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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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248 SYMPTOM SORTER
Ready reckoner
Unknown Prostatitis Post-op GU infection Trauma
Persistent Possible Possible No Possible No
Recent surgical intervention No Possible Yes Possible No
Recent trauma Possible No No No Ye s
Urinary tract symptoms No Possible Possible Ye s No
Prostate markedly tender on PR No Ye s Possible No No
Possible investigations
LI KE LY: Urinalysis, MSU.
POSSIBLE: FBC, ESR/CRP, PSA, urethral swab.
SMALL PRINT: INR, clotting screen, seminal uid culture, transrectal ultrasound, prostate
biopsy, urethroscopy.
Urinalysis: Protein, nitrites, leucocytes and possible haematuria in any genito-urinary
infection or prostatitis. Haematuria possible in malignancy and schistosomiasis.
MSU: To conrm infection and identify pathogen.
FBC and ESR/CRP: WCC may be elevated in infection; Hb may be reduced and ESR/CRP
raised in malignancy; ESR/CRP also raised in infection.
PSA: e pros and cons of this test might be discussed as a pointer to prostatic carcinoma.
Urethral swab: If urethritis suspected (best taken at GUM clinic).
INR, clotting screen: If patient on warfarin or a bleeding disorder suspected.
Other investigations (usually hospital-based): ese might include seminal uid culture to
investigate deep-seated infection; transrectal ultrasound and prostatic biopsy for detailed
investigation of prostate; urethroscopy/cystoscopy if felt to be a structural urethral or bladder
problem.
TOP TIPS
A frank and open approach, using plain language, is important for the patient to feel
comfortable and capable of describing an accurate history.
Do not underestimate the patient’s level of anxiety – and ensure it’s properly addressed. Most
men with this symptom are convinced they have serious pathology.
e approach with this symptom has more to do with deciding on further action than
establishing a precise diagnosis. is is because assessment in primary care rarely reveals any
underlying pathology – management is more likely to be inuenced by the patient’s age and
the history than the clinical ndings (see the following point).
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HAEMOSPERMIA 249
Men under the age of 40 with short-lived symptoms do not require referral, as the chance
of signicant pathology is miniscule. Older men – and those with persistent or recurrent
haemospermia, or abnormalities on initial assessment – require referral for further
assessment.
A serious underlying cause is rare but should be considered in men over the age of 40 who
have more than one episode.
e chances of signicant pathology are increased by the nding of microscopic haematuria –
refer these cases.
NOTES:
https://t.me/med1917
250
PAINFUL INTERCOURSE
The GP overview
is term is taken to apply to women. It causes much misery and may be embarrassing for a
woman to discuss with her doctor. As a result, it may be the ‘hidden agenda’, presenting as a
nonexistent ‘discharge’ or vague ‘soreness down below’. Alternatively, it may be the underlying
cause of a presentation of infertility or stress. Tact and sensitivity are the most valuable diag nostic
and therapeutic tools in these situations.
Differential diagnosis
COMMON
pure vaginismus: psychogenic spasm and dryness
vulvovagi nitis (especial ly infection, e.g. bacter ial or fungal vaginosis , ulceration, bartholinitis)
menopausal vaginal dryness (atrophic vaginitis)
endometriosis
pelvic inammatory disease (PID) and cervicitis
OCCASIONAL
post-partum perineal repair
pelvic congestion (pelvic pain syndrome)
broid and retroverted uterus, ovaries in pouch of Douglas
pelvic adhesions (post-surgical or PID)
cystitis, urethritis
psychogenic/relationship issues
RARE
congenital abnormality
large ovarian cyst or tumour
vulval dysplasia
urethral caruncle
unruptured hymen
anal ssure, thrombosed piles, perianal abscess
https://t.me/med1917
PAINFUL INTERCOURSE 251
Ready reckoner
Vaginismus Vulvovaginitis Atrophic vaginitis Endometriosis PID
Abnormal discharge No Ye s Possible No Possible
Deep dyspareunia No No No Ye s Ye s
Heavy painful periods No No No Ye s Possible
Vaginal dryness Ye s No Ye s No No
Tight introitus O/E Ye s No No No No
Possible investigations
LI KE LY: High vaginal/cervical swabs.
POSSIBLE: Urinalysis, MSU, urethral swab, ultrasound, laparoscopy (in secondary care).
