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FINALS > GenitoUrinary > Flashcards

GenitoUrinary Flashcards

1
Q

 what cells are found within the seminiferous tubules?

A

Germ cells

Sertoli cells

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2
Q

what is the function of germ cells?

A

Allow the process of spermatogenesis

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3
Q

describe the steps of spermatogenesis?

A
  1. spermatogonia
  2. spermatocytes
  3. spermatids
  4. spermatozoon
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4
Q

what is the function of Sertoli cells?

A
  • They are the true epithelium of the seminiferous epithelium
  • support germ cell development
  • secrete inhibin -which enhances FSH biosynthesis and secretion
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5
Q

what are Peritubular Miotubular cells?

A

surround the seminiferous tubules and make up part of the smooth muscle

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6
Q

where our Leydig cells found?

A

Within the interstitium

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7
Q

what is a function of Leydig cells?

A

Secrete testosterone and other androgens as well as presenting macrophages

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8
Q

what is the blood supply to the testicles?

A

testicular arteries however it also has collateral blood supplies

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9
Q

describe the branching of the testicular arteries?

A

Arise from the abdominal aorta and descend through the inguinal canal

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10
Q

what blood supply supplies the scrotum and the rest of the external genitalia?

A

external Pudinal artery and branches of the internal Ilac artery

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11
Q

what is the venous drainage of the testicles?

A

Veins formed from the pimpiniform plexus in the scrotum

the left testicle drains into the left renal vein

the right testicle drains into the inferior VC

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12
Q

what tests are good for imaging the upper urinary tract?

A

CT with contrast

or ultrasound scan

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13
Q

when our ultrasound scans most commonly used when imaging the urinary tract?

A

in accident and emergency for acute situations as they have a lower sensitivity than CT

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14
Q

what investigations are indicated for anyone with haematuria that is unexplained from a simple cause such as UTI?

A

Either CT or ultrasound

and cystoscopy of the bladder

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15
Q

what type of CT is used when investigating haematuria or wanting to visualise the urinary tract?

A

CT urogram with IV contrast

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16
Q

when would you not want to use contrast?

A

If someone has:

  • severe kidney failure
  • allergies
  • or if wanting to view kidney stones
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17
Q

what does a reducible hernia mean?

A

When the contents of the area can be manipulated back into its original position

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18
Q

What does an irreducible hernia mean?

A

the hernia is compressed by the defect causing it to be irreducible

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19
Q

what is an obstructed hernia?

A

mainly refers to hernias containing bowel

contents of the hernia compressed to the extent that the bowel lumen is no longer patent

causes bowel obstruction

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20
Q

what is a strangulated hernia?

A

The compression around the hernia prevents blood flow into the hernias’ content

causing ischaemia and tissue pain

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21
Q

what is one of the most common causes of lump in the groin?

A

Inguinal hernia

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22
Q

Describe the path of the inguinal ligament

A
  1. the inguinal ligament runs between the ASIS and the pubic tubercular
  2. this forms the inguinal canal
  3. inguinal canal allows for the passage of the spermatic cord, round ligament + ilioinguinal nerve
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23
Q

what is a direct inguinal hernia?

A

A hernia caused by a weakness in the posterior wall of the inguinal canal

causes abdominal contents to enter the inguinal canal and go to the superficial ring

but does not pass through the superficial ring

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24
Q

what is an indirect inguinal hernia?

A

the abdominal contents passes through both deep inguinal ring + through the inguinal canal to the superficial ring

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25
Q

what is an easy way to distinguish betweent a direct and an indirect hernia?

A

If you press on where deep inguinal ring is and you can reduce the hernia then it means it is an indirect hernia

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26
Q

what are causes of inguinal hernias?

A
  • Increased intra-abdominal pressure
  • weakness of the abdominal muscles
  • chronic cough
  • constipation
  • heavy lifting
  • being elderly
  • obesity
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27
Q

how would you diagnose an inguinal hernia?

A

Diagnosis is usually clinical with examination

but ultrasound scan can be used to aid diagnosis

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28
Q

what is a typical presentation of an inguinal hernia?

A

The development of a painless swelling in the groin over time

(although can occur suddenly after heavy lifting)

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29
Q

what is the presentation of a symptomatic inguinal hernia?

A
  • Pain particularly on increasing intra-abdominal pressure
  • change in bowel habits such as constipation
  • pain or burning sensation in the groin
  • scrotal swelling
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30
Q

what is the management of an asymptomatic hernia?

A

If it is small and not increasing in size:

  • it can be left alone / expectant management

otherwise:

  • elective surgery
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31
Q

what is the management of a symptomatic inguinal hernia?

A

Surgery - open or laparoscopic

if anything is strangulated or obstructed:

  • emergency surgery
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32
Q

what structures are found beneath the inguinal ligament?

A
  • femoral artery
  • femoral vein
  • femoral nerve
  • femoral canal
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33
Q

where would a femoral hernia usually occur?

A

The femoral canal – abdominal contents protrudes through it

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34
Q

why are femoral hernias particularly problematic?

A

They are at high risk of strangulation and obstruction as it is bordered by the lacuna ligament

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35
Q

what are risk factors associated with femoral hernias?

A

Elderly women who have had childbirth

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36
Q

what is the presentation of a femoral hernia?

A

Swelling can be in the groin like an inguinal hernia

however

it is usually closer to the upper thigh

can cause hip pain as well as pain at the site of herniation

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37
Q

what other benefits of laparoscopic surgery, and what are its cons?

A

PRO:

  • Involves less pain
  • less scarring
  • shorter recovery times

CON:

  • more expensive than open surgery
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38
Q

what other most common causes of uro sepsis?

A

UTI

obstruction in urinary flow causing urinary stasis

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39
Q

Were the most common locations for an obstructed kidney?

A
  • pelvicureteric junction
  • vesicoureteric junctionn
  • ureter
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40
Q

what investigations do you need to perform in urosepsis?

