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Urology > Clinical Presentation Of Urological Conditions > Flashcards

Clinical Presentation Of Urological Conditions Flashcards

1
Q

List the Obstructive voiding symptoms of LUTS

A

Hesitancy

Weak urinary stream

Interrupted stream

Feeling of incomplete voiding

Post-micturation dribbling

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2
Q

List the Irritative voiding symptoms of LUTS

A

Frequency

Nocturia

Urgency

Urge incontinence

Dysuria

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3
Q

What are the complications of bladder outflow obstruction?

A

Chronic renal failure

Infection
• Cystitis
• Pyelonephritis
• Epididymitis

Bladder calculus

Urinary retention

Bladder diverticulum

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4
Q

List the causes of obstructive voiding symptoms in males

A

BPH

Prostate Carcinoma

Urethral strictures

Bladder neck contracture

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5
Q

List the causes of obstructive voiding symptoms in males

A

Urethral diverticulum

Urethral carcinoma

Stricture

Bladder prolapse

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6
Q

What are the causes of irritative voiding symptoms?

A

UTI

Carcinoma in situ

Bladder outflow obstruction

Overactive bladder

Neuropathic bladder

Small bladder capacity
• TB
• interstitial cystitis

PID

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7
Q

Define urinary incontinence

A

Inappropriate involuntary voiding or leakage of urine, producing social and hygiene problems

Inability to suppress reflex bladder contractions

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8
Q

Define total urinary incontinence

A

Continuous dribbling incontinence with low residual volume in the bladder

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9
Q

Define overflow incontinence

A

Continuous dribbling incontinence with high residual volume in the bladder (full bladder)

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10
Q

Define stress incontinence

A

Leakage of urine from the urethra with a rise in intra-abdominal pressure in the absence of a detrusor contraction

Rise in intra-abdominal pressure is caused by:
• coughing
• sneezing
• straining

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11
Q

List 5 types of urinary incontinence

A

Stress incontinence

Overflow incontinence

Total incontinence

Urge incontinence

Paradoxical incontinence

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12
Q

List five possible causes of urge incontinence

A

Age

Cystitis

Radiation

Bladder stones

Bladder tumours

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13
Q

List the non-surgical treatment for stress incontinence

A

Weight loss

Stop smoking

Pelvic floor exercises

Electrical stimulation

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14
Q

List the causes of overflow incontinence

A

Neurogenic bladder

Atonic detrusor muscle

Tricyclic antidepressants

Urethral stricture

Bladder neck stenosis

Prostatic obstruction
• BPH
• Prostate carcinoma

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15
Q

What is the management of urge incontinence?

A

Anticholinergics - Oxybutinin

Augmentation cystoplasty

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16
Q

What is the management of stress/total incontinence?

A

Alpha-adrenergic agonists - pseudoephedrine

Tension free vaginal tape (TVT)

Periurethral injection of Teflon

Artificial urinary sphincter

Bypass urethra by urinary diversion

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17
Q

What is the management of overflow incontinence?

A

Clean intermittent self catheterization

Surgical removal of obstruction

Urethral stricture surgery

Prostatectomy

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18
Q

What are the urological causes of haematuria in the kidney?

A

Blunt/penetrating trauma to the kidneys

Acute pyelonephritis

TB of the kidney

Renal tumor

Renal calculus

Polycystic kidney disease

Renal vein thrombosis

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19
Q

What are the urological causes of haematuria in the bladder?

A

Blunt/Penetrating trauma

Bladder cancer

Bladder calculus

Acute haemorrhagic cystitis

TB of the bladder

Schistosomiasis

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20
Q

Discuss the pathogenesis of a urinary tract infection in adults

A

Urinary tract sterile above the level of the distal urethra

Organisms reach the urinary tract via ascending route

Organisms gain access, adhere to urothelium and multiply

Virulent bacteria overcome normal host defense mechanisms

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21
Q

List the causes of urinary tract infections in adults

A

E. coli

Klebsiella

Proteus

Pseudomonas

Streptococcus infection

Staphylococcal infection

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22
Q

List the common causes of urinary tract infections in immunocompromise patience

A

Candida

Adenovirus

CMV

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23
Q

List the local predisposing factors of UTIs

A

Stones - kidney/ureters

Pelvic ureteric junction obstruction

BPH

Prostate carcinoma

Urethral stricture

Neurogenic bladder

Vesico-ureteric reflux

Vesico-colic fistula

Pregnancy

Vaginal infection

Foreign bodies

Prostate biopsy

Cystoscopy

Urodynamic studies

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24
Q

What is the clinical presentation of acute pyelonephritis?

