Chapter 12 - Urology Flashcards
Presentation of testicular torsion
Young adolescents
Very severe testicular pain of sudden onset, but no fever, pyuria, or recent mumps
Testis is swollen, exquisitely tender, “high riding,” and with a “horizontal lie.”
Cord is not tender
Management of testicular torsion?
Immediate surgical intervention
Orchiopexy after untwisting of testis (many also fix the other side)
Presentation of acute epididymitis?
Young men old enough to be sexually active
Severe testicular pain of sudden onset
Fever, pyuria
Testis in normal position, though swollen and very tender
Cord is also very tender
Lifting the scrotum helps
Dx and Rx acute epididymitis?
U/S to r/o testicular torsion
Rx with ABX
What is the other major urologic emergency besides testicular torsion and why is it a dire emergency?
Combination of obstruction and infection of the urinary tract
Can lead to destruction of the kidney in a few hours and possible death from sepsis
Presentation of obstruction and infection of the urinary tract?
Patient who is being allowed to pass a ureteral stone spontaneously suddenly develops chills, fever spike (104 or 105), and flank pain
Management of combined obstruction and infection of the urinary tract?
IV ABX
Immediate decompression of the urinary tract above the obstruction by the quickest and simplest means (ureteral stent or perc nephrostomy)
An erection lasting more than ___ hours after the use of ED drugs is also a dire emergency. Rx?
4; many need to stick needles in to draw out blood
Urologic work-up uses what three tests? What does each look for?
Sonogram (dilation and obstruction) CT scan (renal tumors) Cystoscopy (only way to detect early bladder cancers)
Presentation, work-up, and management of pyelonephritis?
Chills, high fever, N/V, flank pain
Hospitalization, IV ABX (guided by cultures), urologic work-up (CT or sonogram)
Presentation of acute bacterial prostatitis?
Older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, exquisitely tender prostate on rectal exam
Management of acute bacterial prostatitis?
IV ABX
Do NOT repeat any more rectal exams (continued prostatic massage could lead to septic shock)
Most common reason for a newborn boy not to urinate during the first day of life? Another possible cause?
Posterior urethral valves; meatal stenosis
Dx and Rx posterior urethral valves?
Cath to empty the bladder (valves will not present an obstacle)
Voiding cystourethroram (dx)
Endoscopic fulguration or resection (rx)
Management of hypospadias?
NO circumcision, as the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done
Management of UTI in children?
Always a urologic work-up, as it may be due to vesicoureteral reflux or some other congenital anomaly
Presentation of vesicoureteral reflux and infection?
Burning on urination, frequency, low abdominal/perineal pain, flank pain, fever/chills in a child
Work-up and management of vesicoureteral reflux?
Rx infection with empiric ABX and then culture-guided choice
Voiding cystourethrogram to look for reflux
If found, long-term ABX until the child “grows out of the problem”
Presentation of low implantation of a ureter?
Asymptomatic in little boys
Fascinating clinical presentation in little girls -> feels the need to void, voids normally at appropriate intervals (urine deposited into the bladder by the normal ureter), but is also wet with urine all the time (urine that drips into the vagina from the low-implanted ureter)
Dx and Rx low implantation of a ureter?
Careful vaginoscopy to identify the ectopic ureter
Avoid IVPs in children
Corrective surgery
Presentation of UPJ obstruction?
Allows normal urinary output to flow without difficulty, but if a large diuresis occurs, the narrow area cannot handle it
Classic presentation -> adolescent who goes on a beer-drinking binge for the first time in his life, develops colicky flank pain
Most common presentation for cancer of the kidney, ureter, or bladder?
Hematuria
Work-up of hematuria?
Start with CT scan
Continue with cystoscopy (only reliable way to r/o cancer of the bladder)
Presentation of renal cell carcinoma?
Hematuria, flank pain, flank mass
Can also produce hypercalcemia, erythrocytosis, elevated liver enzymes
CT appearance of renal cell carcinoma?
Heterogenic solid tumor; possible growth into the renal vein and vena cava, which could become a lethal PE if dislodged during the nephrectomy
Rx renal cell carcinoma?
Surgery - only effective therapy
Cancer of the bladder (___ in most cases) has a very close correlation with ___.
Transitional cell carcinoma; smoking
Presentation of bladder cancer?
Hematuria
Sometimes irritative voiding symptoms
Many have been treated for UTI even though cultures were negative and they were febrile
Dx bladder cancer?