A

sepsis six :

  • taking blood cultures
  • urine cultures
    • rest

finding out if there is any obstructive cause - using CT (no contrast)

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41
Q

what is the management of urosepsis?

A

starting empirical antibiotics until cultures come back

if there is obstruction:

  • ureteric stent or…
  • nephrostomy
  • until obstruction is removed
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42
Q

what do you need to ensure in the management of over 65’s for UTI?

A

That you ensure gram-negative pseudomonas is covered

  • penicillin or cephalosporins with gentamicin
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43
Q

what is a femoral aneurysm?

A

classed as ileo femoral aneurysm

can either be on the Ilac or femoral artery

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44
Q

what is the most common cause of of femoral aneurysm?

A

Atherosclerosis

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45
Q

how does atherosclerosis lead to aneurysm?

A
  1. inflammation associated with the atherosclerosis leads to the destruction and thinning of a vascular wall
  2. making it weaker
  3. specifically the tunica media is weekend
  4. leading to dilation of the vessels forming an aneurysm
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46
Q

what is the presentation of a femoral aneurysm?

A

usually asymptomatic

until there is embolisation or rupture

however sometimes a pulsatile mass may be felt at the groin

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47
Q

what is an easy way to distinguish between an aneurysm and a hernia?

A

They may feel very similar

but

in aneurysm you would hear bruit and vascular flow

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48
Q

patient presents with:

  • acute groin pain
  • signs of tachycardia

what should be one of your initial diagnoses?

A

ruptured femoral aneurysm

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49
Q

apart from groin pain what other symptoms can a ruptured femoral aneurysm cause?

A
  1. Weakness of the leg
  2. swelling and numbness (due to compression of nerves and obstructions nearby)
  3. those of acute limb ischaemia (pain paraesthesia paralysis pulselessness pallor perishing with cold)
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50
Q

if you suspect a ruptured femoral artery what investigations should you perform?

A

Duplex ultrasound scan

  • looking at proximal and distal arteries

CT angiography is then used

+ bloods for shock

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51
Q

what is blue toe syndrome?

A

tissue ischaemia

secondary to cholesterol or great embolus

can occur if a clot forms due to an aneurysm and then dislodges

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52
Q

what is the management of a femoral aneurysm?

A

if symptomatic or larger than 3 cm

rapidly expanding

coexisting AAA

any complications present -give surgery

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53
Q

what is testicular torsion?

A

an emergency caused by the twisting of testicles

on the spermatic cord

leads to constriction of the vascular supply

causes rapid ischaemia and necrosis

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54
Q

what is the presentation of testicular torsion?

A

sudden onset of severe scrotal pain

associated nausea and vomiting

no relief of pain upon elevation of scrotum

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55
Q

what can cause testicular torsion?

A

Trauma

inflammatory

infective causes

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56
Q

what symptoms would indicate that infection/inflammation has caused testicular torsion?

A
  • fever
  • dysuria
  • frequency
  • pain
  • discharge
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57
Q

what features in the history of testicular torsion would support your diagnosis?

(apart from symptoms)

A

history of intermittent or acute on and off pain

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58
Q

how would testicular torsion present in a patient with undescended testes?

A

sudden abdominal pain

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59
Q

what features might you find on examination of testicular torsion?

A

Severe tenderness

testis higher than the unaffected testes

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60
Q

what physical features may be present in a delayed presentation of testicular torsion?

A

Erythema and oedema and reactive hydrocele

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61
Q

how would you diagnose testicular torsion?

A

any indication of testicular torsion = ASAP exploratory laparoscopy surgery

do not waste time with ultrasound and Doppler’s

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62
Q

what is the management of testicular torsion?

A

aim to treat within 4 to 6 hours

immediate urological consultation for emergency scrotal exploration

then surgery + orchidoplexy

  • however if there is no reperfusion orchidectomy
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63
Q

what is epididymitis?

A

Inflammation of the epididimis

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64
Q

what are the most common agents which cause epididymitis?

A

Chlamydia

nessieria gonorrhoea

Mycoplasma genitalium

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65
Q

What is the presentation of epididymitis?

A

unilateral pain and swelling

erythema and tender enlargement of the epididymis

systemic features may be present

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66
Q

what is an important differential to exclude in epididymitis?

A

Testicular torsion

  • consider if there is a sudden and severe onset with initial examination showing no evidence of inflammation or infection
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67
Q

what conditions usually accompany epididymitis?

A

Epididymoorchitis or urethritis

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68
Q

how would you investigate Epididymitis?

A

Urine dipstick

first void urine sample for N AAT

  • (chlamydia and gonorrhoea)

urethral swab + Gram stain if also urethritis

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69
Q

what is the management of epididymitis?

A

Once the cultures come back

with antibiotics

stop and discontinue amiodarone if used

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70
Q

patient presents with:

  • a hot swollen erythema to one scrotum
  • the testicle and the epidermis is very tender t
  • discharge and some symptoms of UTSI
  • he reported having had a fever a few days ago

what is most likely diagnosis?

A

epididimoorchitis

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71
Q

what is Epididimoorchitis?

A

an infection of both the epididymitis and the testicle

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72
Q

what pathogenusually causes epididymal orchitis?

A

E. coli or STIs

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73
Q

how would you investigate epididymoorchitis?

A

full STI screen

with urine dipstick + urine cultures

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74
Q

what antibiotics would you give to cover E. coli?

A

Ciprofloxacin

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75
Q

how long should you give antibiotics to cover epididymo orchitis?

A

10 – 14 days

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76
Q

a patient presents with:

  • LUTS
  • dysuria and urinary frequency
  • perineal + genital pain
  • urinary stream diminished + slowing stream
  • a low-grade fever

what is the most likely diagnosis?

A

prostatitis

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77
Q

as well as pain in the perineal or genital regions where else can prostatitis cause pain?

