Male GU
Testicular Assessment
Varicocele
o can cause dull ache that worsens after heavy exercise
o palpable or visible dilation of the vessels of the pampiniform plexus
in the scrotum; retrograde reflux of venous blood in the internal
spermatic vein dilates the pampiniform plexus.
o more common on the left, owing to the greater distance the
internal spermatic vein must traverse to the left renal vein when
compared with the right. The etiology remains unclear, and there
are no specific risk factors. It is unusual for males to exhibit a
varicocele before adolescence, and most varicoceles are
asymptomatic.
o Varicoceles are commonly diagnosed during a routine health
maintenance examination or during a urology or male infertility
evaluation (semen parameters are often decreased; varicoceles
represent a common cause of secondary male infertility) or less
commonly during an evaluation for scrotal pain or a scrotal mass. If
a varicocele is painful, the pain may increase with prolonged
standing, exertion, or sitting; pain is rare after prolonged
recumbency or sleeping. A varicocele typically presents unilaterally
on the left side. The acute onset of a painful varicocele, on the left
or right, may indicate obstruction of the spermatic or renal vein
and warrants more urgent evaluation.
o Most varicoceles are asymptomatic, but the patient may complain
of a dull ache, fullness, pain that does not radiate, or pulling to the
affected side of the scrotum. If the varicocele is large enough, it
typically results in scrotal swelling that is noticeable to the patient,
along with a bluish discoloration beneath the scrotal skin. Primary
or secondary male infertility may be the presenting symptom. The
varicocele can be exaggerated during physical examination by
asking the patient to perform the Valsalva maneuver while
standing; any distension of the pampiniform plexus should
disappear when the patient lies down. A long-standing varicocele
may cause testicular atrophy. If the varicocele is large, it may be
visible during inspection (“bag of worms”).
o A scrotal ultrasound is not necessary but will definitively confirm a
varicocele and rule out any testicular or scrotal pathology.
Epididymitis
, o This inflammation of the epididymis is caused by the spread of an
infection from the bladder or urethra owing to an alteration in the
urethral closure mechanism. Uncircumcised men and men with
indwelling catheters, benign prostatic hypertrophy, recent GU
instrumentation, or prostatic surgery are at risk for epididymitis. In
heterosexual men younger than 35, the causative organisms are
likely to be Neisseria gonorrhoeae and Chlamydia trachomatis. In
gay men, the causative organism is usually Escherichia coli. In
cases where an organism associated with an STI is suspected, the
exposure to the organism can significantly predate the
development of epididymitis. If epididymitis is left unrecognized
and untreated, it can progress to an abscess or chronic infection
with resulting fibrosis, chronic scrotal pain, and infertility.
o Complaints usually involve a sudden onset (over 24 to 48 hours) of
painful swelling in the scrotum, which can be unilateral or
bilateral. Pain may decrease with elevation of the scrotum (Prehn’s
sign), although this is an unreliable indicator. There may be an
associated urethral discharge and/or fever, and complaints of
urethritis, cystitis, or prostatitis are possible. On physical
examination, the pain will localize to the affected epididymis with
palpation, which will be swollen and indurated. The spermatic cord
is usually tender and swollen, and pain may radiate to the inguinal
canal and/or flank. Examination can be difficult, as inflammation
can distort the anatomy, and manipulation is likely to increase the
patient’s complaints of pain.
o An ultrasound will differentiate between testicular torsion and
epididymitis, and it can be helpful in establishing the correct
diagnosis in cases of the acute onset of pain
Prostate Assessment
Prostatitis
o an acute or chronic infection of the prostate gland. Acute bacterial
prostatitis is usually the result of infection by aerobic gram-
negative rods (coliform bacteria or Pseudomonas). Enterococcus
faecalis, an aerobic gram-positive bacteria, can also cause
prostatitis. Routes of infection are ascent from the urethra, reflux
of infected urine into the prostatic ducts, direct extension of
bacteria, and migration via the lymphatic and vascular system. It
may be associated with acute cystitis and may result in urinary
retention.