A

Fever and rigors

Loin or back pain

Nausea and vomiting

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25
Q

What does the complications of acute pyelonephritis?

A

Septicaemia and septic shock

Intra-renal/perinephric abscess

Chronic pyelonephritis

Renal failure

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26
Q

What is the treatment of acute pyelonephritis?

A

Admit if toxically ill

IV fluids

Blood culture

Antibiotics – Gentamicin, ciprofloxacin, cefotaxime

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27
Q

What is the clinical presentation of cystitis?

A

Frequency

Urgency

Dysuria

Apyrexial

Elderly: Incontinence and malodorous urine

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28
Q

How would you manage uncomplicated cystitis?

A

EML Guidelines: Ciprofloxacin 500mg PO BD for 3 days

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29
Q

How would you manage complicated cystitis?

A

EML Guidelines: Ciprofloxacin 500mg PO BD for 7 days

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30
Q

How would you manage recurrent cystitis?

A

High fluid intake

Local Hygiene

Voiding after sex

Topical estrogen for atrophic vaginitis

Treat constipation

Continuous low dose chemo-prophylaxis - noct for 6-9 months

Post-intercourse single dose therapy

“Self-start” therapy - patient has a treatment supply and can initiate treatment when symptoms start

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31
Q

Who is at risk of erectile dysfunction?

A

Ischaemic heart disease

DM

HPT

Dyslipidaemia

Depression

Renal Failure

Any hormonal problems that cause low testosterone

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32
Q

Discuss normal penis vascular and nerve supply

A

Arteries
* cavernous arteries supply the corpus cavernosum

Veins:

  • superficial dorsal veins
  • perforating veins > subtunical venous plexus > circumflex veins
  • cavernous veins
  • internal pudendal veins

Nerves:

  • Sympathetic - T10-L2 > mediates detumescence
  • Parasympathetic - S2-S4 > mediates erection
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33
Q

List the psychogenic causes of erectile dysfunction

A

Poor self-esteem / body image

Anxiety / stress

Depression

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34
Q

List the organic causes of erectile dysfunction

A

CVA

Alzeimer’s disease

Multiple sclerosis

Traumatic paraplegia

DM - Diabetic neuropathy/vasculopathy

Decreased testosterone

Surgery

Radiotherapy

Drugs

Smoking and Alcohol abuse

Heart disease

Renal Disease

Peyronie’s disease

Neglected priaprism

Chordee

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35
Q

What are the management options for erectile dysfunction?

A

Psychogenic - Psychotherapy

Hypogonadism - Parenteral testosterone

Penile deformaties - Penile recontructive surgery

All other organic causes - PDE 5 inhibitors - Sildenafil 50mg (Viagra)

  • ICI therapy
  • Vacuum device
  • Penile prosthesis
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36
Q

What are the side-effects of PDE 5 inhibitors?

A

Headache

Facial flushing

Dyspepsia

Nasal congestion

Altered vision

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37
Q

What are the contraindications for PDE 5 inhibitors

A

Absolute:

  • Nitrate use
  • Unstable angina
  • Retinitis pigmentosa

Relative:

  • Alpha-blocks > Patients with LUTS
  • CYP 450 inhibitor use > Ketaconazole, Erythromycin, Prtease inhibitors
  • MI in last 6 months
  • CVA
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38
Q

Discuss Intra-cavernous injection (ICI) therapy

A

When oral therapy failed

Prostaglandin E1 (Alprostadil) injected into the corpus cavernosa

provides 2-3 hour erection

39
Q

What are the side-effects/complications of ICI?

A

Pain in the penis

Priapism

40
Q

Define Peyronie’s disease

A

Acquired penile abnormalityt characterised by fibrosis of the tunica albugina

41
Q

What are the clinical features of Peyronie’s disease?

A

Penile pain associated with erection

Penile curvature (chordee) - usually dorsal

Loss of erection due to “venous leak”

42
Q

What is the medical management for Peyronie’s disease?

A

50% resolve spontaneously

Vitamin E 400mg PO BD + Colchicine 1mg PO BD

Intra-lesional injections - Verapamil/Interferon

PDE 5 inhibitors

43
Q

What is the surgical management for Peyronie’s disease?

A

Nesbit Procedure - Penile shortening

Excision of plaque

44
Q

List the organisms involved in urethral discharge

A

STDs!!!

Gonoccocal:
* Neisseria gonorrhoeae

Non-Gonoccocal:

  • Chlamydia trachomatis (50-60%)
  • Ureaplasma urealyticum (20%)
  • Trichomonas vaginalis
45
Q

List the complications of urethritis

A 
Urethral stricture (>GU)
Epididymitis (>NGU)
46
Q

What is the clinical presentation of urethritis?

