Clinical Presentation Of Urological Conditions Flashcards
List the Obstructive voiding symptoms of LUTS
Hesitancy
Weak urinary stream
Interrupted stream
Feeling of incomplete voiding
Post-micturation dribbling
List the Irritative voiding symptoms of LUTS
Frequency
Nocturia
Urgency
Urge incontinence
Dysuria
What are the complications of bladder outflow obstruction?
Chronic renal failure
Infection
• Cystitis
• Pyelonephritis
• Epididymitis
Bladder calculus
Urinary retention
Bladder diverticulum
List the causes of obstructive voiding symptoms in males
BPH
Prostate Carcinoma
Urethral strictures
Bladder neck contracture
List the causes of obstructive voiding symptoms in males
Urethral diverticulum
Urethral carcinoma
Stricture
Bladder prolapse
What are the causes of irritative voiding symptoms?
UTI
Carcinoma in situ
Bladder outflow obstruction
Overactive bladder
Neuropathic bladder
Small bladder capacity
• TB
• interstitial cystitis
PID
Define urinary incontinence
Inappropriate involuntary voiding or leakage of urine, producing social and hygiene problems
Inability to suppress reflex bladder contractions
Define total urinary incontinence
Continuous dribbling incontinence with low residual volume in the bladder
Define overflow incontinence
Continuous dribbling incontinence with high residual volume in the bladder (full bladder)
Define stress incontinence
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
List 5 types of urinary incontinence
Stress incontinence
Overflow incontinence
Total incontinence
Urge incontinence
Paradoxical incontinence
List five possible causes of urge incontinence
Age
Cystitis
Radiation
Bladder stones
Bladder tumours
List the non-surgical treatment for stress incontinence
Weight loss
Stop smoking
Pelvic floor exercises
Electrical stimulation
List the causes of overflow incontinence
Neurogenic bladder
Atonic detrusor muscle
Tricyclic antidepressants
Urethral stricture
Bladder neck stenosis
Prostatic obstruction
• BPH
• Prostate carcinoma
What is the management of urge incontinence?
Anticholinergics - Oxybutinin
Augmentation cystoplasty
What is the management of stress/total incontinence?
Alpha-adrenergic agonists - pseudoephedrine
Tension free vaginal tape (TVT)
Periurethral injection of Teflon
Artificial urinary sphincter
Bypass urethra by urinary diversion
What is the management of overflow incontinence?
Clean intermittent self catheterization
Surgical removal of obstruction
Urethral stricture surgery
Prostatectomy
What are the urological causes of haematuria in the kidney?
Blunt/penetrating trauma to the kidneys
Acute pyelonephritis
TB of the kidney
Renal tumor
Renal calculus
Polycystic kidney disease
Renal vein thrombosis
What are the urological causes of haematuria in the bladder?
Blunt/Penetrating trauma
Bladder cancer
Bladder calculus
Acute haemorrhagic cystitis
TB of the bladder
Schistosomiasis
Discuss the pathogenesis of a urinary tract infection in adults
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
List the causes of urinary tract infections in adults
E. coli
Klebsiella
Proteus
Pseudomonas
Streptococcus infection
Staphylococcal infection
List the common causes of urinary tract infections in immunocompromise patience
Candida
Adenovirus
CMV
List the local predisposing factors of UTIs
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
What is the clinical presentation of acute pyelonephritis?
Fever and rigors
Loin or back pain
Nausea and vomiting
What does the complications of acute pyelonephritis?
Septicaemia and septic shock
Intra-renal/perinephric abscess
Chronic pyelonephritis
Renal failure
What is the treatment of acute pyelonephritis?
Admit if toxically ill
IV fluids
Blood culture
Antibiotics – Gentamicin, ciprofloxacin, cefotaxime
What is the clinical presentation of cystitis?
Frequency
Urgency
Dysuria
Apyrexial
Elderly: Incontinence and malodorous urine
How would you manage uncomplicated cystitis?
EML Guidelines: Ciprofloxacin 500mg PO BD for 3 days
How would you manage complicated cystitis?
EML Guidelines: Ciprofloxacin 500mg PO BD for 7 days
How would you manage recurrent cystitis?
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
Who is at risk of erectile dysfunction?