, o Acute symptoms commonly include fever, low back and perineal
pain, possible penis pain, urinary urgency and frequency, nocturia,
dysuria, and muscle and joint aches. Transrectal palpation of the
prostate reveals a very tender, boggy, swollen prostate. Urine may
smell strong and be cloudy. Gross or microscopic hematuria may be
present. CBC will be positive for leukocytosis and a shift to the left.
Chronic prostatitis manifests as recurrent episodes of irritative
symptoms of dysuria, nocturia, frequency, and urgency. Febrile
episodes, gross hematuria, and hematospermia are rare. A tender,
indurated epididymis can be associated with chronic prostatic
infection.
o Low back pain in the sacral area differentiates prostatitis from
pyelonephritis, which manifests as flank pain. A urine culture will
reveal the offending pathogen. Presentation of sudden, severe
onset rather than milder, recurrent episodes differentiates acute
from chronic prostatitis.
BPH
o nonmalignant enlargement of the transition zone of the prostate
gland; the precise etiology is unclear. Risk factors are simply
advancing age and normal androgen status, although there may be
an additional genetic predisposition.
o LUTS associated with bladder outlet obstruction secondary to an
enlarged prostate include urinary urgency, frequency, hesitation in
getting the stream started, decreased caliber and force of stream,
and nocturnal frequency of urination that is bothersome. This
collection of symptoms has also been termed prostatism. A patient
with BPH shows symmetric or asymmetric enlargement and a firm,
smooth, nontender gland.
o If the PSA level is elevated relative to the age-specific reference, or
if there has been a rise greater than 0.75 ng/mL in less than 12
months, the patient should be referred to a urology specialist for
discussion and management, including possible prostate biopsy or
surgery to improve the urinary outlet (transurethral resection of
the prostate).
Women’s GU
Discharge
Yeast Vaginitis (Candidiasis)
, o one of the more common vaginal infections in young patients and is
caused by the fungus Candida albicans.
o The discharge is very thick and curdlike and adheres to the vaginal
walls. Intense vulvar itching accompanies the discharge. Because
the discharge is thick, patients often give a history of itching but
no discharge since it adheres to the vaginal walls and may not be
seen by the patient. In most cases, inflammation and swelling
around the labia and introitus occur. This inflammation causes
dyspareunia and burning of the labia with urination. Partners
generally do not have any related complaints.
o A 10% KOH (potassium hydroxide) wet prep is most helpful for
visualizing budding yeast and hyphae microscopically.
Bacterial Vaginosis
o G. vaginalis is the most prevalent vaginal infection, although many
of the patients with this infection are asymptomatic.
o the overwhelming complaint is of a malodorous discharge. G.
vaginalis has a distinct fishy odor. The odor is usually noticeable
during the pelvic examination, but a few drops of 10% KOH
solution on the wet prep slide augment the odor. The discharge is
fairly thick and white. Patients do not complain of itching, and,
generally, there is no inflammation of the vaginal mucosa. Male
partners do not complain of discharge, odor, or dysuria, although it
is believed they may harbor the bacteria without being
symptomatic.
o The diagnosis is made on symptomatology and KOH wet prep.
o Trichomoniasis
The presenting complaints with trichomoniasis are discharge
and itching. the discharge is thin and frothy. presence of
vulvar itching and inflammation but no complaint of odor.
