Lauren Valentine

laurenvalentinemd@[Link]
@[Link]

STIs

● Syphilis: painless lesion, painless lymphadenopathy

● Donovanosis: painless lesion, NO lymphadenopathy
● LGV: painless lesion, painFUL lymphadenopathy

All sexually women age <25 and those with

low-risk sexual behavior are recommended
annual screening for Chlamydia and Neisseria
d/t high rates of asymptomatic infection or risk
of long-term sequelae
● NAAT is the gold standard testing
method
● Most common cause of cervicitis =
chlamydia and gonorrhea
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

H. ducreyi: fastidious gram-negative rod

● Develops erythematous papules that evolve into pustules and erode into painful ulcers
● Painful lymphadenitis is common

Herpes simplex (HSV): painful, pruritic, vesicular or ulcerative lesions

● Inguinal LAD
● Can have urinary retention and sterile pyuria
● Dx: viral culture (in active lesions) or PCR

Condyloma acuminata: d/t

HPV 6 and 11
● Asymptomatic but
can be
itching/burning
● HPV 16 and 18 are at
increased risk of SCC
of anus, genital
organs and throat
● HIV screening should
be offered to pts with
new dx of HPV
● Risk factors: tobacco use and immunosuppression
Appear as skin-colored lesions that are friable and itchy

Tx: self-limited, but options include:

● Chemical or physical agents (podophyllin, trichloroacetic acid)
● Immune therapy (imiquimod)
● Surgery (cryosurgery, excision, laser treatment) for larger lesions

Most common causes of urethritis in males:

● Neisseria gonorrhoeae
● Chlamydia
● Mycoplasma genitalium
● Trichomonas vaginalis
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Gonococcal infection:
● Pharyngitis
● Urethritis
● Cervicitis
● PID
● Proctitis

Gonococcal pharyngitis occurs d/t inoculation of the

pharynx during orogenital contact → pharyngeal
edema, erythema and nontender cervical LAD

Can cause lower cervicitis or upper genital tract

disease (PID) → fever, mucopurulent discharge and
pelvic pain

-to reduce sequelae, pts are treated empirically at the

time of care while awaiting results
-first-line tx: single dose of IM ceftriaxone + 7-day
course of oral doxy

**azithromycin is first-line tx for isolated Chlamydia infection, but is not recommended for empiric therapy
when gonococcus may be present d/t increasing rates of resistance

Gonococcal proctitis: gram-negative diplococci

-most commonly occurs in adolescents and young
adults who have unprotected sexual intercourse
-occurs through receptive anal intercourse and via
proximal spread from the vagina

Sx: tenesmus, anal discharge, bleeding, pain

’

Disseminated gonococcal infection: asymmetric polyarthralgia, tenosynovitis, dermatitis

→ can also present w/ septic
monoarthritis but many pts
have NO urogenital sx
● Identification of
organism is generally
made with NAAT of
urethral swab (even
w/o sx)
● Tx: IV cephalosporin
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Primary syphilis: painless chancre

-arises ~3 weeks after inoculation and lasts 4-6 weeks in the
absence of treatment
-inguinal LAD

Testing:
● Nontreponemal testing has higher false-negative
rates in pts with primary syphilis, especially early
● FTA-ABS has highest diagnostic sensitivity and can
establish diagnosis in pts with negative initial VDRL
when there is a high suspicion

In pts with high suspicion and classic presentation →

empiric tx w/ IM benzathine penicillin G

Condyloma lata: manifestation of secondary syphilis

● Flattened pink/gray velvety papules seen at mucous membranes and moist skin

Secondary syphilis: systemic sx,

widespread LAD, gray mucosal patches,
condyloma lata, diffuse maculopapular
rash on palms and soles
→ tx = one dose of IM penicillin G

