial adhesions release and dilatation

Q. 1

The recommended treatment for preputial adhesions producing ballooning of prepuce during micturition in a 5  years old boy is:
(AIIMS June 2003)

 A

 Wait and watch policy

 B

Circumcision

 C

 Dorsal slit

 D

Preputial adhesions release and dilatation

Ans. A

Explanation:

A
If phimosis is associated with considerable infection, it should be treated with broad-spectrum antimicrobial drugs. The dorsal slit of foreskin, if improved drainage is necessary.
• Circumcision for phimosis should be avoided in children requiring general anesthesia; except in cases with recurrent infections.
• The procedure should be postponed until the child reaches an age when local anesthesia can be used.

Quiz In Between



Paraphimosis

PARAPHIMOSIS


PARAPHIMOSIS

  • Inability to place back the retracted prepucial skin over the glans.
  • The retracted skin acts like a tight ring constricting proximal to the corona and prepuceal skin resulting in venous congestion.
  • Congestion results n glans swelling, oedematous with severe pain and tenderness.
  • Glans will undergo necrosis or gangrenous change.

ETIOLOGY

  • Catherization
  • After sexual intercourse

CLINICAL FEATURES-

  • Severe pain
  • Swelling and oedema

TREATMENT-

  • Sedation
  • Injection hyluronidase (250 units in 10- 15 ml of saline injected into constricting ring reduces oedema and paraphimosis also gets reduced)
  • Dorsal slit is given for reduction which is followed by circumcision later.

Exam Important

  • Inability to place back the retracted prepucial skin over the glans.
  • The retracted skin acts like a tight ring constricting proximal to the corona and prepuceal skin resulting in venous congestion.
  • Congestion results n glans swelling, oedematous with severe pain and tenderness.
  • Glans will undergo necrosis or gangrenous change.

TREATMENT-

  • Sedation
  • Injection hyluronidase (250 units in 10- 15 ml of saline injected into constricting ring reduces oedema and paraphimosis also gets reduced)
  • Dorsal slit is given for reduction which is followed by circumcision later.
Don’t Forget to Solve all the previous Year Question asked on PARAPHIMOSIS

Module Below Start Quiz

Paraphimosis

Paraphimosis

Q. 1 Not true about paraphimosis is –

 A

Iatrogenic

 B

Seen in Diabetes mellitus

 C

Gangrene of glans

 D

Circumcision is the t/t

Q. 1

Not true about paraphimosis is –

 A

Iatrogenic

 B

Seen in Diabetes mellitus

 C

Gangrene of glans

 D

Circumcision is the t/t

Ans. B

Explanation:

Ans is ‘b’ ie Seen in Diabetes mellitns 

  • Diabetes mellitus has no role in paraphimosis.

Paraphimosis

  • Etiology: When a prepuce is forcibly retracted over the glans penis, it may get stuck behind the glans. This condition is k/a paraphimosis.
  • Pathology –>

This constricting band of phimotic prepuce causes obstruction to the venous flow, which lead to edema and congestion of the glans.

The glans swells leading to more difficulty in retracting back the prepuce.

In neglected cases gangrene may result.

  • Treatment —>
  • Ice bags, gentle manual compression and injection of a solution of hyaluronidase in normal saline may help to reduce the swelling.
  • If conservative method fails then the pt. can be t/t by circumcision*.

A dorsal slit of the prepuce under local anaesthetic may be enough in an emergency

  • It is uncommon for the urethra to be compressed, so the micturition is normally not affected.

Q. 2 About Paraphimosis true is :

 A

Catheter induced

 B

Circumcision is treatment

 C

Hyaluronidase inj

 D

All of the above

Q. 2

About Paraphimosis true is :

 A

Catheter induced

 B

Circumcision is treatment

 C

Hyaluronidase inj

 D

All of the above

Ans. D

Explanation:

Ans. is ‘d’ i.e. All of the above 
Paraphimosis may be produced when during catheterization the prepuce is forcibly retracted over gland penis. 

Quiz In Between



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