A
  • Scrotum
  • testes
  • suprapubic
  • lower back
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78
Q

what is the most common cause for prostatitis?

A

E coli or STIs - if untreated and ascend

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79
Q

what findings would be present on DRE in a patient with prostatitis?

A

Intensely tender prostate

may also feel abnormally soft and boggy

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80
Q

what investigations need to be performed in prostatitis?

A

urinalysis urine cultures blood cultures- in febrile patients with acute symptoms PSA may be performed- raised

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81
Q

what is the management of prostatitis?

A

Antibiotic therapy – quinolone PO,

signs of sepsis: parenteral antibiotics:

  • broad-spectrum penicillin
  • cephalosporins
  • or quinolone with gentamicin
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82
Q

What is the name of the pathogen that causes chlamydia?

A

Chlamydia trachomitis

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83
Q

what are the symptoms of chlamydia in women?

A
  • 85% of women are asymptomatic
  • post coital or inter menstrual bleeding
  • odourless vaginal discharge
  • dysuria
  • pelvic pain
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84
Q

what are symptoms of chlamydia which goes untreated in females?

A

pelvic inflammatory disease

  • ascends urogenital tract
  • causing fever myalgia nausea and vomiting pelvic or abdominal pain
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85
Q

what are the symptoms of chlamydia in a male?

A

Dysuria

clear white urethral discharge

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86
Q

what are the complications of untreated chlamydia in males?

A

epididymitis

prostatitis

epididimoorchitis

+systemic symptoms

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87
Q

how do you test for chlamydia?

A

First pass urine test

swabs from high vagina or urethra

NAAT testing

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88
Q

what is the management of chlamydia?

A

If there is a high index of suspicion you don’t have to wait until test results

  • doxycycline
  • 7days (azithromycin is another option)
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89
Q

what is involved in a full STI screen?

A

First pass urine

high vagina charcoal swab

endocervical charcoal swab

endocervical NAAT test

swab or urethra - in males

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90
Q

what pathogen causes gonorrhoea?

A

Gram-negative diplococcus Neisseria gonorrhoea

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91
Q

what is the presentation of gonorrhoea in a male?

A

Thick green yellow discharge

muco purulent

dysuria + urethral pruritus (sx of urethritis)

if it ascends can cause symptoms of prostatitis and epididimoorchitis

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92
Q

what are the symptoms of gonorrhoea in females?

A

Yellow green vaginal discharge

pelvic pain

fever

pain on urination

intermenstrual bleeding

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93
Q

What would be the rectal presentation of gonorrhoea?

A

rectal pruritus

muco purulent discharge

  • usually with bowel movements

rectal pain and sometimes rectal bleeding

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94
Q

what is a common complication of untreated gonorrhoea?

A

PID

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95
Q

What is disseminated gonococcal infections?

A

skin and synovium

as well as systemic features

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96
Q

what is the management of gonorrhoea?

A

Ceftriaxone and azithromycin

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97
Q

what is the pathogen which causes syphilis?

A

Trepenema pallidum

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98
Q

How is syphilis spread?

A

Contact with a syphilitic lesion

(on genitals or mucous membrane)

it can also be passed on congenitally

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99
Q

what is the presentation of syphilis and which is the main symptom to be aware of?

A

Solitary painless genital ulcer!

In the anogenital or cervical area

mouth ulcers may also be present

regional lymphadenopathy are all features of primary infection

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100
Q

what does a painful lesions suggestive of syphilis indicate?

A

Coinfection with genital herpes

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101
Q

what do multiple vesicles in primary syphilis indicate?

A

Coinfection of HIV

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102
Q

when does secondary syphilis occur?

A

4 to 8 weeks after primary syphilis

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103
Q

what is the presentation of secondary syphilis ?

A
  • Systemic features
  • arthralgia
  • generalised lymphadenopathy
  • symmetrical maculopapular rash on palms, soles of feet, trunk and scalp
  • rash may ulcerate
  • mucosal ulceration causing snail track
  • painless ulceration on genitals
  • patchy alopecia
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104
Q

what is neuro syphilis?

A

specific organ involvement of the brain causing headaches, meningismus, hearing loss and seizures

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105
Q

what are some areas of specific organ involvement which can occur in secondary syphilis?

A

Neurological

ophthalmological - iritis uveitis and choridoretinitis

vasculitis - causing nephrotic syndrome or hepatitis

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106
Q

what is the opthalmological involvment syphilis can have?

A

iritis uveitis and choridoretinitis

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107
Q

what vasculitic consequences can occur due to syphillis?

A

nephrotic syndrome or hepatitis

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108
Q

what is the definition of latent syphilis?

A

A patient is seropositive with the absence of any clinical features

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109
Q

how do you diagnose syphilis?

A

swab testing and PCR from lesion and additional serological testing / if anyone is presenting with neurological symptoms than a CSF PCR should be performed

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110
Q

What is management syphilis?

A

IM benzylpenicillin

  • unless is neurological involvement in which case give IV
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111
Q

what is trichomoniasis?

A

Infection caused by protozoan parasite ‘trichomonal vaginalis’

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112
Q

what is the presentation of trichomonas in women?

A
  • Usually asymptomatic but can cause:
  • itching
  • burning
  • redness
  • soreness of the genitals
  • discomfort urinating
  • changing vaginal discharge
  • discomfort during sex
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113
Q

what is the presentation of trichomonas in men?

A
  • usually is asymptomatic:
  • Itching or irritation inside the penis
  • burning after urinating or ejaculating
  • discharge
  • soreness, swelling, redness of the head of the penis or the foreskin
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114
Q

how do you diagnose trichomonas?

A

swabbing either the penis or the vagina and looking for the parasite under the microscope

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115
Q

How do you manage trichomonas?

A

metronidazole

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116
Q

What is the presentation of Thrush in women?