Ischaemic heart disease
DM
HPT
Dyslipidaemia
Depression
Renal Failure
Any hormonal problems that cause low testosterone
Discuss normal penis vascular and nerve supply
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
List the psychogenic causes of erectile dysfunction
Poor self-esteem / body image
Anxiety / stress
Depression
List the organic causes of erectile dysfunction
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
What are the management options for erectile dysfunction?
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
What are the side-effects of PDE 5 inhibitors?
Headache
Facial flushing
Dyspepsia
Nasal congestion
Altered vision
What are the contraindications for PDE 5 inhibitors
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
Discuss Intra-cavernous injection (ICI) therapy
When oral therapy failed
Prostaglandin E1 (Alprostadil) injected into the corpus cavernosa
provides 2-3 hour erection
What are the side-effects/complications of ICI?
Pain in the penis
Priapism
Define Peyronie’s disease
Acquired penile abnormalityt characterised by fibrosis of the tunica albugina
What are the clinical features of Peyronie’s disease?
Penile pain associated with erection
Penile curvature (chordee) - usually dorsal
Loss of erection due to “venous leak”
What is the medical management for Peyronie’s disease?
50% resolve spontaneously
Vitamin E 400mg PO BD + Colchicine 1mg PO BD
Intra-lesional injections - Verapamil/Interferon
PDE 5 inhibitors
What is the surgical management for Peyronie’s disease?
Nesbit Procedure - Penile shortening
Excision of plaque
List the organisms involved in urethral discharge
STDs!!!
Gonoccocal:
* Neisseria gonorrhoeae
Non-Gonoccocal:
- Chlamydia trachomatis (50-60%)
- Ureaplasma urealyticum (20%)
- Trichomonas vaginalis
List the complications of urethritis
Urethral stricture (>GU) Epididymitis (>NGU)
What is the clinical presentation of urethritis?
Urethral discharge
- GU - Thick, purulent, yellow
- NGU - watery, scanty
Dysuria
Urethral itching
Discuss the treatment of gonoccocal urethris
Counselling
Ofloxacin 400mg PO STAT
Doxycycline 100mg BD for 7 days
Discuss the treatment of gonoccocal urethris
Counselling
Doxycycline 100mg BD for 7 days
Provide a DDx for male genital ulceration
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
How do you diagnose syphilis?
VDRL
RPR
TPHA
FTA
How do you diagnose HSV?
Immunoflorescent antibody testing against HSV
How do you diagnose Chancroid?
Selective culture medium
How do you diagnose Granuloma Inguinale?
Donovan bodies on histology
What are the clinical features of syphilis?
Cause: Treponema palidum
Apyrexial
Deep, single painless ulcer with well-defined edges
Non-purulent ulcer
What are the clinical features of HSV?
Cause: HSV Type 2
Apyrexial
Multiple superficial vesicular, painful lesions with erythematous edges
Tender bilateral inguinal LN
What are the clinical features of Chancroid?
Cause: Haemophilus ducreyi
Pyrexial
Single deep vesicular lesion with irregular edges
Purulent induration
Tender unilateral inguinal LN
What are the treatment of syphilis?
Benzathine penicillin 2.4 million units IMI STAT
What are the treatment of chancroid?
Erythromycin 500mg 8hrly for 5 days
OR
Ciprofloxacin 500mg PO STAT
What are the treatment of HSV?
Acyclovir 200-400mg 5 p/day (5hrly) for 7 days
What are the treatment of lymphogranulosa venerum/granuloma inguinale?
Doxycycline 100mg BD
For 3wks in LGV
Define a hydrocele
A collection of fluid between the visceral and parietal layers of the tunica vaginalis
What are the secondary causes of a hydrocele
Acute epedidymitis
Testicular Tumour
Testicular torsion
Scrotal trauma
What are the clinical features of a communicating (congenital) hydrocele?
Scrotal swelling when crying
Scrotal swelling larger in evening/morning
What are the clinical features of a non-communicating (acquired) hydrocele?
Painless cystic scrotal swelling with transluminates
Testis situated posterior to fluid/impalpable
Provide a DDx for painless scrotal swelling
Hydrocele
Spermatocoele
Epididymal cyst
Chronic epididymitis
Inguinal hernia
Varicocele
Testicular tumour
What is the treatment for a primary non-commuicating hydrocele?
