Professional Skills Urology Core Module

1. Professional SkillsUrology Core Module Trustin Domes

2. 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

3. 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

4. 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

5. Clinical Anatomy of the Prostate Verma S , Rajesh A AJR 2011;196:S1-S10

6. Prostate Anatomy • Peripheral Zone = 85% of prostate cancer originate in this zone, therefore are detected on DRE • Transition Zone = site of benign prostatic hyperplasia

7. 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

8. 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

9. 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%

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

11. 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”

12. Digital Rectal Examination • Comment on: • Prostate • Size • Symmetry • Consistency • Tenderness • Nodules • Rectal/Anal Masses • Rectal Tone

13. 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)?