A

white discharge

  • cottage cheese appearance

no unusual smell

itching and irritation around the vagina and vulva

soreness + stinging during sex or urinating

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117
Q

what is a presentation of Thrush in men?

A

irritation or burning

redness around the head of the penis

under the foreskin

white discharge like cottage cheese

unpleasant smell

difficulty pulling back the foreskin

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118
Q

what are some signs of severe vulvovaginal candidiasis?

A

erythema -can extend to the labia majora and perineum

vaginal fissuring or oedema

excoriation of the vulva

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119
Q

is thrush an STI?

A

Technically no but can still be spread from sexual partners

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120
Q

what investigations are necessary in thrush?

A

high vaginal carbon swab

can be a swab taken from patient

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121
Q

what is the management of thrush?

A

pessary- clotramiozloe or fluconazole PO

younger than 15:

  • prescribe topical cream only

only vulval symptoms:

  • then prescribe topical only - top clotramidazole
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122
Q

what should you check in a patient who has recurrent or severe infections of thrush?

A

HbA1c and offer STI screening

123
Q

What is a hypospadias?

A

Abnormality of the penis

ureteric opening is not in its normal position

it is a congenital condition

124
Q

on newborn examination of the male genitals you notice that the urethra has its opening on the mid shaft what is this?

A

ventral urethral meatus – hypospadias

125
Q

on newborn examination of male genitalia you noticed that there is failure of the foreskin to fuse ventrally - what is this?

A

hooded dorsal foreskin hypospadias

126
Q

a 16 year old patient presents to you worried because they noticed that on erection there is a severe ventral curvature of the shaft of their penis what is this??

A

Chordee hypospadias

127
Q

what are some complications of hypospadias?

A

Inability to mictuate in a normal direction

erectile dysfunction

deformity

128
Q

What is the management of a hypospadias??

A

corrective surgery in patients younger than 2y

aims of surgery:

  • terminal urethral meatus
  • a straight urinary flow
  • straight erection
  • normal cosmetic appearance
129
Q

what are storage symptoms of LUTS?

A

Frequency

urgency

nocturia

130
Q

what are voiding systems of LUTS

A
  • weak stream
  • hesitancy
  • intermittency
  • straining
  • incomplete emptying
  • post void dribbling
131
Q

a 60-year-old man presents to you complaining of LUTS

  • what are the most likely diagnoses?
A

BPH

UTI

Prostate cancer

132
Q

what is benign prostatic enlargement / hyperplasia?

A

smooth muscle hyperplasia

causing prostatic enlargement

symptoms also arising because of central nervous system dysfunction + blood flow dysfunction

133
Q

describe the pathophysiology of benign prostatic enlargement

A
  • Increase in the number of epithelial and stromal cells within the prostate gland
  • usually within the transitional zone of the prostate
  • testosterone is converted to dihydrotestosterone by five alpha reductase
  • dihydrotestosterone receptors inside the prostate cells
  • causing them to increase their secretions and increase cell division
  • eventually resulting in gland enlargement
134
Q

what is the main hormone that drives BPH? And what enzyme is involved?

A

dihydrotestosterone (testosterone converted by five alpha reductase)

135
Q

which area of the prostate is most affected by BPH?

A

The transitional zone

136
Q

what examination should you perform on a male presenting with L UTS and what is the result for BPH?

A

DRE will reveal soft enlarged gland

137
Q

what investigations should you perform in someone with LUTS?

A

PSA / U+E - check for renal causes of LUTS (may also want to do urine dipstick)

138
Q

why is the PSA not very specific for prostate cancer?

A

Because it can be raised in normal BPH as well as UTIs prostatitis urinary retention catheterisation and ejaculation

139
Q

what is the most important risk factor for developing BPH?

A

Being over 50

140
Q

describe a diagnostic questionnaire which can be used for LUTS?

A

the international prostate scoring symptom score: questionnaire which helps assess the severity of symptoms from mild (0 – 7) moderate (8 – 19) severe (20 – 35)

141
Q

how would you manage mild L UTS?

A

Managed conservatively with lifestyle factors

142
Q

how would you manage moderate L UTS?

A

Alpha blockers (tamsulosin) +/- five alpha reductase inhibitors (finasteride)/if any storage symptoms are present add an antique cholinergic drug (oxybutanine)

143
Q

What are side effects of alpha blockers?

A

Anterograde ejaculation dizziness hypertension

144
Q

how do alpha blockers work in terms of BPH?

A

Is an alpha one adrenoceptor antagonist so relaxes smooth muscles

145
Q

how do five alpha reductase inhibitors work?

A

inhibit the conversion of testosterone to dihydrotestosterone thus reducing prostatic growth it takes six weeks to 6 months to work

146
Q

what are side effects of five alpha reductase inhibitors?

A

Erectile dysfunction reduced libido ejaculatory disorders

147
Q

what is the management of severe L UTS?

A

surgical intervention TURP if this is not possible long term catheter

148
Q

what type of cancer is prostate cancer?

A

Glandular cancer

149
Q

apart from LUTS what other symptoms may be present in prostate cancer and when with these be present ?

A

In more advanced disease the symptoms such as haematuria lethargy bone pain palpable lymph nodes and weight loss

150
Q

what are the indications for referring men for a two-week wait pathway in terms of prostate cancer?

A

Abnormal/malignant DRE or elevated PSA above age specific range

151
Q

when should you offer PS a and D R E testing?

A

any man with L UTS erectile dysfunction or visible haematuria

152
Q

what investigations are done in the q. week weights pathway?

A

MRI is offered before biopsy in order to limits invasive tests But the biopsy is diagnostic/confirms diagnosis

153
Q

what is the management of prostatic cancer?

A

low risk: watchful waiting / elective prostectomy Intermediate risk: radical prostectomy or watchful waiting High risk: NO WATCHFUL WAIT radical prostectomy or chemo + long term androgen deprivation therapy (also needs cancer scores T3/4 or PSA > 40 and NO co morbidities), radio therapy also offered.

