13 - Common Urological Conditions Flashcards
What scoring system can be used to evaluate LTS in accordance with possible prostate problems?
I-PSS
(International Prostate Symptom Score)
What are storage Sx?
Frequency
Urgency
Nocturia
Feeling of incomplete emptying
What are voiding Sx?
Hesitancy
Weak flow
Dribbling
Intermittency
What are the symptoms of urinary tract obstruction?
Why can you get cardiac arrythmias with renal failure?
Because K+ isn’t being excreted - therefore potassium levels rise.
What is the definitive test for urinary infection?
MSU test
What structure is a USS not good at showing in terms of the urinary tract?
Ureters
Which is the best mode of imaging to see the ureters?
CT Urogram
Is an absence of nitrites on dipstick a definite sign that no UTI is present?
What is the definitive test for a UTI?
No - not all bacteria produce nitrites.
Definitive test = MSU (midstream specimen urinalysis)
What is CT contrast good for showing in terms of urology? What does it sometimes not show well?
CT contrast - good for showing renal parenchyma and tissue. However not always good for showing stones - sometimes better to do CT without contrast for stones, and then add contrast after initial CT and do another one.
What does a triple phase CT show?
It will show contrast at different stages = so when it is initially going through the kidneys, then the ureters and then the bladder.
Which investigation is best for showing the urinary tract?
CT Urogram
What investigations should you carry out for haematuria?
What can cause UTIs / LUTS?
Infection
Stones
Obstruction
Incomplete voiding
What investigations should you carry out for UTIs / LUTS?
What investigations should you carry out for incontinence?
Urodynamic tests
What investigations should you carry out for pain?
What are the following types of incontinence called?
- Due to increased intrabdominal pressure (e.g. coughing)
- Associated with increased frequency and urgency
- Can be caused by obstructed labour or malignancy
- Can be caused by lack of awareness / dementia
- Can be as a result of chronic retention
- Stress incontience
- Urge incontinence
- Fistula incontinence
- Functional incontinence
- Overflow incontinence
Which nerves provide parasympathetic innervation to the bladder? Which neurotransmitter do they use?
Pelvic nerves - S2-4
ACh = muscarinic receptors
Which nerve provides sympathetic innervation to the bladder? Which neurotransmitter does it use?
Which receptors are found in the bladder for this NT?
Hypogastric nerve
Noradrenaline
Β receptors = body of bladder - inhibit contraction
Α receptors = found in neck of bladder - make the neck of the bladder contract.
Which nerve provides somatic control for seeing? What receptor does it use?
Pudendal nerve (S2-4)
Uses nicotinic receptors (ACh)
Allows relaxation of the external urethral sphincter to wee
Which drugs can be used for urge incontinence?
Anticholinergics = Oxybutynin & Solifenacin
Β 3 Agonist = Mirabegron
Neurotoxin for the detrusor muscle to stop contraction = botulinum
What causes urge incontinence?
Overactivity of bladder muscles whilst sphincter is closed => internal pressure increases until grater than closing muscle pressure = discharge of urine.
What medical procedure can be done for urge incontinence?
Intravesicle botulinum injection into the bladder = paralyses the bladder
Sacral neuromodulation
Percutaneous Tibial Nerve Stimulation
What causes stress incontinence?
Reduced closing efficiency of sphincter or pelvic floor
What non-drug Rx can be given for stress incontience?
Weight loss
Pelvic floor exercise
Physio
Surgery
What drug can be given for stress incontinence?
Duloxetine (nicotinic agonist)
What surgical procedures can be given for stress incontinence?
Urethral bulking agent
Transvaginal tape or sling
Colposuspension
What 3 questions should you look for when examining a scrotal swelling?
Can you get above it?
Is it separate from the testicle?
Is it solid or cystic? (Transilluminate?)
What does it mean if you cannot get above the mass in the scrotum?
Is likely to be a hernia
What does it mean if the swelling is separate from the testicle?
It is likely to be an epididymal problem
What do you need to look for when describing a testicular lump?
What is painless haematuria presumed to be until proven otherwise?
Transitional cell carcinoma
What investigations can you do for haematuria?
When should you refer to nephrology if a P has haematuria?
If reduced eGFR, proteinuria, hypertension - refer
What are common causes of erectile dysfunction?
Vascular disease
DM
Pelvic injury
SE of meds - BP or hormonal
Hormonal cause (Low testosterone)
XS Alcohol, smoking to recreational drugs
Obesity
Name a PDE5 Inhibitor for erectile dysfunction.
How do they work?
Sildenafil
Tadalafil (Cialis) - longer acting
Vardenail - quicker acting
All work by inhibiting phosphodiesterase 5 enzyme - this breaks down cAMP. Therefore inc levels of cAMP in the penis.
When are PDE5 inhibitors contraindicated?
When Ps are using nitrates - can cause dangerous hypotension!
Recent - MI, TIA or CVA
Hypotension <90/50
Hypertension >170/100
Severe renal or hepatic failure
What invasive Rx can be given for erectile dysfunction?
Intracavernosal prostaglandins
Prostheses
What anatomical variants can cause testicular torsion?
Intravaginal torsion can be caused by bell clapper deformity
If you have a bell clapper deformity, your testicles hang in your scrotum and swing freely, like a clapper in a bell. The free-swinging can lead to twisting.
Extravaginal torsion can occur because the tunica vaginalis is not attached properly.
When is the biggest age incidence of testicular torsion?
peak incidence is in neonates and adolescents between the ages of 12-25yrs
What are the S&S of testicular torsion?