-treat with penicillin

-doxycycline is an alternate abx for pts
with PCN allergy
-for neurosyphilis, PCN desensitization is
required for tx
-if pregnant with penicillin allergy - get
penicillin skin test to assess for
IgE-mediated response and if positive,
penicillin desensitization is necessary
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Reactive arthritis: enthesitis, conjunctivitis, urethritis, oral ulcers

● Often d/t chlamydia

Vaginitis: due to bacterial vaginosis (BV), trichomonas or candida

Bacterial vaginosis: occurs d/t shift in microbiota with overgrowth of anaerobic bacteria and loss of
lactobacilli
● Has no associated inflammation (no pruritus, erythema, etc)
● Risk factors: douching, tobacco use, vaginal-vaginal sexual intercourse
● Diagnose: wet-mount prep with pH >4.5, clue cells, and positive whiff test
○ Pap test cytology has low sensitivity and specificity for identifying BV
● Pts w/ BV on cytology should be asked about sx
○ If sx present - pts should undergo further eval w/ wet mount microscopy and receive tx
w/ metronidazole if dx is confirmed
■ Clindamycin if intolerant to metronidazole
○ If asymptomatic - no treatment

Trichomonas: flagellated,
motile protozoan
● Most commonly causes
of vaginitis with thin,
malodorous discharge
● Can also cause acute
cervicitis that results in
postcoital bleeding

Dx: wet mount visualization of

motile, ovoid-shaped organisms
or NAAT (wet mount prep only
works for women)

Tx: oral metronidazole or

tinidazole for pt and sexual
partner, even if partner is
asymptomatic

Actinomyces: anaerobic
bacteria that colonizes IUDs
and may cause PID
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Pelvic Inflammatory disease: presents with pelvic pain and

abnormal vaginal bleeding d/t an inflamed, friable cervix
● Often d/t gonorrhea or chlamydia
● Diagnosed clinically
● In pts who have an IUD in place, removal is NOT
required

Complication: Fitz-Hugh-Curtis syndrome

-infection spread into the intraperitoneal cavity →
inflammation of the liver capsule
-presents w/ vomiting and RUQ tenderness
Tx: hospitalization and broad-spectrum IV abx (cefoxitin
plus doxy)

For patients with an active STI or those who request testing:

Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Breast Disorders

Male

Klinefielter syndrome has testicular fibrosis and an increased estrogen/androgen ratio → gynecomastia
and elevated risk of breast cancer

Klinefelter syndrome: 47,XXY

● Tall stature
● Gynecomastia
● Small tests
● Decreased body hair
● Euchnoid body
● Male breast cancer
● Infertility
-due to testicular fibrosis with
seminiferous tubule dysgenesis,
azoospermia, hypogonadism
and elevated FSH/LH levels
Dx: karyotype analysis

Gynecomastia:
● Gynecomastia is symmetric, centrally located and may have indistinct margins
● Pseudogynecomastia: diffuse enlargement of breasts w/o a distinct margin, w/p pain,
tenderness, nodules or skin dimpling d/t obesity → tx w/ weight loss

Anabolic steroid use

can also cause
decreased gonadal
size, gynecomastia and
lower sperm counts but
presents with increased
libido and does not
lead to sparse facial
hair
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Gynecomastia + headaches → suggestive of a nonfunctioning pituitary adenoma

● Arises from gonadotrophs
● All pituitary hormones are decreased while prolactin levels are often mild-moderately increased
due to the stalk effect
○ Prolactin >200 ng/mL suggests a prolactin-secreting adenoma rather than a
nonfunctioning adenoma
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Female

Fibroadenoma: isolated, firm, well circumscribed and mobile breast mass in women age <30
-sensitive to estrogen, usually located in upper outer quadrant of breast

Fibrocystic changes: cyclic,

premenstrual breast tenderness and
improvement in pain during/after
menstruation
-diffusely nodular breasts
-benign
-tx w/ NSAIDs and/or OCPs