154
Q

what are side effects of androgen deprivation therapy?

A

hot flushes sexual dysfunction gynaecomastia and more

155
Q

a young adult male (25) presents to GP with a palpable lump in the testicle which is painless on examination there is no discharge no erythema the lump is non-trans illuminable - what is the most likely diagnosis

A

Testicular cancer

156
Q

what type of cancer is testicular cancer?

A

can be in germ-cell (90%) or non-germ-cell tumours

157
Q

what are examples of germ-cell tumours?

A

seminomas / teratoma/ choriocarcinoma / yolk sac

158
Q

what are red flags for testicular cancer?

A

Haemoptysis / bone or back pain / weight loss/ fatigue / night sweats / loss of apetite

159
Q

what are risk factors associated with testicular cancer?

A

Aged 20 – 45/Caucasian/cryptoorchidism/previous testicular cancer/HIV/family history of testicular cancer

160
Q

if you suspect testicular cancer what is the first line investigation?

A

ultrasound scan of the testis

161
Q

after you have confirmed testicular cancer what other imaging should be performed?

A

Abdominal CT pelvic CT chest x-ray if you suspect any extra testicular mets

162
Q

what markers may be raised in testicular cancer?

A

Alpha-fetoprotein (teratoma and yolk sac) serum beta hCG (chorio carcinoma) lactate dehydrogenase (in half of cases)

163
Q

what is the management of testicular cancer?

A

radical inguinal orchidectomy with seeming cryopreservation and testicular prosthesis may be offered

164
Q

what muscle allows for micturition?

A

detrusor

165
Q

Describe the physiology of micturition

A

the detrusor muscle fills and stretches allowing for a constant intra-vesicular pressure (known as stress relaxation) / urine is passed through parasympathetic control / using pelvic nerves S2 – four releasing a CH which works on M3 muscarinic receptors causing the detrusor muscle to contract there is also inhibition in a different pathway resulting in the re-used sympathetic stimulation of the inner urethral sphincter causing relaxation in females urination is assisted by gravity whereas in males there is bulbospungiosus contractions

166
Q

which parasympathetic nervous control micturition?

A

S2-4

167
Q

What receptors are involved in detrusor micturition?

A

ACH controlled M3 Muscarinic

168
Q

what drugs are associated with urinary retention?

A

antiarrhythmic’s anticholinergic (atropine Oxley Peter Nina) antidepressants (amitriptyline) antihistamines (chlorofrenamine) antihypertensives (nifedipine) auntie parkinsonian drugs (amantadine levodopa) antipsychotics (haloperidol) hormonal agents (oestrogen progesterone testosterone) muscle relaxants (baclofen diazepam) anti-adrenergic drugs (phenylphrine) beta-adrenergic drugs - plus carbamazepine dopamine morphine NSAIDS amphetamines

169
Q

what are common causes of obstruction of the urinary tract in males?

A

BPH prostatic cancer for most this paraffin meiosis urethral strangulation stones infection prostatitis clots

170
Q

what are common causes of obstruction of the urinary tract in women?

A

stones cystocele ovarian tumours uterine tumours complication of incontinence surgery PID lblood clots

171
Q

what are some common causes of urinary retention?

A

See image below - in acute urinary retention page

172
Q

describes the difference between acute and chronic presentations of urinary retention?

A

Acute: painful smaller volumes of urine and no long history of LUTS chronic: painless very large volumes of urine insidious onset with often a long history of LUTS

173
Q

what is acute on chronic urinary retention?

A

A history of progressive L UTS followed by an episode of acute retention due to a precipitating event such as UTI or surgery

174
Q

patient presents with difficulty passing urine (possibly anuric) abdominal/suprapubic pain they are restless on examination you note a palpable bladder what is most likely diagnosis?

A

Acute urinary retention

175
Q

what examinations are important to assess in a patient with acute urinary retention?

A

Examine bladder which may be palpable performance DRE to check for an enlarged or abnormal prostate always take neurological examination to see for abnormalities to rule out cauda equina

176
Q

what is the acute management of acute urinary retention?

A

A senior should be informed do ABCDE and gain IV access, insert a two-way catheter unless there is a history of haematuria in which case a three-way catheter, record residual volumes and send urine samples from the catheter

177
Q

what investigations are required in acute urinary retention?

A

Urine sample after catheter is inserted, FBC and Urea, creatinine + electroytes, con do imaging USS/Ct to try and find cause

178
Q

what is a TW OC?

A

trial without catheter

179
Q

what drug is required by patients with L UTS history to help them pass their TW OC?

A

Alpha blockers (tamsulosin) +/- five alpha reductase inhibitors (finasteride)/if any storage symptoms are present add an antique cholinergic drug (oxybutanine)

180
Q

why can diuresis occur in some patients after having a catheter inserted?

A

Occurs as the bladder is being decompressed

181
Q

what are indications for high pressure chronic urinary retention?

A

large residual volume (1L+) deranged renal function

182
Q

what is the discharge of a patient with high pressure chronic retention?

A

go home with a catheter in situ may need overnight observation as patients often develop haematuria and diuresis

183
Q

what is a hydrocele?

A

an accumulation of fluid within the tunica vaginalis

184
Q

What causes of secondary hydrocele?

A

malignancy trauma infection torsion

185
Q

what other different types of hydrocele?

A

primary secondary/ communicating or non-communicating

186
Q

what are non-communicating hydrocele caused by stroke their pathophysiology?

A

and increased production of fluid by the tunica vaginalis / reduce resorption of fluid / impairment in lymphatic drainage

187
Q

what is the pathophysiology of communicating hydrocele?

A

they communicate with the peritoneum due to a patented processus vaginalis / these can change in size when standing versus lying down/ due to increased intra-abdominal pressure

188
Q

what is the main diagnostic feature of a hydrocele?

