Surgery
Urology — testicular, prostate, scrotal, renal masses
Surgery

Urology — testicular, prostate, scrotal, renal masses

Testicular torsion (the emergency), BPH vs prostate cancer, scrotal mass workup, RCC + bladder cancer.

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◆Acute scrotum — torsion vs epididymitis

  • •Testicular torsion: SUDDEN severe pain, NAUSEA/vomiting, high-riding testis, ABSENT cremasteric reflex, horizontal lie, NEGATIVE Prehn sign (pain NOT relieved with elevation)
  • •Time-critical: detorsion within 6 hr → ~100% salvage; >24 hr → ~0%
  • •If high clinical suspicion → OR for manual detorsion + bilateral orchiopexy (don't delay for imaging)
  • •If equivocal → Doppler US (decreased flow); torsion of appendix testis (blue dot sign) is benign mimic
  • •Epididymitis: GRADUAL onset, fever, dysuria, POSITIVE Prehn sign (relief with elevation), PRESERVED cremasteric reflex; treat ceftriaxone + doxycycline (<35 yo, suspect GC/CT) or fluoroquinolone (>35 yo)

◆Scrotal masses

  • •Varicocele: 'bag of worms', usually LEFT side (left gonadal vein drains into left renal vein), worse with standing/Valsalva; can cause infertility; surgical or embolization repair
  • •Hydrocele: transilluminates; congenital (resolves <1 yr) or reactive; surgery only if persistent or symptomatic
  • •Spermatocele: transilluminates; smooth, mobile, painless; observe
  • •Inguinal hernia: bulge with Valsalva; surgical repair if symptomatic
  • •Testicular cancer (young men 15–35): PAINLESS testicular mass, hard, does NOT transilluminate; AFP (yolk sac), β-hCG (choriocarcinoma), LDH; do NOT trans-scrotal biopsy — INGUINAL orchiectomy
  • •Risk factors testicular cancer: cryptorchidism (orchiopexy before age 1 reduces risk), family hx, Klinefelter (mediastinal germ cell)

◆Prostate

  • •BPH: nocturia, hesitancy, weak stream, sense of incomplete emptying; AUA score; α-blockers (tamsulosin) → 5α-reductase inhibitors (finasteride) → combination → TURP
  • •Avoid anticholinergics in BPH (worsen urinary retention)
  • •Acute urinary retention from BPH → Foley + α-blocker, then trial of voiding
  • •Prostate cancer: most common cancer in men; PSA screen 55–69 (shared decision); DRE finds hard posterior nodule; biopsy if PSA >4 or DRE abnormal
  • •Prostate cancer treatment: localized → active surveillance vs radical prostatectomy vs radiation; metastatic → androgen deprivation (leuprolide + flutamide); osteoblastic bone mets
  • •Acute bacterial prostatitis: fever, perineal pain, dysuria, very tender prostate on DRE (DO NOT MASSAGE — bacteremia risk); fluoroquinolones × 4–6 weeks
  • •Chronic prostatitis: pelvic pain, normal exam often; fluoroquinolones × 6 weeks

◆Renal masses & bladder cancer

  • •Renal cell carcinoma (RCC): hematuria + flank pain + palpable mass (classic triad rare); paraneoplastic (EPO, PTHrP, renin); risk factors smoking, obesity, HTN, VHL; CT abdomen/pelvis → partial or radical nephrectomy
  • •Wilms tumor: kids 2–5 yr, palpable abdominal mass, hematuria; associated with WAGR, Beckwith-Wiedemann, Denys-Drash
  • •Bladder cancer: PAINLESS gross hematuria in older smoker; transitional cell most common; cystoscopy with biopsy → TURBT ± BCG ± radical cystectomy
  • •Renal stones: severe colicky flank pain radiating to groin, hematuria; non-contrast CT (best test); <5 mm pass spontaneously, >10 mm need intervention (lithotripsy, ureteroscopy, percutaneous nephrolithotomy)
  • •Calcium oxalate stones (most common): low oxalate diet, thiazide (reduces urine Ca)
  • •Uric acid stones: radiolucent on X-ray; alkalinize urine (potassium citrate), allopurinol
  • •Struvite stones: 'staghorn'; UTI with urease-producing bugs (Proteus, Klebsiella); treat infection + surgery
  • •Cystine stones: kids, recurrent; cystinuria

◆Erectile dysfunction

  • •Causes: vascular (atherosclerosis), neurogenic (DM, MS), endocrine (low T, hyperPRL), psychogenic, drugs (β-blockers, antipsychotics, SSRIs)
  • •Workup: morning T, prolactin, lipid panel, glucose, TSH
  • •Treat underlying cause first; PDE5 inhibitors (sildenafil) first-line
  • •Sildenafil + nitrates = hypotension (CONTRAINDICATED)
  • •Sildenafil + α-blockers can cause hypotension (caution)
  • •Refractory: intracavernosal injection, vacuum, penile prosthesis

High-yield pearls

  • ◆Testicular torsion = surgical EMERGENCY — do NOT delay for imaging if suspicion is high
  • ◆Painless testicular mass in young man = cancer until proven otherwise → INGUINAL orchiectomy (never trans-scrotal biopsy)
  • ◆Painless gross hematuria in older smoker = bladder cancer → cystoscopy
  • ◆Acute prostatitis: DO NOT massage the prostate (bacteremia risk)
  • ◆Tamsulosin (α1A-selective) is the BPH α-blocker of choice (less orthostatic hypotension)
  • ◆Hydrocele transilluminates; testicular cancer does NOT
  • ◆Sildenafil + nitrates = absolute contraindication (severe hypotension)
  • ◆Calcium oxalate stones treated with THIAZIDE diuretic (reduces urine Ca via DCT reabsorption)
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