Inflammation with petechiae of the vaginal walls, known as
strawberry spots. Male partners are usually asymptomatic
but harbor the organism, and they must be treated along
with the patient; intercourse should be avoided or condoms
used until treatment is completed by each partner.
easily seen on a wet prep as a flagellate protozoan in the
majority of cases
o Chlamydia
Patients are often asymptomatic with chlamydia infections
but may present with mucopurulent discharge, dysuria,
Testicular Assessment
Varicocele
o can cause dull ache that worsens after heavy exercise
o palpable or visible dilation of the vessels of the pampiniform plexus
in the scrotum; retrograde reflux of venous blood in the internal
spermatic vein dilates the pampiniform plexus.
o more common on the left, owing to the greater distance the
internal spermatic vein must traverse to the left renal vein when
compared with the right. The etiology remains unclear, and there
are no specific risk factors. It is unusual for males to exhibit a
varicocele before adolescence, and most varicoceles are
asymptomatic.
o Varicoceles are commonly diagnosed during a routine health
maintenance examination or during a urology or male infertility
evaluation (semen parameters are often decreased; varicoceles
represent a common cause of secondary male infertility) or less
commonly during an evaluation for scrotal pain or a scrotal mass. If
a varicocele is painful, the pain may increase with prolonged
standing, exertion, or sitting; pain is rare after prolonged
recumbency or sleeping. A varicocele typically presents unilaterally
on the left side. The acute onset of a painful varicocele, on the left
or right, may indicate obstruction of the spermatic or renal vein
and warrants more urgent evaluation.
o Most varicoceles are asymptomatic, but the patient may complain
of a dull ache, fullness, pain that does not radiate, or pulling to the
affected side of the scrotum. If the varicocele is large enough, it
typically results in scrotal swelling that is noticeable to the patient,
along with a bluish discoloration beneath the scrotal skin. Primary
or secondary male infertility may be the presenting symptom. The
varicocele can be exaggerated during physical examination by
asking the patient to perform the Valsalva maneuver while
standing; any distension of the pampiniform plexus should
disappear when the patient lies down. A long-standing varicocele
may cause testicular atrophy. If the varicocele is large, it may be
visible during inspection (“bag of worms”).
o A scrotal ultrasound is not necessary but will definitively confirm a
varicocele and rule out any testicular or scrotal pathology.
Epididymitis
, o This inflammation of the epididymis is caused by the spread of an
infection from the bladder or urethra owing to an alteration in the
urethral closure mechanism. Uncircumcised men and men with
indwelling catheters, benign prostatic hypertrophy, recent GU
instrumentation, or prostatic surgery are at risk for epididymitis. In
heterosexual men younger than 35, the causative organisms are
likely to be Neisseria gonorrhoeae and Chlamydia trachomatis. In
gay men, the causative organism is usually Escherichia coli. In
cases where an organism associated with an STI is suspected, the
exposure to the organism can significantly predate the
development of epididymitis. If epididymitis is left unrecognized
and untreated, it can progress to an abscess or chronic infection
with resulting fibrosis, chronic scrotal pain, and infertility.
o Complaints usually involve a sudden onset (over 24 to 48 hours) of
painful swelling in the scrotum, which can be unilateral or
bilateral. Pain may decrease with elevation of the scrotum (Prehn’s
sign), although this is an unreliable indicator. There may be an
associated urethral discharge and/or fever, and complaints of
urethritis, cystitis, or prostatitis are possible. On physical
examination, the pain will localize to the affected epididymis with
palpation, which will be swollen and indurated. The spermatic cord
is usually tender and swollen, and pain may radiate to the inguinal
canal and/or flank. Examination can be difficult, as inflammation
can distort the anatomy, and manipulation is likely to increase the
patient’s complaints of pain.
o An ultrasound will differentiate between testicular torsion and
epididymitis, and it can be helpful in establishing the correct
diagnosis in cases of the acute onset of pain
Prostate Assessment
Prostatitis
o an acute or chronic infection of the prostate gland. Acute bacterial
prostatitis is usually the result of infection by aerobic gram-
negative rods (coliform bacteria or Pseudomonas). Enterococcus
faecalis, an aerobic gram-positive bacteria, can also cause
prostatitis. Routes of infection are ascent from the urethra, reflux
of infected urine into the prostatic ducts, direct extension of
bacteria, and migration via the lymphatic and vascular system. It
may be associated with acute cystitis and may result in urinary
retention.
