Category: Module

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
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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
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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

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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.
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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.
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Peyronie’s Disease

PEYRONIE’S DISEASE


PEYRONIE’S DISEASE (PENILE FIBROMATOSIS/ INDURATION- PENIS PLASTICA)

  • It is a development of fibrous tissue plaque on the covering of corpus cavernosum involving tunica albuginea which may later calcify or ossify.
  • Palmar fibromatosis + plantar fibromatosis + penile fibromatosis = superficial fibromatosis

ETIOLOGY

  • Associated with-

a) Dupuytren’s contracture (plamar fibromatosis)

b) Retroperitoneal fibrosis

c) Plantar facitis

  • Trauma
  • Venereal disease

CLINICAL FEATURES-

  • Painful erection, curvature of penis and poor erection distal to involved area
  • Palpable induration or mass present on dorsolateral aspect of the penis
  • Later erectile dysfunction, penile shortening
  • Indurated plaque in the penis
  • Spontaneous regression occurs in 50% of the cases.

 

TREATMENT-

  1. Drugs- steroids, Vitamin E, tsmoxifen, terfenadine and fexafenadine (not very effective)
  2. Intralesional injection- verapamil
  3. Surgery-

a) Excision and placation to opposite side- fitzpatric

b) Multiple incisions over fibrous plaque and temporal fascia bridging- Gelhard’s operation

Exam Important

ETIOLOGY

  • Associated with-

a) Dupuytren’s contracture (plamar fibromatosis)

b) Retroperitoneal fibrosis

c) Plantar facitis

  • Trauma
  • Venereal disease

CLINICAL FEATURES-

  • Painful erection, curvature of penis and poor erection distal to involved area
  • Palpable induration or mass present on dorsolateral aspect of the penis
  • Later erectile dysfunction, penile shortening
  • Indurated plaque in the penis
  • Spontaneous regression occurs in 50% of the cases.

TREATMENT-

  1. Drugs- steroids, Vitamin E, tsmoxifen, terfenadine and fexafenadine (not very effective)
  2. Intralesional injection- verapamil
  3. Surgery-

a) Excision and placation to opposite side- fitzpatric

b) Multiple incisions over fibrous plaque and temporal fascia bridging- Gelhard’s operation

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Circumcision

CIRCUMCISION


CIRCUMCISION

INDICATIONS-

  • Religious (jews and muslims)
  • Phimosis
  • Paraphimosis
  • Balanitis & balanoposthitis
  • Early carcinoma of prepuce or glans penis
  • STD
  • Recurrent UTI

PROCEDURE-

  • In children, it is done under GA
  • In adults, it is done under LA.

COMPLICATIONS-

  • Reactionary haemorrhage
  • Infection
  • Stricture urethra near external meatus in children
  • Chordee

Exam Important

INDICATIONS-

  • Religious (jews and muslims)
  • Phimosis
  • Paraphimosis
  • Balanitis & balanoposthitis
  • Early carcinoma of prepuce or glans penis
  • STD
  • Recurrent UTI

PROCEDURE-

  • In children, it is done under GA
  • In adults, it is done under LA.

COMPLICATIONS-

  • Reactionary haemorrhage
  • Infection
  • Stricture urethra near external meatus in children
  • Chordee
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Carcinoma Of Penis

CARCINOMA OF PENIS


CARCINOMA OF PENIS

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

PATHOLOGY-

  1. Infiltrating type- pre-existing leukoplakia
  2. Papilliferous type
  3. Ulcerative type- glans penis MC site. 80% are low grade tumours

SPREAD-

  1. Lymphatics-
  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN.

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

 

INVESTIGATIONS-

  • Incisional biopsy for grade and depth of invasion and wedge biopsy for SCC
  • Senitel LN biopsy (Cabana sentinel LN)
  • USG- assessment of depth
  • MRI- IOC for staging in CA penis

STAGING-

  1. Stage 1- Confined to glans or prepuce
  2. Stage 2- involving penile shaft or copora cavernosa
  3. Stage 3- Operable inguinal LN metastasis
  4. Stage 4- inoperable inguinal LN metastasis Or advanced spread

TNM STAGING 

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection

Exam Important

  • MC type – SCC

ETIOLOGY-

  1. Premalignant lesions-
  • Genital warts- Bushke- Lowenstein tumour is a giant penile condyloma (verrucous carcinoma of penis)
  • Erythroplasia of Queyrat or Paget’s disease of penis- precancerous lesion
  • Leukoplakia of glans
  • Bowen’s disease- small eczematous plaque
  • Chronic balanoposthitis, phimosis (50%), Balanitis xerotica obliterans
  • Condyloma auminata (HPV)
  • Most important carcinogens- HPV (16, 18, 31, 33)
  • Poor hygiene