A

painless swollen scrotum in one or both sides which feels like a water-filled balloon

189
Q

which type of patients develop primary hydrocele?

A

male infants and newborns - usually resolved within first year of life

190
Q

what is the management of hydrocele?

A

if over 2 y + discomfort : surgery otherwise watch and wait

191
Q

what is a variocele?

A

a dilatation of the testicular veins which van be unilateral or bilateral

192
Q

what usually causes a variocele?

A

usually caused by an incompetent valce of the spearmatic verin however can also be a feature of renal cancer (L sided renal cancer)

193
Q

why does L sided renal cancer cause variocele?

A

as it can involve the L renal vein causing obstruction of the L spermatic vein auseing L sided hydrocele

194
Q

what all complications of as it can involve the L renal vein causing obstruction of the L spermatic vein auseing L sided hydrocele ?

A

may impede asked that adolescents testicular growth - large variocele is associated with small testes - and affect adults and their reproduction - 40% of men being evaluated in fertility clinics will have variocele

195
Q

what is a presentation of variocele?

A

feels like a bag of worms/feels like a dragging sensation/aching

196
Q

how do you diagnose a variocele?

A

using ultrasound

197
Q

what is the management of variocele?

A

small and not causing many disturbances: conservative watch and wait / if there is a large size difference between the two testicles ports affecting fertility/testicular growth: surgical ligation or embolisation

198
Q

what are the different ways you can classify undescended testes?

A

palpable/impalpable / maldescended/ectopic

199
Q

what is a maldescended testes?

A

testes that lies somewhere along the normal path of descent – most common

200
Q

what is an ectopic testes?

A

Lies outside the normal path of decent often lying in the thigh, perineum, opposite side of the scrotum

201
Q

when are undescended testes usually diagnosed?

A

During the newborn baby check the scrotum is checked to see if the testes are palpable

202
Q

what are palpable undescended testes?

A

Most common type of undescended testes are palpable ones usually within the upper portion of the scrotum or the inguinal canal during the exam the testicle can be felt and looked down into the scrotum (retractile)

203
Q

are retractable test is considered normal?

A

Yes they do not require surgical intervention

204
Q

what should you be careful of in retractable testes?

A

they are of a high risk of progression to an ascending testicle meaning that they require recurrent checks

205
Q

what is the management of undescended testes?

A

Mainly resolve spontaneously within six months of corrected gestation age this is more common in premature babies, if the testes are palpable and require surgery then orchid a plexi is performed if they are impalpable laparoscopy is used to identify the testes and bring it down into the scrotum if it’s viable

206
Q

what test is recommended in children with undescended testes?

A

Karyotyping

207
Q

what are the different types of impalpable testes?

A

abdominal (40%) vessels and vast and blindly in the deep inguinal ring (30%) vessels and bass ending blindly within the inguinal link (20%) testes existing within the inguinal canal (10%)

208
Q

what does an blind ended underfunded testicle mean?

A

Testes is no longer existent and most likely this is been caused by intrauterine testicular torsion

209
Q

what complications can occur if you do not treat and undescended testes?

A

Infertility/torsion/testicular cancer – doesn’t increase the risk that the testes can never be examined

210
Q

What is an epididymal cyst?

A

A fluctuating swelling that is separate from the body of the testis

211
Q

what are the symptoms of an epididymal cyst?

A

Palpable lump within the epididymis/ difficult to transilluminate/ may be painful or painless/ vary greatly in size

212
Q

how do you diagnose an epididymal cyst?

A

ultrasound

213
Q

what is the management of epididymal cysts?

A

management depends on the size and severity of symptoms treatment options are conservative and surgical excision

214
Q

what is a sebaceous cyst?

A

hall cysts usually containing a white/yellowish substance

215
Q

what is the presentation of a sebaceous cyst?

A

Palpable lump within the scrotal skin/ tethered to the skin and is separate to the underlying testis/lamp feels rubbery/non-transit innumerable/often multiple cysts/not painful

216
Q

what does a painful sebaceous cyst indicate?

A

Infection

217
Q

what is the management of a sebaceous cyst?

A

Conservative unless they are very large or infected then surgery

218
Q

What are risk factors for incontinence?

A

Older age/female/oestrogen deficiency (postmenopausal)/anatomical disorders (fistula)/childbirth and pregnancy/abdominal, pelvic, perineal and prostate surgery/ diabetes and smoking/obesity/urinary tract infection/poor mobility/neurological disorders (MS, Parkinson’s, spinal-cord injury)

219
Q

a patient presents with: in voluntary leakage of urine on exertion also when coughing/sneezing or laughing what is the diagnosis?

A

stress incontinence

220
Q

patient presents with: in voluntary leakage of urine accompanied by/immediately preceded by feelings of urgency what is the diagnosis?

A

Urge urinary incontinence

221
Q

a patient presents with symptoms of urgency (which may cause urination), nocturia and frequency what type of incontinence is this?

A

Overactive bladder syndrome

222
Q

what is overflow incontinence?

A

in voluntary leakage of urine when the bladder is abnormally distended with large volumes of urine

223
Q

what questions are important to ask in incontinence histories?

A

What is the timing of the incontinence (continuous or at specific times such as increased intra-abdominal pressure) are their associated symptoms of El UTS do they use incontinence pads and if so how many do they use per day or night what is their obstetric history are they postmenopausal are there any symptoms of bowel and sexual dysfunction (indicates neurological cause) past medical history of uro- gynaecological, neurological

224
Q

what is the pathophysiology of stress urinary incontinence?

A

Hypermobility of the bladder as well as pelvic floor dysfunction which can occur with or without urethral sphincter dysfunction

225
Q

what is the management of stress urinary incontinence?