Fat necrosis: d/t breast trauma

-presents w/ firm, irregularly shaped
breast mass without nipple discharge

Intraductal papilloma: unilateral bloody discharge

WITHOUT a coexisting breast mass
● No lymphadenopathy
● benign
● d/t papillary projections composed of epithelial
and myoepithelial cells
● Have a fibrovascular core on histology
● Breast imaging required to evaluate for breast
cancer as it can present similarly

Galactocele: milk retention cyst d/t obstructed duct

● Occurs in breastfeeding pts
● Usually soft and cystic

Inflammatory breast
cancer - aggressive
breast cancer presenting
w/ unilateral breast rash,
erythema and edema

-characterized by invasion of dermal lymphovascular spaces

-rapid tumor growth and mets
-pts often have metastatic disease at initial presentation

Work-up: core needle bx and full-thickness skin bx

Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Physiologic nipple discharge: bilateral,

multiductal, milky or nonbloody, expressed
only w/ manipulation of the breast
● Usually d/t hyperprolactinemia

Pathologic nipple discharge: unilateral,

uniductal, bloody or serous, and spontaneous

If patient has bilateral nipple discharge, get a

pregnancy test
→ if negative get serum TSH
→ galactorrhea can be milky, clear, yellow,
gray, brown or green

Mammary duct ectasia: subareolar ductal

dilation, inflammation and fibrosis
● Green-brown and sticky nipple discharge
● Mass is subareolar rather than peripheral

Management of Breast Cysts

Breast cysts have noninvasive features on exam:
● Mobile
● Smooth
● Well-circumscribed
● Can be tender
Imaging required to r/o cancer

If complex on imaging → bx
If simple on imaging → observe if asymptomatic or get
an FNA if tender

If FNA has bloody aspirate → bx

If recurrent → bx
If fluid is non-bloody and cyst resolves → no additional
management
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Breast pain: can be broken down into -

● Cyclic breast pain - benign and d/t
estrogen and progesterone changes
associated w/ the menstrual cycle
○ Heavy, diffuse
○ No exam abnormalities - no
masses, no skin changes or LAD
● Noncyclic breast pain - not associated w/
menses, variable location, involves a single
breast
○ Should undergo imaging or bx

Palpable Breast Mass

Women >30 = mammography, can use ultrasound to further
characterize the mass

Women <30 = targeted ultrasound, but mammography can be

used for further characterization if an abnormality is seen

Tissue bx is required to confirm the diagnosis

Breast cancer -
eccentric to nipple,
well-defined or
spiculated margins,
calcifications
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Prostate Disorders

Work-up of lower urinary tract symptoms:

1) Urinalysis
2) PSA level in symptomatic patients
→ Routine screening for prostate cancer in asymptomatic pts is not advised

Pts with acute bacterial prostatitis are acutely ill

and frequently present with a flu-like illness &
lower urinary tract sx

PE: markedly swollen, tender prostate on digital

rectal exam

Dx: urine culture to establish infecting organism

→ obtain via suprapubic catheter if retaining
Tx: 6 weeks of TMP-SMX or levofloxacin

Chronic prostatitis: chronic pelvic pain for >3 months

w/o an identifiable cause
● Voiding irritability
● Pain with ejaculation
● Blood in semen
● little/no prostate tenderness!
Pts are afebrile with normal UA and culture, normal PSA
→ tx = abx, alpha blockers, 5-alpha reductase inhibitors

Chronic bacterial prostatitis: presents with

dysuria, urinary frequency
● Hx of UTI
● May or may NOT have prostate
tenderness or induration (often not)
● Positive urine culture
● Pain w/ ejaculation
● Confirmation of dx requires prostatic
massage → examination of prostatic
fluid
● Tx: 6 weeks fluoroquinolones
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Benign Prostatic Hyperplasia: most common cause of bladder outlet obstruction:

-more common w/ increasing age
-involves the center (transitional
zone) of the prostate