SPREAD-

1. Lymphatics-

  • Spreads to horizontal group of inguinal lymph nodes and are nodular, hard, fixed which suggests metstasis.
  • Carcinoma from shaft of penis spreads to external iliac LN
  • Initernal and paraaortic LN get enlarged

2. Blood spread is rare

3. Death may occur due to erosions of femoral vessels by iguinal LN. 

CLINICAL FEATURES-

  • Occurs in 6th decade
  • Neonatal circumcision helps in immunity against carcinoma penis, HIV or STD.
  • MC orginates from glans > sulcus > prepuce > shaft
  • Foul smelling discharge is common
  • In adults, recent onset of phimosis
  • Haematuria, pain while passing urine- advanced tumours
  • On examination, fungation and induration, everted edge
  • Pain, oedema, tenderness, redness present on infection
  • Urethra is rarely involved as it is protected by tough Buck’s fascia

TREATMENT-

  • Surgery is the TOC
  • Ca in situ- topical 5- FU cream, Nd- YAG laser, radiotherapy + follow up
  • Ca in situ
  • Young’s operation- for glans involvement without extending into proximal part of shaft
  • Total amputation with perineal urethrostomy- if shaft is involved
  • Piersey Gold operation- total amputation + total scrotectomy + total orchidectomy
  • Laser ablation- stage T1 tumour
  • Enlarged inguinal node- block dissection
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Priapism

PRIAPISM


PRIAPISM

  • Painful, persistent erection, not normally associated with sexual excitement.
  • Erection may be atleast for 24 hours
  • May occur due to Cantharide poisoning

TYPES-

  1. High flow priapism- secondary to penile or perneal trauma
  2. Low flow flow priapism- painful, more common

CLINICAL FEATURES-

  • Children 5 to 10 years – MC due to sickle cell disease, leukemia
  • Adults 20 to 50 years- mostly iatrogenic 

TREATMENT-

  • Ketamine (within 4- 6 weeks)
  • Winter’s procedure

Exam Important

  • Painful, persistent erection, not normally associated with sexual excitement.
  • Erection may be atleast for 24 hours
  • May occur due to Cantharide poisoning

CLINICAL FEATURES-

  • Children 5 to 10 years – MC due to sickle cell disease, leukemia
  • Adults 20 to 50 years- mostly iatrogenic
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Fournier Gangrene

FOURNIER GANGRENE


FOURNIER’S GANGRENE

  • Also called as idiopathic gangrene of the scrotum.
  • It is a vascular gangrene, a form of necrotizing fasciitis, with abrupt onset of a rapidly fulminating genital gangrene of idiopathic origin and gangrene upto deep fascia.
  • Trauma, infection → microorganism → inflammation → obliterative arteritis → scrotal gangrene
  • Common in diabetics (MC)

ETIOLOGY-

  • Haemolytic streptococci, staphylococci, E.coli,Bacteriodes (anaerobes)
  • Malnourished, immunosuppression

CLINICAL FEATURES-

  • Sudden pain and inflammation in scrotum along with fever, toxicity
  • Extensive gangrene of the scrotal skin results in sloughing of the scrotal skin exposing testicles (skin, superficial and deep fascia are destroyed)
  • Perineal phlegmon– gangrene involving skin of penis, anterior abdominal wall, medial side of thigh, perianal region.
  • Testis not involved due to thick tunica albuginea.
  • Crepitus is present

TREATMENT-

  • IV hydration, antibiotics, surgical debridement of the necrotic fat and fascia.
  • Mortality without treatment (7- 75%)
  • Surgical debridement is the needed with serial debridement is required too.

Exam Important

  • Also called as idiopathic gangrene of the scrotum.
  • It is a vascular gangrene, a form of necrotizing fasciitis, with abrupt onset of a rapidly fulminating genital gangrene of idiopathic origin and gangrene upto deep fascia.
  • Trauma, infection → microorganism → inflammation → obliterative arteritis → scrotal gangrene
  • Common in diabetics (MC)

ETIOLOGY-

  • Haemolytic streptococci, staphylococci, E.coli,Bacteriodes (anaerobes)
  • Malnourished, immunosuppression

CLINICAL FEATURES-

  • Sudden pain and inflammation in scrotum along with fever, toxicity
  • Extensive gangrene of the scrotal skin results in sloughing of the scrotal skin exposing testicles (skin, superficial and deep fascia are destroyed)
  • Perineal phlegmon– gangrene involving skin of penis, anterior abdominal wall, medial side of thigh, perianal region.
  • Testis not involved due to thick tunica albuginea.
  • Crepitus is present

TREATMENT-

  • IV hydration, antibiotics, surgical debridement of the necrotic fat and fascia.
  • Mortality without treatment (7- 75%)
  • Surgical debridement is the needed with serial debridement is required too.
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