A

Conservative measures (weight loss, exercise, smoking cessation) pelvic floor physiotherapy and training surgery (tape procedures or artificial urinary sphincter implant – mainly used in men post prostatectomy)

226
Q

what is the pathophysiology of urge urinary incontinence?

A

overactive detrusor muscle

227
Q

how do you manage urge urinary incontinence/overactive bladder syndrome?

A

conservative measures (reduced alcohol caffeine

anti-muscarinic medication ocybutanin ,

B3 adrenoceptor agonist (mirabregron)

neuro modulation/Botox injection into bladder

scystoplasty or urinary diversion

228
Q

which type of incontinence does prolapse usually cause?

A

Stress although oftentimes pictures are mixed

229
Q

how do you manage overflow incontinence?

A

treat any causes of bladder outflow obstruction / long-term catheter/intermittent self catheterisation

230
Q

what are the causes of overflow incontinence?

A

Obstruction of urinary tract/ detrusor failure

231
Q

what examination should be performed on women presenting with incontinence?

A

vaginal examination checking for prolapse pelvic floor strength (asking the patient to squeeze pelvic floor/cough)

232
Q

what examination should be performed in a male presenting with incontinence?

A

DRE you may find an enlarged prostate

233
Q

what investigations should be performed in a patient with incontinence?

A

urinalysis, cystoscopy, in patients with overflow incontinence residual urine test should be performed - urodynamic testing is usually not performed as it is very uncomfortable and invasive

234
Q

defined erectile dysfunction?

A

the recurrent inability to achieve or maintain an erections for satisfactory amount of time to allow for sexual intercourse

235
Q

what is a key feature of erectile dysfunction caused by organic causes?

A

usually has a more gradual onset with no significant loss of libido

236
Q

what questions are important to ask in a history of erectile dysfunction?

A

Is it getting worse/are you able to achieve and direction and for how long/are you able to achieve penetrative sex/is there a morning erection/is a loss of libido/ what have they already tried/ onset description

237
Q

what past medical history is significant in erectile dysfunction?

A

Diabetes/hypertension/vascular disease/neurological conditions/pelvic surgery

238
Q

what psychosocial causes are there for erectile dysfunction

A

relationship status/relationship difficulties/anxieties and depressions/any past traumatic sexual experiences

239
Q

what endocrine causes are there for erectile dysfunction?

A

diabetes hyper- or hypothyroidism hyperprolactinaemia hypogonadism

240
Q

what neurogenic causes are therefore erectile dysfunction?

A

Spinal-cord pathology (Bifuda, compression) Multiple Sclerosis Parkinson’s disease

241
Q

what vascular causes are there for erectile dysfunction?

A

Hyperlipidaemia peripheral vascular disease hypertension

242
Q

what drugs can cause erectile dysfunction?

A

Antidepressants Parkinson’s medication antiandrogen antihypertensives

243
Q

what blood tests should you perform in a patient with erectile dysfunction?

A

testosterone luteinising hormone FSH prolactin sex hormone binding globulin thyroid function glucose levels

244
Q

what examinations should you perform in erectile dysfunction?

A

Cardiovascular neurological abdominal DRE genital (deformity testicular atrophy)

245
Q

what investigations (apart from blood tests) would you perform in erectile dysfunction?

A

Nocturnal penile tumescence testing/MRI/Doppler ultrasound for vascular - all of these tests are not routinely used

246
Q

what drugs can be given to help erectile dysfunction?

A

phosphodiesterase inhibitors intra urethral prostaglandins inter cavernosum injection therapy testosterone replacement therapy in hypogonadism

247
Q

what management should be given for psychogenic erectile dysfunction?

A

psychosexual therapy

248
Q

apart from drugs what other management can be given to organic erectile dysfunction?

A

vacuum erecting device penile prosthesis

249
Q

how do phosphodiesterase inhibitors work in erectile dysfunction?

A

Block the breakdown of CGAMP made by phosphodiesterase causing vasodilation- still requires sexual stimulation

250
Q

what is periones disease?

A

a benign condition that becomes more common with age characterised by the curvature of the penis/holes by the development of fibrotic tissue on the tunica albunginea

251
Q

what is the pathophysiology of periones disease?

A

initial inflammation characterised by increasing deformity of the penis and painful erections/ followed by quiescent phase during which the deformity stabilises/ thought to be caused by minor trauma over time causing microvascular damage in genetically predisposed males

252
Q

what is periones disease associated with?

A

diabetes hypertension high cholesterol dupatrons contracture and plantar fasciitis

253
Q

what’s is the presentation of periones disease?

A

significant curvature to the penis noticeable when erect/ penile shortening penile pain erectile dysfunction difficulty having penetrative intercourse can have palpable fibrous plaques along the shaft at the deviation/ penis can have hourglass appearance due to plaques

254
Q

what is the management of periones disease?

A

oral pentoxifylline verapamil injections surgery only performed on stable plaques and can include the insertion of a penile prosthesis

255
Q

what is phymosis?

A

tight foreskin which is unable to attract over the glans

256
Q

what is the presentation of phymosis?

A

usually asymptomatic/may notice balooning of the foreskin on urination/may cause pain and irritation during sexual intercourse/ men may develop infections of the foreskin and glans - balanoprosthisis

257
Q

what are some key features to ask for in a history of phymosis?

A

are you able to retract the foreskin (v severe) / checked for diabetes previous neurological surgery or if they have had any steroid cream use in the past

258
Q

what is balantis xerotica obliterans?

A

chronic inflammatory condition which is the male equivalent of light and sclerosis and it can cause phymosis

259
Q

what awesome features that you may find on examination of balantis xerotica obliterans?

A

grey white discolouration of the foreskin

260
Q

what are some complications of balantis xerotica obliterans?

A

urethral stenosis penile cancer phimosis

261
Q

how do you treat balantis xerotica obliterans?

A

steroids topically often circumcision as required

262
Q

a teenager of 14 years old presents with phimosis, it isn’t causing too many problems apart from some balooning on urination, what is the management?