A

Urethral discharge

  • GU - Thick, purulent, yellow
  • NGU - watery, scanty

Dysuria

Urethral itching

47
Q

Discuss the treatment of gonoccocal urethris

A

Counselling

Ofloxacin 400mg PO STAT
Doxycycline 100mg BD for 7 days

48
Q

Discuss the treatment of gonoccocal urethris

A

Counselling

Doxycycline 100mg BD for 7 days

49
Q

Provide a DDx for male genital ulceration

A 
Syphilis - Painless
Chancroid - Haemophilus ducreyi
Lymphogranula venerum
Herpes simplex virus
Granuloma Inguinale

Pre-malignant lesion - Carcinoma in situ/Leukoplakia

Malignant lesion - Squamous cell carcinoma of the penis

Trauma

50
Q

How do you diagnose syphilis?

A

VDRL

RPR

TPHA

FTA

51
Q

How do you diagnose HSV?

A

Immunoflorescent antibody testing against HSV

52
Q

How do you diagnose Chancroid?

A

Selective culture medium

53
Q

How do you diagnose Granuloma Inguinale?

A

Donovan bodies on histology

54
Q

What are the clinical features of syphilis?

A

Cause: Treponema palidum

Apyrexial

Deep, single painless ulcer with well-defined edges

Non-purulent ulcer

55
Q

What are the clinical features of HSV?

A

Cause: HSV Type 2

Apyrexial

Multiple superficial vesicular, painful lesions with erythematous edges

Tender bilateral inguinal LN

56
Q

What are the clinical features of Chancroid?

A

Cause: Haemophilus ducreyi

Pyrexial

Single deep vesicular lesion with irregular edges

Purulent induration

Tender unilateral inguinal LN

57
Q

What are the treatment of syphilis?

A

Benzathine penicillin 2.4 million units IMI STAT

58
Q

What are the treatment of chancroid?

A

Erythromycin 500mg 8hrly for 5 days

OR

Ciprofloxacin 500mg PO STAT

59
Q

What are the treatment of HSV?

A

Acyclovir 200-400mg 5 p/day (5hrly) for 7 days

60
Q

What are the treatment of lymphogranulosa venerum/granuloma inguinale?

A

Doxycycline 100mg BD

For 3wks in LGV

61
Q

Define a hydrocele

A

A collection of fluid between the visceral and parietal layers of the tunica vaginalis

62
Q

What are the secondary causes of a hydrocele

A

Acute epedidymitis

Testicular Tumour

Testicular torsion

Scrotal trauma

63
Q

What are the clinical features of a communicating (congenital) hydrocele?

A

Scrotal swelling when crying

Scrotal swelling larger in evening/morning

64
Q

What are the clinical features of a non-communicating (acquired) hydrocele?

A

Painless cystic scrotal swelling with transluminates

Testis situated posterior to fluid/impalpable

65
Q

Provide a DDx for painless scrotal swelling

A

Hydrocele

Spermatocoele

Epididymal cyst

Chronic epididymitis

Inguinal hernia

Varicocele

Testicular tumour

66
Q

What is the treatment for a primary non-commuicating hydrocele?

A

Aspiration and sclerotherapy

Hydrolectomy - Lord’s procedure

67
Q

Define a varicocle

A

Varicose veins of the pampiniform plexus of the spermatic cord

68
Q

How does a varicocele affect fertility?

A

Increased intra-scrotal temperature interferes with spermatogenesis

venous anoxia interferes with epididymal function which is vital for sperm maturation

69
Q

What are the clinical features of a varicocele?

A

Pain - esp when erect

Infertility (late)

Examination:

  • “Bag of worms” above testis
  • Valsalva manoeuvre makes it obvious
  • Ipsilateral testicular atrophy

Semenanalysis:

  • oligospermia
  • asthenospermia
  • teratospermia
70
Q

What is the treatment for a varicocele?

A

Only for pt’s with complications to prevent retrograde flow

Open surgical ligation of vessel

Spermatic vein embolization

  • Antegrade sclerotherapy
  • Retrograde embolization
  • Laproscopy
71
Q

What are the clinical features of TB (chronic) epididymitis?

A

Painless scrotal swelling

Craggy non-tender mass in epididymis

Normal Testis

Scrotal sinus

Thickened vas deferens

Seminal vesicle and prostate is hard on rectal exam

72
Q

How is TB epididymitis diagnosed?

A

Microscopy > ZN staining and TB culture of urine, semen and pus from scrotal sinus

IVP - to exclude urinary TB

CXR

Histology

73
Q

What is the treatment of TB epididymitis?

