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Urology

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• local: Kidney Stones, Renal

Acute scrotum

• Diagnosis and Treatment of the Acute Scrotum - February 15 1999 - AAFP

Torsion

• 16 - 42%  acute scrotum is  testicular torsion.
• short duration of symptoms esp with abrupt onset, U/A negative. May have history of intermittent similar symptoms. Elevating testicle does not relieve pain.
• Manual detorsion: rotate testis away from midline. If works can have elective surgery, else Surgeon.

Appendiceal Torsion

• younger child, localize to upper pole, gradual onset, positive cremasteric reflex. A hard, tender nodule may be palpable. Small bluish discoloration ("blue dot sign") + tenderness is very predictive.
• days of bed rest and scrotal elevation

Epididymitis

• older child, slower onset, elevating testes decrease pain, positive U/A.
• traumatic epididymitis same therapy.
• younger child: urinary tract anomaly (need sonogram, VCUG)
• ab Rx until culture known, abacterial epididymitis -> urine reflux.
• Bed rest and scrotal elevation,  NSAID
• pain and swelling resolve <= 1 wk, induration  weeks.

Trauma

• pain > 1 hour, need evaluate for testicular rupture or acute torsion. Resolves promptly,  recur gradually days later -> traumatic epididymitis.
• intratesticular hematoma, hematocele, laceration tunica albuginea (testicular rupture)
• Color Doppler ultrasonography
• rupture immediate drainage and repair

Other

• Long duration of Sx and positive U/A: color doppler U/S to diagnose
• Misc d/dx: incarcerated hernias, varicoceles, hematomas and testicular ruptures
• Acute idiopathic scrotal edema: rapid onset of significant edema without tenderness. Tests neg. Bed rest, scrotal elevation, analgesia.
• HSP -> scrotal pain +/- hematuria (rare)
• Inguinal hernia -> u/s if unsure
• hydrocele, varicocele

Age and D/Dx

• neonates and postpubertal: testicular torsion
• prepubertal: Schönlein-Henoch purpura and torsion of a testicular appendage
• postpubertal: epididymitis

BPH Drug therapy (see PSA)

(Many urologists follow PSA if threating for Prost Hypertrophy as this group has a higher incidence of CA prostate than a normal group.)

• Hytrin: main effect at 1 mg qHS, incremental benefit up to 10 mg. Main s/e: fatigue. Works quickly.
• Proscar: 30% of patients improve at 6-12 months.

Cremasteric Reflex

• age 30 mo - 12 y: stroking or gently pinching the skin of the upper inner thigh while observing the scrotum -> contraction of the cremasteric muscles on the ipsilateral side with unilateral elevation of the testis.

Evaluation of urinary symptoms

1. irritative symptoms without obstructive symptoms and negative UTI: r/o bladder CA or CIS (do cytology)

2. post-void residual (see Incontinence)

• normal < 50
• marginal: 50-200
• decompensation: > 200 ml

Incontinence

stress incontinence

• DHIC is most common bladder contraction abnormality -- frequent nerve firing, weak response. Most women seen for stress incontinence also have some DHIC
• voiding frequency and fluid management best test for management -- measure how much drink, how often void
• indications for urodynamics
  • elevated post-void residual
  • risk factors: radiation, neuro, surgery, trauma
  • previous failed procedure
• FemSoft insert: small number of patients
  • insert into urethra
  • occlusive device
  • place prior to substantial activity
  • 1/3 in trials got UTIs
• Kegel Exercises
• Estrogen therapy does not change urodynamics but pts think they do better.
• phenylpropanolamine can increase tone, but no-one can tolerate it. Useful prn for more critical needs (traveling, etc)

urge incontinence

• Ditropan/Oxybutinin: anticholinergic, local anesthetic, muscle relaxant.
• Kegel Exercises

Kegel Exercises

• Classically for stress incontinence, but some data suggests work best for urge incontinence
• Kegels are hard to teach and learn and do! Need to have very high motivation and discipline to get them to work. Pt has to do Kegel's forever and very frequently. Can be very effective.
• Biofeedback very useful for training control of pelvic floor. Teaching pelvic floor exercies during pelvic exam -- see if pt can "draw in" fingers (like tampon), isolate pelvic floor for Kegel exercises. Same muscle as preventing "passing gas". Need to do Kegel very often for 4-6 seconds. Start training with 2 second holds, 3 second pause.
• vaginal weights are about $30, only helpful if patient can contract the pelvic floor (as above)

management of high volume leakage

• all incontinent patients have some degree of sphincteric dysfunction
• bulking agents around urethra are much more commonly used; 1/3 of really wet pts have significant improvement, 1/3 moderate, 1/3 no result
• long history of experimental procedures that have failed
• slings are only surgery with a history of durability and success, probably need to use own tissue, they are "tried and true"

Interstitial cystitis

• nortriptyline 25 mg PO qD
• elmiron has FDA approval

Paraphimosis

• wrap penis from tip using gauze bandages soaked in 5% lidocaine ointment (max 1.25 g for child)
• wrap firmly, maximal at glans then decrease towards base. After 5-10 minutes remove, should be able to reduce the foreskin. Refer for circumcision?

PSA

• Use age-adjusted normative values
• If use Proscar must measure post-Rx to establish baseline?

Trapped Zipper Syndrome

• mineral oil best, lidocaine infrequently needed