SMALL PRINT: FBC, ESR/CRP, CA-125, vulval biopsy (secondary care).
Urinalysis for nitrite, pus cells and blood useful to rule out UTI.
MSU will help guide treatment in UTI.
If abnormal discharge, take high vaginal and cervical swabs to establish nature of pathogen.
Urethral swab usef ul if possible urethritis (usually at genito-urinary medicine [GUM] clinic).
FBC may show raised WCC in chronic PID.
ESR/CRP elevated in PID.
Pelvic ultrasound can dene lie of the uterus and ovaries, presence of cysts and gross
endometriosis.
CA-125: If any suspicion of ovarian cancer.
Investigations aer referral may include laparoscopy (e.g. for endometriosis and PID) and
vulval biopsy (for suspected dysplasia).
TOP TIPS
Supercial dyspareunia (pain at the introitus) is usually caused by infection, vaginismus or
atrophy; deep dyspareunia (deep pain) may be caused by pelvic pathology.
If a sexually transmitted infection could be the cause, refer to a GUM clinic – these are best
equipped for thorough screening, counselling and contact tracing.
e patient complaining that her ‘vagina feels too small’ to accommodate her partner’s penis
probably has vaginismus.
Deep dyspareunia which is long-standing and positional is ‘collision’ dyspareunia and is very
unlikely to be due to signicant pathology.
Deep dyspareunia usually resolves immediately on withdrawal; if it lasts a day or two aer
intercourse, it may well have a psychological basis.
https://t.me/med1917
252 SYMPTOM SORTER
Relationship problems may cause dislike of intercourse which presents as pain. Disharmony
may be the cause rather than result of the problem.
Cyclical dyspareunia with generalised pelvic pain and heavy, painful periods suggest
endometriosis or PID – refer for gynaecological opinion.
Pelvic tumour is rare in this context, but consider this possibility in the older woman
presenting with deep dyspareunia of recent onset.
Examine the menopausal or perimenopausal woman complaining of persistent supercial
dyspareunia – vulval dysplasia, rather than atrophic vaginitis, may be the cause.
NOTES:
https://t.me/med1917
253
PENILE PAIN
The GP overview
Pain in the penis occurs not just as a result of local causes, but also by referral from remote lesions.
It frequently generates embarrassment for the patient, who may also be frightened that he has a
sexually transmitted disease. e diagnosis will oen be clear aer a carefully taken history and
appropriate examination.
Differential diagnosis
COMMON
balanitis (fungal, bacterial or allergic)
acute urethritis
phimosis (e.g. balanitis xerotica obliterans)
urinary calculus (at any point in ureter or urethra)
prostatitis/prostatic abscess
OCCASIONAL
herpes simplex (and rarely zoster)
carcinoma of bladder or prostate
trauma: torn frenulum, zipper injury, urethral injury or foreign body
acute cystitis
Peyronie’s disease (pain usually on erection)
paraphimosis
tight frenulum
RARE
anal ssure/inamed haemorrhoid
carcinoma of penis
carcinoma of rectum/anus
tuberculosis of urinary tract
schistosomiasis (Schistosoma haematobium): common in Africa and the Middle East
https://t.me/med1917
254 SYMPTOM SORTER
Ready reckoner
Balanitis Prostatitis Calculus Phimosis Urethritis
Dysuria Possible Possible Possible Possible Ye s
Discharge Ye s Possible No Possible Ye s
Rectal pain No Ye s Possible No Possible
Haematuria No Possible Ye s No Possible
Tender glans Ye s No No Possible No
Possible investigations
LI KE LY: Urinalysis, MSU, swabs.
POSSIBLE: FBC, ESR/CRP, PSA.
SMALL PRINT: Renal tract imaging, cystoscopy, terminal stream urine.
Urinalysis: May reveal proteinuria, haematuria, pus cells and nitrites in the presence of
infection; haematuria alone with a stone or tumour. Will also reveal glycosuria in the
previously undiagnosed diabetic (may present with candidal balanitis).
MSU (for MC&S): To establish pathogen in UTI (may also reveal infective agent in
prostatitis).
Swabs for microbiology: Urethral swab if urethritis likely (best performed at GUM clinic).
In balanitis with discharge, a swab may help guide treatment.
FBC and ESR/CRP: WCC and ESR/CRP raised in signicant infection and inammation
(e.g. prostatitis or prostatic abscess). ESR/CRP may be raised in malignancy.
