Conditions Flashcards
Voiding (obstructive) symptoms
Hesitancy
Weak stream
Postmicturition dribble
Incomplete emptying
Straining
Storage (irritative) sx
Urgency
Urge incontinence
Frequency
Nocturia
Suprapubic pain
History taking for BPH
IPSS to evaluate severity and effect on qol
Voiding sx
Storage sx
Bladder diary
Fluid intake
FHx BPH
Physical exam of BPH
PR; size, symmetry, nodules, tenderness, constipation
Penis; phimosis, meatal stenosis, balanitis
Neuro; anal tone, sensation, lower limb neuro
BPH Ix
Urinalysis; exclude haematuria, proteinuria, infection
Renal function
USS; if mod-severe sx, abnormal renal function, retention
Causes of elevated PSA
Cancer
BPH
Exercise
Sex
Prostatitis
PR exam
Recent IDC
PSA screening
Not routine
Consider 2 yearly from 50-69yo if family hx
if doubles in 12mo - suspicious for cancer
Mx BPH
Cease caffeine/alcohol
Cease acidic/spicy foods
Tx constipation
Reduce nocte fluid intake
Bladder training + pelvic floor exercises
Moderate-severe BPH
- Alpha blockers, 5 alpha reductase inhibitors
Monitor; annual urinalysis + renal function
Alpha antagonists for BPH
1st line monotherapy
Prazosin (0.5mg BD) / tamsulosin
ADR; hypotension, retrograde ejaculation, erectile dysfunction
5-alpha-reductase inhibitors
Dutasteride / finasteride
Good if prostate vol >4ml / 30cc
ADR; gyno, ED, reduced sperm count, infertility
Indications for urology referral for BPH
Urinary retention
Hydronephrosis
Refractory to medical mx
Recurrent UTI
Gross haematuria
Renal insufficiency
Risk factors prostate cancer
FHx
African-American
BRCA
Fhx breast-ovarian Ca syndrome
Lynch syndrome
Acute bacterial prostatitis mx
Trimethoprim 300mg 2/52
OR keflex 500mg QID 2/52
Chronic bacterial prostatitis mx
Ciprofloxacin 500mg BD 4/52
Hydrocoele mx
Neonate; monitor until 12/12 - if not resolve by then OR very large at any stage - refer surg
Child; resolve by 2 years - outpatient referral is ongoing after 2 years
Risk factors of Peyronie’s disease
DM
Obesity
HTN
HLIPID
Smoking
Pelvic surgery
Dupuytren’s disease
Cause of priapism
Idiopathic
Sickle cell
Spinal shock
Penile trauma
Viagra, antiHTN, antidepressants
Gouts
DM
Priapism mx
Cold shower
Pseudoephedrine 120mg
Gentle job
Urgent urology input
- Corporal aspiration
- Intracavernous injection phenylephrine
Causes of LUTs
UTI
BPH/Prostate Ca/Prostatitis
Urethral stricture
Phimosis
OAB
Parkinson’s disease/MS/CVA
OSA (nocturnal polyuria)
Hx for LUTs
Storage sx
Voiding sx
Post-micturition sx
Haematuria
Polyuria/polydipsia
Weight loss
Smoking (risk bladder Ca)
Fhx prostate Ca
caffeine/ETOH
Volume fluid intake
Causes of haematuria
Postinfectious GN
IgA nephropathy
PCKD
Stones
Malignancy
Rigorous exercise
Coagulopathy
Sickle cell
Microscopic Haematuria work up
Dipstick - 1+ is significant (trace isn’t)
do UMCS to rule out infection
If proteinuria / reduced eGFr -> consider glomerulonephritis - do USS and refer nephrologist
If nil proteinuria/reduced GFR and have malignancy risk factors -> urine cytology x3, USS, refer to urologist for cystoscopy
Risk factors of urological malignancy
Male
>40yo
Hx macroscopic haematuria
Smoking
Pelvic irritation
Exposure to occupational chemical dyes or cyclophosphamide
Overactive bladder sx
Urgency
Frequency
Nocturia
Urge incontinence
Causes OAB
Neuro; stroke, MS, diabetic neuropathy
Urothelial carcinoma
Recurrent UTI
BPH
Urethral stricture
Overflow incontinence