Start with CT scan
Cystoscopy (best way to diagnose)
Rx bladder cancer?
Surgery and intravesical BCG
Very high rate of local recurrence makes lifelong close follow-up a necessity
Presentation of prostatic cancer?
Incidence increases with age
Most asymptomatic and have to be sought by rectal exam (rock-hard discrete nodule) and PSA (elevated for age group)
Dx prostate cancer?
Transrectal needle biopsy (guided by sonogram when discovered by PSA)
CT helps assess extent and choose therapy
Rx prostate cancer?
Surgery and/or radiation
Widespread bone mets respond for a few years to androgen ablation, surgical (orchiectomy) or medical (LH-releasing hormone agonists, or anti-androgens like flutamide)
Presentation of testicular cancer?
Young men
Painless testicular mass
Work-up suspected testicular cancer?
Because benign testicular tumors are virtually non-existent, biopsy is done with a radical orchiectomy by the inguinal route.
Blood samples pre-op for serum markers (AFP, Beta-hCG) to use for follow-up
LN dissection in some cases
Rx testicular cancer?
As above, plus radiation and chemo (platinum-based)
Presentation of acute urinary retention?
Very common in men who already have significant symptoms from BPH
Often precipitated during a cold by the use of antihistamines and nasal drops, and by abundant fluid intake
Patient wants to void but cannot
Palpable distended bladder
Management of acute urinary retention?
Indwelling bladder cath placed and left in for at least 3 days
First line of long-term therapy is alpha-blockers (most selective is tamsulosin); 5-alpha-reductase inhibitors (finasteride or dutasteride) are for very large glands (>40 g)
Minimally invasive procedures using thermal ablation of prostatic tissue have not gained popularity
Transurethral resection of the prostate (TURP) remains the final surgical option for BPH
Presentation of post-op urinary retention?
Very common, sometimes masquerades as incontinence
May not feel the need to void because of post-op pain, meds, etc., but will report that every few minutes there is involuntary release of small amounts of urine
Huge distended bladder will be palpable
Manage post-op urinary retention?
Indwelling bladder cath
Presentation of stress incontinence?
Very common in middle-age women who have had many pregnancies and vaginal delivers
Leak small amounts of urine whenever intra-abdominal pressure increases (sneezing, laughing, getting out of a chair, lifting a heavy object)
No nighttime incontinence
Exam - weak pelvic floor, prolapsed bladder neck outside of the “high-pressure” abdominal area
Rx stress incontinence?
Pelvic floor exercises may be sufficient for early cases
Surgical repair of the pelvic floor is indicated in advanced cases with large cystoceles
Presentation of passage of ureteral stones?
Classic colicky flank pain with irradiation to the inner thigh and labia or scrotum, and sometimes N/V
Dx ureteral stones?
CT scan
Management of ureteral stones?
Small (3 mm or less) at ureterovesical junction have a 70% chance of passing spontaneously -> analgesics, fluids, watchful waiting
7-mm stone at the UPJ only has a 5% probability of passing
Intervention: most common tool used is extracorporeal shock-wave lithotripsy (ESWL)
Other options - basket extraction, sonic probes, laser beams, open surgery
Everyone - abundant water intake for prevention
Contraindications to ESWL?
Pregnant women, bleeding diathesis, stones that are several cm large
Pneumaturia is almost always caused by ___, most commonly the ___, and most commonly from ___.
Fistulization between the bladder and GI tract; sigmoid colon; diverticulitis
(second possibility is cancer of the sigmoid, distant third - bladder cancer)
Work-up and Rx of pneumaturia?
Start with CT (will show inflammatory diverticular mass)
Sigmoidoscopy later to r/o cancer
Surgical therapy
Presentation of psychogenic impotence?
Sudden onset
Partner or situation specific
Does not interfere with nocturnal erections
Can be effectively treated with psychotherapy ONLY if done promptly
Presentation of organic impotence?
If caused by trauma - sudden onset, specifically related to traumatic event (after pelvic surgery 2/2 nerve damage or after trauma to the peritoneum 2/2 arterial disruption)
If caused by chronic disease (arteriosclerosis, DM) - very gradual onset, going from erections not lasting long enough, to being of poor quality, to not happening at all including at night
Rx impotence?
Sildenafil, tadalafil, vardenafil
Many other options - vascular surgery (well-suited if arterial injury), suction devices (almost anyone), prosthetic implants (irreversible and fraught with complications)