A

nothing as it is not severe and phimosis is often physiological in childhood and almost always becomes retractable by the age of 16

263
Q

what is the management of phimosis?

A

circumcision

264
Q

what is the pathophysiology of urethral strictures disease?

A

sub epithelial fibrosis within the corpus spongiosum causing the narrowing of the urethra

265
Q

what can cause a urethral structure disease?

A

trauma (straddle injuries) catheterisation (catheterisation) inflammatory urethritis

266
Q

what are symptoms of urethral strictures disease?

A

L UTS voiding symptoms urinary retention multiple UTIs difficulty passing catheter and hitting resistance/obstruction distal to the prostate

267
Q

what is the management of urethral strictures disease?

A

sequential urethral dilation in theatre/ optical urethrotomy

268
Q

what is the ongoing management of urethral strictures disease?

A

Following initial operation patients taught how to intermittently self-dilate prevent future recurrence

269
Q

what is paraphimosis?

A

the foreskin is retracted behind the glands and cannot be replaced to its original position resulting in a tight ring of tissue around the corona - it is a medical emergency that is not to be mistaken with phimosis

270
Q

why is paraphimosis a medical emergency?

A

It leads to venous occlusion congestive oedema and eventually will compromise the blood supply to the glans and foreskin causing ischaemia

271
Q

what is the presentation of paraphimosis?

A

foreskin retracted behind the corona of the glans penile oedema possible discolouration and necrosis cracks in the skin can be painful

272
Q

what is a common cause for paraphimosis?

A

catheterisation patients

273
Q

what is the management of paraphimosis?

A

lies again and applying ice with then manually replacing the foreskin surgical interventions are rarely needed follow-up by urologist is required as circumcision may be needed as long-term management

274
Q

what is fourniers gangrene?

A

necrotising fascitis of the genitalia and perineum - is a urological emergancy

275
Q

what pathogens usually cause fourniers gangrene?

A

usually caused by both aerobic and anaerobic organisms – E. coli Klebsiella or enterococcus/colostrum

276
Q

what is the presentation of fourniers gangrene?

A

an acutely unwell patient with septic symptoms erythematous tender area along the genitalia or penny blistering of the skin practice caused by gas forming from the organisms blue or black skin as necrosis occurs

277
Q

what are risk factors for developing fourniers gangrene?

A

diabetes catheterisation immunocompromised postsurgical perineal and perianal infections steroid therapy

278
Q

what is the management of fourniers gangrene?

A

sepsis six do a group group and save stop broad-spectrum antibiotics keep patient nil by mouth as requires prompt surgery inform ITU

279
Q

what is priapism?

A

The presence of an unwanted erections more than four hours in the absence of sexual stimulation

280
Q

what is in low flow priapism?

A

Caused by ischaemia: venous occlusion resulting in a rigid painful erection

281
Q

how do you manage low flow priapism?

A

aspiration of intra-cavernosal blood (blood will be acidotic with low O2 high CO2 and high lactate) must be done by urologist

282
Q

what is high flow priapism?

A

is arterial caused by dysfunctional arterial flow resulting in a semi rigid painless erection / associated with a history of trauma which then results in the formation of AV fistula

283
Q

what is the management of high flow priapism?

A

can be managed conservatively but if intervention is required then embolise the supplying artery

284
Q

what happens if aspiration of intracavernosal blood does not solve low-flow priapism?

A

immediate escalation intra cavernosal injection of alpha-1 adrenergic agonist ( phenothrin) failing that surgery

285
Q

what can you do if a patient presents a low flow priapism and you are waiting for urologist to arrive?

A

as patient exercise walking up and down the stairs and called the area with ice

286
Q

what is the most common cause for recurrent priapism?

A

sickle-cell anaemia

287
Q

what is the presentation of recurrent priapism?

A

self-limiting but painful erection however it can turn into low flow priapism

288
Q

how do you manage a sickle-cell caused priapism?

A

hyper hydration hyper oxygenation and haematological optimisation with analgesia

289
Q

Why do bladder stones form?

A

to urinary stasis either from obstruction or any other method of failure of the bladder

290
Q

what properties of bladder stones usually made of?

A

calcium

291
Q

what is the presentation of bladder stones?

A

Pain / L UTS/ haematuria/ UTI/ asymptomatic and found incidentally

292
Q

what is the diagnosis of bladder stones?

A

Ultrasound scan or x-ray normal contrast / flexible cystoscopy may be part of Ix or on way to confirm / treat

293
Q

how do you treat bladder stones?

A

cystolotholapaxy - stone crusher in bladder / lazer or open surgery

294
Q

What is the most common cause of penetrative bladder trauma?

A

iatrogenic - most commonly from the section of bladder tumour or in operation

295
Q

what is the most common cause of blunt bladder trauma

A

high risk of injury in pelvic fractures and seatbelt injuries in road crashes

296
Q

what is the presentation of bladder trauma?

A

peritonism / abdominal distension ideas and your ES haematuria blood at urethral meatus perianal/scrotal bruising a high riding prostate

297
Q

how do you diagnose bladder trauma?

A

CT with contrast or cysto gram

298
Q

what is absolutely contraindicated in bladder trauma?

A

catheterisation this should only be done by neurologists or senior clinicians

299
Q

what is the management of an extra peritoneal bladder injury?

A

catheterisation for 2/3 weeks

300
Q

what is the management of an inter peritoneal bladder trauma?

A

open surgical repair

301
Q

what part of the penis gets injured in a penile fracture?

A

tunica albunginea

302
Q

what is the presentation of a penile fracture?

A

feeling of a snap or pop whilst the penis is erect/ immediate de tumescence/ eggplant appearance due to swelling discolouration and deformity

303
Q

what is the management of a penile fracture?

A

urgent neurological review and surgical repair

FINALS (24 decks)

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