A

Anti-TB medication for 6 months - FDC

74
Q

Define infertility

A

Failure to conceive after 12 months of unprotected sex

75
Q

What are the testicular causes of male infertility?

A

Varicocele

Undescended testis

Previous trauma

Mumps orchitis

Radiotherapy

Previous Surgery

76
Q

List the options for assisted reproduction

A

Intra-uterine insemination

IVF

Intra-cytoplasmic sperm injection

Donor insemination

Adoption

77
Q

How would you counsel a patient before a vasectomy?

A

Both the patient and his partner

A permanent form of male sterilization

Pt will not be sterile immediately after surgery

All short and long-term complications

Sterility cannot be confirm

78
Q

How would you counsel a patient before a vasectomy?

A

Pt will not be sterile immediately - use other forms of contraceptives

Pt may have safe unprotected intercourse after a single negative spermiogram

If there is persistent motile spermatozoa in the second spermiogram it indicates vasectomy failure

79
Q

What are the complications of a vasectomy

A

Pain

Haematoma

Infection

Post-vasectomy pain syndrome

80
Q

What are the mechanical causes of urinary retention?

A

Males…

  • BPH
  • Prostate Ca
  • Acute prostitis
  • Urethral Trauma
  • Urethral Stricture
  • PUV - Boy kids

Females…

  • Pregnancy
  • Fibroid uterus
  • Urethral diverticulum
  • Urethral stricture
  • Urethral Ca
81
Q

What are the features of acute urinary retention?

A

Acute lower abdominal pain

Patient wants to void but cannot

Palpable tender bladder

Rectal and vaginal examinations - to determine cause

82
Q

What is the treatment of acute urinary retention?

A

Immediate relief by passing a transurethral catheter
* Failure may indicate a stricture

Suprapubic catheter

Treatment dependent on cause

83
Q

What are the features of chronic urinary retention?

A

A decompensated bladder due to chronic outflow obstruction or neuropathy

Painless

Obstructive symptoms

Disurnal and nocturnal incontinence (overflow)

84
Q

What are the indications for immediate catheterization in chronic bladder retention?

A

UTI

Renal Failure

Incontinence

Acute on chronic retension

85
Q

What are the complications of immediate catheterisation in chronic retention?

A

NB!! Admit a CUR patient after immediate catheterisation

Complications…

  • Severe macroscopic haematuria
  • Post-obstructive diuresis
86
Q

Provide a DDx of acute scrotum

A

Testicular torsion

Epididymitis

Orchitis

Scrotal cellulitis/abscess

Post traumatic Haematocele

Ruptured testis after trauma

Strangulated inguinal hernia

87
Q

What is the pathophysiology of testicular torsion in an adult?

A

Twisting of the spermatic cord

> venous obstruction

> Arterial obstruction

> Ischaemic necrosis of testis and epididymis

88
Q

Clinical features of testicular torsion

A

History…

  • Minor traums
  • Sudden onset pain in a previous well patient
  • Pain radiates to ipsilateral fossa
  • Associated nausea and vomiting
  • No urinary symptoms

Examination…

  • Acutely tender unilateral scrotal swelling
  • Unable to distinguish testes and epididymis
  • Testes drawn up on affected side
  • Negative cremaster reflex
  • Redness (late)
  • Oedema (late)
  • Hard testicle (late)
89
Q

What is the emergency management of testicular torsion?

A

Presentation within 24 hours

  • Scrotal inscision
  • If testes viable : Detorsion + orchidopexy
  • If ischaemic : Orchidectomy
  • Orchidopexy for contralateral testicle
90
Q

What are the most common causes of acute epididymitis?

A

<35 years..

  • Gonococcal urethral infection
  • Chlamydial urethral infection

> 35 years…

  • BPH
  • Prostate Ca
91
Q

What is the clinical presentation of acute epididymitis?

A

Gradual onset pain

Hx of Urethral discharge

Pyrexia

Swollen tender epididymis posteriorly

Positive cremaster reflex

92
Q

What is the mangement of acute epididymitis?

A

Antibiotics for STD

  • Ceftriaxone 250mg IMI state
  • Doxycycline 100 BD for 10 days

Antibiotics for urological cause
* Augmentin

Management complications
* Scrotal abscess - incision and drainage

93
Q

What is the clinical presentation of acute prostatitis?

A

Pyrexia and rigors

Acute lower abdominal pain

Difficult urination / urinary retention

Rectal exam - Boggy tender prostate

94
Q

What is the management of acute protatitis?

A

Admit

Blood culture

Urine MCS

Suprapubic catheter if in retention

ABs - Flouroquionolines for 6 weeks
* coz’ usually gram (-) infection

If prostatic abscess then > Transurethral drainage

Urology (5 decks)

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