Sx:
● Slow urinary stream
● Post-void dribbling
● Urgency
● Hesitancy
● Nocturia
Tx:
● First-line is alpha blockers
(terazosin, tamsulosin)
○ Relax bladder neck
and prostatic
smooth muscle
● Can add 5-alpha reductase
inhibitors (finasteride) for persistent symptoms
○ They act by reducing prostate size and have slower onset of action
● Surgical intervention (TURP)
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Prostate adenocarcinoma: prostatic nodules, inguinal LAD and elevations of PSA support diagnosis
● Definitive diagnosis: transrectal biopsy
● Risk factors: increasing age, African American and Black patients, diet high in meat

Acute epididymitis: arise when pathogens

from the urethra travel in retrograde
fashion through the ejaculatory duct to
ductus deferens and epididymis

● Age <35 - gonorrhea/chlamydia

○ Tx w/ ceftriaxone + doxy
● Age >35 - E. Coli d/t bladder outlet
obstruction
○ Tx w/ fluoroquinolones

Presents w/ posterior testicular swelling

that improves with elevation of testes
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Anorectal Disorders

Pilonidal disease: frequently affects males aged 15-30, particularly obese individuals w/ sedentary
lifestyles or occupations and those w/ deep gluteal clefts
● Painful, fluctuant mass 4-5 cm cephalad to the anus
● Mucoid, purulent or bloody drainage
● D/t occluded hair follicle
Tx: surgical excision

Proctalgia fugax: functional anorectal

disorder characterized by recurrent
episodes of rectal pain unrelated to
defecation
● Attacks precipitated by stress,
sex and/oro sitting
● Physical exam totally normal
● Labs totally normal
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Anal fissure: most common at posterior

midline
-related to chronic constipation
-seen with frequent diarrhea or anal
sexual intercourse

Tx:
-First-line: Dietary modifications, stool
softeners, sitz baths

-Second-line: pharmacological
→ topical anesthetics (lidocaine) or
vasodilators (nifedipine, nitroglycerin)

Refractory: lateral sphincterotomy and

fissure excision

Rectovaginal fistula: complication of Crohn

disease, obstetric trauma or pelvic surgery
-caused by transmural inflammation of GI tract
-presents w/ malodorous, tan vaginal
discharge and passing of flatus through the
vagina
-tx = surgery

Colovesical fistula: commonly d/t diverticular

disease or Crohn’s
● Presents with pneumaturia, fecaluria,
UTI symptoms
● Dx w/ CT w/ oral or rectal contrast
● Tx: surgery

Anorectal fistula: perianal lesion

associated with pain on defecation and
chronic discharge
-often d/t Crohns, radiation proctitis, LGV
or trauma

Dx: clinical, but endoscopic u/s, MRI or

fistulogram can be used

Tx: surgical intervention

Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Perianal abscess: indurated, erythematous mass near anal orifice

● Severe, constant anal pain and low-grade fever
● d/t occlusion of anal crypt gland
● If untreated, can develop into anorectal fistula → requires prompt incision & drainage
● Risk factors: anoreceptive intercourse and chronic constipation

Hemorrhoids
● Internal hemorrhoids - originate above dentate line
○ Associated w/ painless rectal bleeding
● External hemorrhoids - originate below dentate line
○ Thrombosis can lead to exquisite pain and
tenderness

Thrombosed external hemorrhoid: appear as purple or blue

bulges below the dentate line
● Cause severe pain
○ If mild - conservative management w/ fiber,
stool softeners, NSAIDs, antispasmodics
○ If severe - hemorrhoidectomy and hemorrhoidal
incision/thrombus removal if delayed

Initial management of
hemorrhoids
Dietary: increase fluid and
fiber intake, reduce fat intake,
moderation of EtOH intake

Behavioral: limit time sitting

on toilet, limit defecation to
once daily, avoid straining

Topical agents: analgesics

(benzocaine), hydrocortisone

Refractory symptoms -
hemorrhoidectomy or banding
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Radiation proctitis: d/t mucosal damage associated w/ pelvic radiation therapy