Sudden onset pain
N&V
Hx trauma
Mild pyrexia
Testicular swelling and tenderness
High riding testicle
Absent cremasteric reflex
Which sign can differentiate between torsion and epididymitis?
Prehn’s sign = elevating the testicle relieves the pain in epididymitis but not torsion.
Which score is used to evaulate testicular torsion?
TWIST Score
- Swelling (2)
- Hard Testicle (2)
- Absent cremaster (1)
- N&V (1)
- High riding (1)
2-4 intermediate risk
5-7 high risk
What is the blue dot sign?
Torsion of the Hydatid of Morgagni
The hydatid of Morgagni is a remnant of the Mullerian duct and is a common testicular appendage. This structure can also become torted, presenting with similar sudden onset pain.
Torsion of these structures is more common in a younger age group than testicular torsion, and the scrotum is usually less erythematous with a normal lie of the testis.
The ‘blue dot’ sign may be present in the upper half of the hemiscrotum, which is the visible infarcted hydatid.
What is Fournier’s gangrene?
Fournier gangrene is an acute necrotic infection of the scrotum, penis or perineum. It is characterized by scrotum pain and redness with rapid progression to gangrene and sloughing of tissue.
Can cause crepitus under the skin.
What investigations are done for urinary tract obstruction?
What are the DDs of ureteric colic?
Pyelonephritis
Blood clot
PUJ obstruction
Appendicitis
Diverticulitis
Pancreatitis
IBD
Bowel obstruction
Leaking aortic aneurysm
Ectopic pregnancy
Torsion of ovarian cyst
Prolapsed disc
What can cause obstruction in the ureters?
stones, tumours, strictures
lymph nodes, fibrosis (external pressure)
Can get failure to relax PUJ
What can cause bladder outflow obstruction?
BPH
Prostate cancer
Reflux
Urethral strictures and valves
Which imaging is most useful for urinary tract obstruction?
CT
Which test is good to determine how much function is found in each kidney?
Dynamic renography test
- Uses MAG3
Which are the most common urinary tract stones?
Calcium oxalate and phosphate
What are the RF for calcium oxalate stones?
Hypercalcaemia, dehydration and hypercalcaeuria
Which kidney stones are commonly caused by infection?
Staghorn stones (Ca, Mg, NH3)
Which kidney stones are associated with gout?
Uric acid stones
Which kidney stones are rare, seen in younger Ps and often have multiple recurrences?
Cystine stones
What are the three common areas of obstruction for stones?
PUJ
Crossing the iliac arteries
The uretero-vesical junction
What are the S&S of ureteric colic?
Severe pain
N&V
Intermittent
Restless
Loin to groin
Urinary frequency
Blood in urine
What is the first line investigation for kidney stone?
CT KUB
What are the Rx options for urinary tract stones?
Extracorporal shockwave lithotripsy
Percutaneous nephrolithotomy - for complicated stones - e.g. staghorn
Ureteroscopy - uses ureteric baskets to remove the stone
Cystolitholapaxy - uses Helium laser stone fragmentation
What causes PUJ Obstruction?
Can be
- failure of peristalsis
chronic obstruction
congenital condition
What symptom can you get with PUJ obstruction?
Pain in the kidney with high fluid intake or alcohol
What investigations can be done for PUJ obstruction?
USS
CT Urogram
MAG3 Renogram
What is the Rx for PUJ obstruction?
Laparoscopic or robotic pyeloplasty
The prostate grows throughout your lifetime. Which hormone controls this growth?
Testosterone is converted to DHT (dihydrotestosterone) by 5-α reductase. DHT encourages prostate to grow.
What percentage of men aged 61-70 will have BPH?
70%
80% over 80s!
What complications can arise from BPH?
Urinary retention ->
Nephropathy = raised creatinine and dec renal drainage
diverticulum of bladder
thick walled bladder
bladder stones
What medical treatment can be given for urinary retention?
Alpha blocker - Tamsulosin
5 α reductase inhibitor - Finasteride, Duasteride (not dramatic effect but overtime can reduce progression of disease)
What surgical procedures can be done for BPH?
TURP
HoLEP
Where do urethral strictures most commonly occur?
Navicular fossa
What Rx can be given for urethral strictures?
Dilation
Optical urethrotomy
Urethroplasty (reconstruction - removal and graft using skin from inside the mouth)
What causes urethral strictures?
Congenital
Post infection
Instrumentation
What is WBC in the urine called?
Pyuria
What is a complicated UTI?
One that happens when there is also an anatomical or functional abnormality.
What is the definition of a recurrent UTI?
> 2 UTIs in 6m or
3 UTIs in 12m
What investigation should you do for UTI or LUTS?
USS
MSU
Flow Test
Post micturition US
What management can Ps take for recurrent UTIs?
Inc fluids
Regular emptying
Probiotics
Cranberry juice
Avoid bubblebath / spermicides
Can consider
- post coital Abx
- self start Abx
- low dose Abx prophylaxis
Methanemine Hippurate (Hiprex)
Intravesicle iAluril
What ABx is given for acute pyelonephritis?
IV Ceftrixaone
PO Cefalexin
What ABx is given for lower UTIs in pregnancy?
Nitrofurantoin
Cefalexin
Which Abx is given for urosepsis?
IV Gentamicin
Fosfomycin
Where can urinary catheters be placed?
Urethral
Suprapubic
Nephrostomy
When should Abx be prescribed in Ps with a catheter?
Only if they have S&S of catheter related UTI -
inch
- tenderness, loin pain, pelvic discomfort
- rigors
- new onset delirium
- fever >37.9
- unexplained acute haematuria
How should a catheter related infection be managed?
Remove or change catheter if possible
Give gentamicin - 5mg/kg stat