OSA
CHF
Diabetes
Diuretics
Work up of OAB
Urinalysis; exclude infection, blood, glucose
USS and post-residual vol
Bladder diary 3 days
Consider; cytology, urodynamics, cystoscopy etc
Mx OAB
Reduce fluid intake 6-8 glasses per day
Constipation
Incontinence pads
Topical oestrogen in females
1st line; Bladder retraining/pelvic floor
2nd line; oxybutynin 5mg TDS, mirabegron 25mg daily (beta-3 agonist)
3rd; intravesical botox
4th; bladder augmentation, urinary diversion
Nocturia mx
Reduce fluid intake
Low Na diet
Lasix 6hr prior to bed
Desmopressin
Complications of catheter
CAUTI
Catheter obstruction; clots, crystals, biofilms
Catheter bypass (urine bypassing catheter) - due to small IDC size, underflated balloon, constipation, bladder spasms
Workup of suspected renal colic
Urine dipstick + MCS
bHCG
FBC/CRP/U+E/calcium/uric acid
24hr urine collection volume, calcium, oxalate, uric acid
Stone analysis
CT KUB - gold standard (do with XR KUB)
- if single kidney or renal failure - urgent imaging
Renal colic indications for admission
Diabetes
eGFR <30
Intractable pain/nausea
Single kidney
Bilateral ureteric obstruction
UTI/sepsis
Anuric renal failure
Renal colic
Conservative if <=7mm stone
- Panadol
- NSAID 1st line; celecoxib 200mg single dose
- Other; Indomethacin 50mg TDS PRN
Medical expulsive therapy (MET)
- Tamsulosin 400mcg daily
Prevention of renal stones
Increase fluid intake to ensure 2L UO / day
Increase K+; nuts, beans
Reduce salt/protein intake
Normal calcium intake
Thiazides can reduce Ca excretion
Patient instructions for renal colic
Safety net red flag; fever, intolerable pain
Strain urine and catch stone - bring in for analysis
Repeat scan 4/52 if not passed stone -> refer urologist if present
Causes of testicular lump
Cancer
Torsion
Orchitis
Hydrocoele
Varicocoele
Spermatocoele
Epididymal cyst
Epididymitis
Varicocele mx
Conservative
<=21yo; if assoc atrophy and decreased sperm quality then do surgical ligation
If normal sperm - monitor semen analysis every 2 years
Orchitis/epididymitis Ix
MSU MCS
Urethral swab or FPU chlam/gonorrhoea if sexually active in last 6/12
Consider USS if suspect tumour, torsion etc
Orchitis / epididymitis mx
Sexually active tx for chlam + gon (ceftriaxone + doxy)
Not sexually active tx for acute cystitis/acute prostatitis (trimethoprim 300mg 2/52)
No sex 7/7 after tx
No sex w/ partners from last 6/12
Bed rest
Scrotal support
Analgesia
F/u 5/7; tx response, Abx sens, sexual education
Risk factors testicular cancer
Fhx
Cryptorchidism
Previous tumour
Down syndrome
Testicular ca work up
USS
BHCG, AFP, LDH
Mx testicular ca
Discuss sperm banking
Discuss prosthesis
Secondary prevention
- weight, diet exercise
- continued self examination
Undescended testes mx
Unilateral
- Routine paed surg referral
- Elective repair at 6/12 age
- if impalpable - lap exam + staged procedure
Bilateral
- Palpable; if normal genitalia - routine surg referral. If abnormal genitalia - urgent paed surg referral
- Impalpable; urgent referral
Retractile testis mx
Annual review to make sure still can be manipulated
If >6yo and retractile or cannot be longer manipulated - urgent referral to surg
Risk factors ED
Atherosclerosis; CVD, DM, lipid, HTN, smoking
Neuro; stroke, dementia, parkinsons, DM
Pelvic surgery
Endocrine; thyroid, hypogonadism, HPRL
Obesity
Peyronie’s disease
Stress/relationship issues/depression