● Acute RP: <8 weeks s/p radiation
○ Diarrhea, tenesmus, mucus discharge
● Chronic RP: months-years after radiation
○ Hematochezia, anemia, strictures
Colonoscopy demonstrates mucosal pallor, friability, telangiectasias in rectum
Tx: local thermal coagulation and glucocorticoid enemas

Rectal prolapse: rectal

mass that protrudes with
Valsalva maneuver

Common in women age >40

w/ hx of multiparity, vaginal
delivery and chronic
constipation

Rectal prolapse causes

fecal incontinence,
constipation and abdominal
discomfort

Tx: surgery
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Testicular Disorders

Testicular torsion: acute testicular pain and

swelling after mild trauma
● Often clinical but when dx is unclear, get
doppler u/s which shows no flow
● Can occur after trauma
● Horizontal testicular lie
Tx: surgical detorsion and fixation of BOTH sides

Varicocele: dilation of pampiniform plexus

● Presents w/ irregular scrotal mass that
increases in size w/ Valsalva maneuver
● Does not transilluminate
● More common on left side
● Often asx, may ache

Primary varicocele: idiopathic, d/t compression of

left renal vein between SMA and aorta
→ Presents as irregular, L-sided scrotal mass in an adolescent or adult pt that increases with standing
and decreases in supine position

Secondary varicocele: d/t venous thrombosis or extrinsic compression of IVC by abdominal mass
-features to look out for:
● Prepubertal
boy
● Right-sided
mass
● Mass that fails
to decrease in
size when
supine
Next step: get
abdominal u/s to look
for Wilms tumor
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Cryptorchidism: failure of in utero testicular descent from abdomen into the scrotum

Risk factors: prematurity, SGA, low birth weight

● Boys typically have an empty, poorly
rugated scrotum

Testes normally descend spontaneously within

the first few months of life
● Monitor for testicular descent
● Testes that have not descended by 6
months require surgical intervention via
orchiopexy
● Reduces complications such as
testicular torsion, infertility and
testicular malignancy

Patient w/ known cryptorchidism presenting w/ an acute abdomen → torsion of intra-abdominal testis

● Torsion 10x more likely in undescended testis compared to scrotal testis
● Presents w/ acute, severe abd pain and vomiting
● Emergency surgery required to salvage testis

Testicular cancer: presents as a painless

testicular mass
-spreads throughout regional lymphatics and
presents with symptoms of retroperitoneal
lymph nodes → leads to lumbar back pain

If a mass is present, scrotal ultrasound and

tumor markers should be performed without
delay

Work up includes:
● Scrotal u/s
● Serum tumor markers (bHCG, AFP, LDH)

Do not biopsy these tumors - patients should

obtain a radical inguinal orchiectomy to confirm dx
-Metastatic disease travel to lungs and liver

Tumors
● Seminomas: more common than germ cell tumors
○ Can have elevated beta-hCG
○ AFP is always normal
● Nonseminomatous germ cell tumors - elevated AFP and/or beta-hCG
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Penile Disorders

Hypospadias: failure of urethral folds to fuse

● Ventrally displaced urethral meatus
● Severe hypospadias presents w/ underdeveloped
penis/glans and severe penile curvature
● Can be indicative of disorders of sex development
● Next steps:
○ Urologic eval
○ Do NOT circumcise
○ Obtain karyotype and pelvic u/s if severe

Hydrocele: fluid collection within tunica vaginalis

→ peritoneal fluid collections between parietal and
visceral layers of tunica vaginalis
● Transilluminates
● Painless unilateral or b/l scrotal swelling
● Most resolve spontaneously by age 1 - can
be observed. If persistent, can be surgically
removed

Spermatocele: fluid-filled cyst at head of epididymis

that transilluminates
● Painless mass at superior pole of testis
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Balanitis: inflammation of the glans penis

