Professional Skills Urology Core Module

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Professional SkillsUrology Core Module

• Trustin Domes

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Outline

• Brief Anatomy of Scrotum and Prostate
• Physical Examination CVA, Scrotum and DRE
• Case Scenarios
• LUTS
• Hematuria
• Upper and lower urinary tract obstruction
• Scrotal Masses/Pain

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Anatomy of Scrotal Contents

• Vessels
• Testicle has 3 arterial blood supplies
• Testicular artery
• Cremasteric artery
• Deferential artery
• Pampiniform venous plexus
• Lymphatics
• Nerves
• Cremasteric muscle/fascia
• Vas deferens

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Anatomy of Scrotal Contents

• Vas is the most posterior component of spermatic
  cord
• Tunica vaginalis surrounds the anterior 2/3rd of
  the testicle and creates a potential space for
  hydroceles and hematoceles

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Clinical Anatomy of the Prostate
Verma S , Rajesh A AJR 2011196S1-S10
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Prostate Anatomy

• Peripheral Zone 85 of prostate cancer
  originate in this zone, therefore are detected on
  DRE
• Transition Zone site of benign prostatic
  hyperplasia

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CVA and Ballottement

• If CVA tenderness think
• Renal colic
• Pyelonephritis
• Significant renal trauma
• Renal vascular occlusion

If you can ballot the kidney think - Large renal
mass - Polycystic kidney disease - Severely
hydronephrotic kidney
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Physical Examination of the Scrotum

• Best to examine the man in both the supine and
  upright positions
• Helps to demonstrate conditions that change with
  position hernias and varicoceles
• Bimanual examination of each testicle, adenxa and
  spermatic cord
• Testicular size, consistency, masses, tenderness
• Normal testis size 16-20 cc (2 x 4 cm)
• Examine cord upright (/- valsalva) to assess for
  presence of vas deferens, inguinal hernia and
  varicocele

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Cremasteric Reflex

• Reflex elicited by stroking the medial thigh
  causes an ipsilateral contraction of the
  cremasteric muscle (bringing the testicle closer
  to the external inguinal ring)
• Reflex tests L1-L2 (genitofemoral nerve
  responsible for afferent and efferent limbs)
• Typically absent in testicular torsion
• Negative predictive value of over 90

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Transillumination

• Important to help differentiate solid from
  fluid-filled masses
• Hydroceles and spermatoceles will
  transilluminate, other scrotal masses typically
  WILL NOT

Hydrocele
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Varicoceles

• Dilated veins of the paminiform plexus
• Predominant left-sided (98)
• Isolated right-sided varicocele may be caused by
  a retroperitoneal
• NEED abdominal imaging
• Varicocele grading
• Grade I palpable only with valsalva
• Grade II easily palpable without valsalva
• Grade III large, visible through scrotal skin

Grade III bag of worms
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Digital Rectal Examination

• Comment on
• Prostate
• Size
• Symmetry
• Consistency
• Tenderness
• Nodules
• Rectal/Anal Masses
• Rectal Tone

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Prostate size
Average prostate size is approximately 25 cc in
men older than 50 years
25 cc
150 cc
How many finger-breadths across? Can you get to
the top (base)?