Medication; diuretics, beta-blockers, SSRI
Alcohol, cocaine
OSA
ED evaluation
CVD risk; if high risk stop all sexual activity and refer cardiologist
- High risk; ACS in last 2/52, high risk arrhythmias, severe AS, NYHA IV
BMI
BP
Testes Size
Penile exam
Ix
- Lipid, HbA1c
- Serum testosterone
- Sleep study
ED mx
Smoking/ETOH cessation
Exercise
Weight loss
Healthy diet
Sildenafil 25-100mg
Urologist
- Intracaversonal injection
- Vacuum erection device
Psychosexual therapy; masturbation retraining, glans stimulation with vibrator, condom with hole in tip
Phosphodiesterase type 5 inhibitor for ED
Contra; nitrates, MI/CVA in last 6/12, HTN >170/100, unstable angina
ADR; headache, flushing, priapism
Instruction
- empty stomach
- wait 45min prior to sex
- Engage in stimulation prior to sex
- Allow 6-7 attempts with medication for full effect
- Trial on self with masturbation
Mx premature ejaculation
IELT <1min (primary) or <3min (acquired)
Sexology referral for techniques to control ejaculation, reduce anxiety
Reduce sensitivity; thick condoms, topical EMLA 20min prior to interoucrse
Behaviour
- stop-start, squeeze technique, extended foreplay, cognitive distractions,
Psychosexual
- meditation, relaxation
SSRI
- Dapoxetine
- can combined with viagra
Causes of haematospermia
Infection; STD
Iatrogenic; prostate biopsy/tx, vasectomy
Cancer; prostate/testis/bladder/urethral
Prolonged intercourse
Prolonged abstinence
HTN
Leukaemia/lymphoma
Coagulopathy
Idiopathic
Initial workup of haematospermia
UMCS
urine cytology
FBC
Coagulation
+/- STI screen
PSA if >40yo, abnormal DRE or prostate Ca risk factors
Urine and semen AFB/parasites
Causes of male infertility
HPRL
Hypogonadotrophic hypogonadism
Varicocoele
Radiation
Klinefelter syndrome
Anti-sperm Ab
Retrograde ejaculation
Male infertility Ix
Serum FSH + morning testosterone
- Low test -> repeat with free test, SHBG, albumin, LH, PRL
Semen analysis; 2-3 abstinence, analysed within 1hr, always repeat abnormal result after 1/12
anti-sperm Abs
Karyotype if severe oligospermia
Scrotal USS; if risk factor for cancer
Post-ejaculatory urine analysis - exclude retrograde
General measures for male infertility
Cease smoking/alcohol
Weight loss
Reduce scrotal temperature
Avoid drugs
Avoid exposure to vibration/pesticides
Optimal intercourse timing
Clinical features Klinefelter
Small testis <4ml and firm palpation
Osteoporosis
Gyno
Tall
Reduce facial/body hair
Klinefelter long term complications
CVD
COPD
osteoporosis
Parkinson-like syndrome
Breast Ca x50 risk
Non-Hodgkin lymphoma
Hashimoto’s
T1DM
Klinefelter dx
2x morning fasting test low
Raised LH/FSH
Consider
- BMD
- Semen analysis
Klinefelter tx
Lifelong TRT from mid-puberty
Education risk of osteoporosis/IHD/breast Ca
Discuss fertility +/- IVF
Functional hypogonadism
Cause; age, overweight, chronic disease
Sx; fatigue, hot flushes, low libido, ED
Serum test - modest reduction 6-10nmol/L
Tx
- 10% weight loss
- Tx depression/OSA
- Remove opioids/steroids
Vasectomy patient counselling
Ask if tried other contraception
Make sure they know its permanent
Determine whether relationship stable
Ask about future family intent
Not 100% reliable in preventing pregnancy - 1/2000 risk
Need for condoms for STI prevention
Risk; haematoma, infection, pain
Avoid sex for 1 week post-op
Need 3/12 interim contraception and 20 ejaculations with semen analysis prior to being declared sterile