-commonly affect
uncircumcised
children aged 2-5

Causes: irritation,
infection w/ C.
albicans, and trauma

If infection
suspected, obtain
KOH microscopy

Tx: foreskin hygiene,

sitz baths, avoid
irritants, tx w/ topical
antifungals if relevant

Erectile dysfunction: common in pts w/ CVD d/t decreased penile blood flow, endothelial dysfunction and
vasoactive meds
● First-line tx =
PDE-5 inhibitors
→ Contraindicated to
use with nitrates and
alpha blockers

Drugs: spironolactone,
cimetidine, thiazides
and beta blockers

Persistence of
nonsexual nocturnal
erections →
psychogenic
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Priapism: persistent, painful erection that develops w/o sexual stimulation and has a long duration
→ Medical emergency that requires urgent medical intervention - aspiration of blood from corpus
Cavernosa +/- intracavernous injections of phenylephrine
● Meds - trazodone, alpha-1 antagonists,
antidepressants, PDE-5 inhibitors, stimulants
● Conditions - sickle cell disease, leukemia
● Surgery
● Neurogenic lesions

Penile fracture: urologic emergency most

commonly d/t blunt trauma to an erect penis

Path: Rupture of fibrous tunica albuginea that

envelopes the corpus cavernosum

Presents w/ snapping sound → rapid penile

detumescence and formation of penile
hematoma

Following findings warrant retrograde

urethrography prior to surgery to assess for
concomitant urethral injury:
● Blood at meatus
● Hematuria
● Dysuria
● Urinary retention
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Miscellaneous

Uncomplicated cystitis: diagnosed with a UA and without a urine culture

● Culture reserved for those who fail initial therapy
● Tx with oral TMP-SMX, nitrofurantoin or fosfomycin

Complicated cystitis: diabetes, CKD, pregnancy, immunocompromised pts, urinary tract obstruction
hospital-acquired infection, indwelling catheters
● Should always get urine cultures prior to therapy
● Treatment = oral fluoroquinolones

Pyelonephritis: requires urine culture prior to starting treatment

● Nonpregnant, stable pts - oral abx (fluoroquinolones)
● Unstable require IV abx (ceftriaxone)

Renal abscess: renal and perinephric abscesses can form in setting of urologic infection or through
hematogenous spread
● Develops insidiously
● More common in pts w/ anatomic abnormalities, nephrolithiasis, DM, tobacco use
● Systemic sx are often present but UTI sx are often absent
● Dx confirmed with CT or u/s
● Management: abx tx and percutaneous drainage
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Hernias
Inguinal hernias: hernias above the
inguinal ligament
● Associated with lower risk for
incarceration and strangulation
● Asymptomatic hernias can be
managed with reassurance and
watchful waiting
● Most patients with asymptomatic
inguinal hernias will eventually
develop symptoms and require
repair
Strangulation: has nausea, vomiting and
abdominal pain

Femoral hernias: displacement of

abd/pelvic contents through femoral ring
● medial to femoral artery
● Under the inguinal ligament
● Risk factors: chronic cough,
constipation, smoking
● Normally in older women
● High risk of strangulation, so asx femoral hernias are referred for elective surgical repair

Incisional hernia: d/t fascial closure

breakdown
-presents with a slowly enlarging mass that is
palpable while supine and enlarges w/
Valsalva
-common in pts w/ obesity and prior vertical
midline incisions
Lauren Valentine
laurenvalentinemd@[Link]
@[Link]

Urethral stricture: fibrotic narrowing of urethra

● Often idiopathic but can be 2/2 urethral trauma,
infection or radiotherapy
● Leads to acute urine retention, recurrent UTI,
bladder stones or hydronephrosis
● Elevated postvoid residual
● Dx: voiding cystourethrogram
● Tx: urethral dilation or urethroplasty

In pts w/ neurogenic bladder, long-term catheter use is

required
-clean intermittent catheterization (periodic insertion and
removal of a clean urinary catheter) is the initial tx
-lowers risk of CAUTI