, o Acute symptoms commonly include fever, low back and perineal
pain, possible penis pain, urinary urgency and frequency, nocturia,
dysuria, and muscle and joint aches. Transrectal palpation of the
prostate reveals a very tender, boggy, swollen prostate. Urine may
smell strong and be cloudy. Gross or microscopic hematuria may be
present. CBC will be positive for leukocytosis and a shift to the left.
Chronic prostatitis manifests as recurrent episodes of irritative
symptoms of dysuria, nocturia, frequency, and urgency. Febrile
episodes, gross hematuria, and hematospermia are rare. A tender,
indurated epididymis can be associated with chronic prostatic
infection.
o Low back pain in the sacral area differentiates prostatitis from
pyelonephritis, which manifests as flank pain. A urine culture will
reveal the offending pathogen. Presentation of sudden, severe
onset rather than milder, recurrent episodes differentiates acute
from chronic prostatitis.
BPH
o nonmalignant enlargement of the transition zone of the prostate
gland; the precise etiology is unclear. Risk factors are simply
advancing age and normal androgen status, although there may be
an additional genetic predisposition.
o LUTS associated with bladder outlet obstruction secondary to an
enlarged prostate include urinary urgency, frequency, hesitation in
getting the stream started, decreased caliber and force of stream,
and nocturnal frequency of urination that is bothersome. This
collection of symptoms has also been termed prostatism. A patient
with BPH shows symmetric or asymmetric enlargement and a firm,
smooth, nontender gland.
o If the PSA level is elevated relative to the age-specific reference, or
if there has been a rise greater than 0.75 ng/mL in less than 12
months, the patient should be referred to a urology specialist for
discussion and management, including possible prostate biopsy or
surgery to improve the urinary outlet (transurethral resection of
the prostate).
Women’s GU
Discharge
Yeast Vaginitis (Candidiasis)
, o one of the more common vaginal infections in young patients and is
caused by the fungus Candida albicans.
o The discharge is very thick and curdlike and adheres to the vaginal
walls. Intense vulvar itching accompanies the discharge. Because
the discharge is thick, patients often give a history of itching but
no discharge since it adheres to the vaginal walls and may not be
seen by the patient. In most cases, inflammation and swelling
around the labia and introitus occur. This inflammation causes
dyspareunia and burning of the labia with urination. Partners
generally do not have any related complaints.
o A 10% KOH (potassium hydroxide) wet prep is most helpful for
visualizing budding yeast and hyphae microscopically.
Bacterial Vaginosis
o G. vaginalis is the most prevalent vaginal infection, although many
of the patients with this infection are asymptomatic.
o the overwhelming complaint is of a malodorous discharge. G.
vaginalis has a distinct fishy odor. The odor is usually noticeable
during the pelvic examination, but a few drops of 10% KOH
solution on the wet prep slide augment the odor. The discharge is
fairly thick and white. Patients do not complain of itching, and,
generally, there is no inflammation of the vaginal mucosa. Male
partners do not complain of discharge, odor, or dysuria, although it
is believed they may harbor the bacteria without being
symptomatic.
o The diagnosis is made on symptomatology and KOH wet prep.
o Trichomoniasis
The presenting complaints with trichomoniasis are discharge
and itching. the discharge is thin and frothy. presence of
vulvar itching and inflammation but no complaint of odor.
Inflammation with petechiae of the vaginal walls, known as
strawberry spots. Male partners are usually asymptomatic
but harbor the organism, and they must be treated along
with the patient; intercourse should be avoided or condoms
used until treatment is completed by each partner.
easily seen on a wet prep as a flagellate protozoan in the
majority of cases
o Chlamydia
Patients are often asymptomatic with chlamydia infections
but may present with mucopurulent discharge, dysuria,