PSA: Consider this test if carcinoma of the prostate a possibility.
Renal tract imaging (usually hospital-based) to investigate the urinary tract if stone or
carcinoma suspected, or if chronic UTI suspected.
Terminal stream urine: For schistosomiasis.
Cystoscopy: May be required in secondary care to conrm and treat stone or tumour.
TOP TIPS
e man who has symptoms suggesting cystitis but who has sterile pyuria on MSU probably
has urethritis.
GUM clinics are organised to undertake full investigation, counselling and contact tracing.
Referral is essential if STD is likely.
Prostatitis is oen forgotten as a diagnosis – but is very dicult to diagnose with certainty,
especially when chronic. A trial of a prolonged course of antibiotics may be justied.
Painful intercourse: Usually a sudden pain – accompanied by bleeding suggests a torn
frenulum. is oen occurs in a younger man who is frequently very alarmed by the event.
Reassure him by explaining that this is not sinister and is easily treatable.
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PENILE PAIN 255
Pain aer micturition suggests cystitis. is is unusual in men, and further investigation is
indicated if recurrent.
Intermittent pain with passage of blood clots interspersed with painless haematuria suggests
a carcinoma (bladder, ureter [rare] or kidney).
Remember that candidal balanitis may be the rst sign of diabetes.
Refer the elderly man with an adherent foreskin and balanitis. ere could be an underlying
carcinoma.
NOTES:
https://t.me/med1917
256
PENILE ULCERATION/
SORES
The GP overview
Presentation of this symptom is nearly always accompanied by fear of sexually transmitted
disease, even in elderly or no longer sexually active men. ere are a number of other causes,
many of which are signicant and require investigation.
Differential diagnosis
COMMON
herpes simplex virus (HSV)
boil/infected sebaceous cyst
balanitis: bacterial or fungal
trauma: zipper injury commonest; also torn frenulum, bites, self-mutilation
balanitis xerotica obliterans (BXO)
OCCASIONAL
herpes zoster
Reiter’s syndrome: circinate balanitis
allergic contact eczema
chancroid (so sore: Haemophilus ducreyi)
granuloma inguinale (Klebsiella granulomatis: tropical infection)
lymphogranuloma venereum (tropical infection)
RARE
sy philis (cha ncre)
carcinoma of the penis
tuberculosis
dermatological conditions (e.g. Behçet’s syndrome, lichen planus)
xed drug eruption
https://t.me/med1917
PENILE ULCERATION/SORES 257
Ready reckoner
Herpes simplex Boil Balanitis Trauma BXO
Dysuria Possible No Possible Possible Possible
Contact with symptoms Possible No Possible No No
Inguinal nodes enlarged Ye s Possible Possible No No
Discrete single lesion No Ye s No Possible No
Generally unwell Possible No No No No
Possible investigations
LI KE LY: Swab, syphilis serology.
POSSIBLE: Urinalysis, FBC, ESR/CRP.
SMALL PRINT: Patch testing, biopsy.
Urinalysis: In balanitis, may detect undiagnosed diabetes.
Swab: May reveal infectious cau se, e.g. herpes simplex, Candida, ch ancroid, lympho granuloma
venereum and granuloma inguinale (if STD suspected, then other appropriate swabs and
blood tests for coexistent disease will be performed at GUM clinic).
FBC and ESR/CRP: Raised WCC and ESR/CRP in signicant infection or inammation
(e.g. Reiter’s syndrome).
Syphilis serology: If syphilis suspected (Note: May take up to 3 months to become positive
aer initial infection).
Patch testing: If allergic contact eczema a possibility.
Biopsy (in secondary care): To conrm suspected malignancy or reveal underlying skin
condition (e.g. lichen planus).
TOP TIPS
Take a full sexual history, even in the older patient. If STD is suspected, refer to a GUM
clinic for investigation, counselling and contact tracing.
A diagnosis of HSV may induce a number of worries in the patient, some of them well
founded, others less so. Give the patient plenty of time to talk through the diagnosis and its
implications properly.
Whatever the cause, the patient is very likely to fear an STD. Ensure that inappropriate
anxieties are resolved.
Enquire aer coexistent or previous dermatological problems in obscure cases – this may
provide the diagnosis (e.g. lichen planus).
https://t.me/med1917
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