Aspiration and sclerotherapy
Hydrolectomy - Lord’s procedure
Define a varicocle
Varicose veins of the pampiniform plexus of the spermatic cord
How does a varicocele affect fertility?
Increased intra-scrotal temperature interferes with spermatogenesis
venous anoxia interferes with epididymal function which is vital for sperm maturation
What are the clinical features of a varicocele?
Pain - esp when erect
Infertility (late)
Examination:
- “Bag of worms” above testis
- Valsalva manoeuvre makes it obvious
- Ipsilateral testicular atrophy
Semenanalysis:
- oligospermia
- asthenospermia
- teratospermia
What is the treatment for a varicocele?
Only for pt’s with complications to prevent retrograde flow
Open surgical ligation of vessel
Spermatic vein embolization
- Antegrade sclerotherapy
- Retrograde embolization
- Laproscopy
What are the clinical features of TB (chronic) epididymitis?
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
How is TB epididymitis diagnosed?
Microscopy > ZN staining and TB culture of urine, semen and pus from scrotal sinus
IVP - to exclude urinary TB
CXR
Histology
What is the treatment of TB epididymitis?
Anti-TB medication for 6 months - FDC
Define infertility
Failure to conceive after 12 months of unprotected sex
What are the testicular causes of male infertility?
Varicocele
Undescended testis
Previous trauma
Mumps orchitis
Radiotherapy
Previous Surgery
List the options for assisted reproduction
Intra-uterine insemination
IVF
Intra-cytoplasmic sperm injection
Donor insemination
Adoption
How would you counsel a patient before a vasectomy?
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
How would you counsel a patient before a vasectomy?
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
What are the complications of a vasectomy
Pain
Haematoma
Infection
Post-vasectomy pain syndrome
What are the mechanical causes of urinary retention?
Males…
- BPH
- Prostate Ca
- Acute prostitis
- Urethral Trauma
- Urethral Stricture
- PUV - Boy kids
Females…
- Pregnancy
- Fibroid uterus
- Urethral diverticulum
- Urethral stricture
- Urethral Ca
What are the features of acute urinary retention?
Acute lower abdominal pain
Patient wants to void but cannot
Palpable tender bladder
Rectal and vaginal examinations - to determine cause
What is the treatment of acute urinary retention?
Immediate relief by passing a transurethral catheter
* Failure may indicate a stricture
Suprapubic catheter
Treatment dependent on cause
What are the features of chronic urinary retention?
A decompensated bladder due to chronic outflow obstruction or neuropathy
Painless
Obstructive symptoms
Disurnal and nocturnal incontinence (overflow)
What are the indications for immediate catheterization in chronic bladder retention?
UTI
Renal Failure
Incontinence
Acute on chronic retension
What are the complications of immediate catheterisation in chronic retention?
NB!! Admit a CUR patient after immediate catheterisation
Complications…
- Severe macroscopic haematuria
- Post-obstructive diuresis
Provide a DDx of acute scrotum
Testicular torsion
Epididymitis
Orchitis
Scrotal cellulitis/abscess
Post traumatic Haematocele
Ruptured testis after trauma
Strangulated inguinal hernia
What is the pathophysiology of testicular torsion in an adult?
Twisting of the spermatic cord
> venous obstruction
> Arterial obstruction
> Ischaemic necrosis of testis and epididymis
Clinical features of testicular torsion
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)
What is the emergency management of testicular torsion?
Presentation within 24 hours
- Scrotal inscision
- If testes viable : Detorsion + orchidopexy
- If ischaemic : Orchidectomy
- Orchidopexy for contralateral testicle
What are the most common causes of acute epididymitis?
<35 years..
- Gonococcal urethral infection
- Chlamydial urethral infection
> 35 years…
- BPH
- Prostate Ca
What is the clinical presentation of acute epididymitis?
Gradual onset pain
Hx of Urethral discharge
Pyrexia
Swollen tender epididymis posteriorly
Positive cremaster reflex
What is the mangement of acute epididymitis?
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
What is the clinical presentation of acute prostatitis?
Pyrexia and rigors
Acute lower abdominal pain
Difficult urination / urinary retention
Rectal exam - Boggy tender prostate
What is the management of acute protatitis?
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
