Genitourology and renal Flashcards
Describe the nerves involved with the control of the bladder
- Parasympathetic nerve: pelvic nerve (S2-S4), involuntary control, contraction of detrusor, relaxation of internal sphincter
- Sympathetic nerve: hypogastric nerve (T11-L2), involuntary control, relaxation of detrusor, contraction of internal sphincter
- Somatic nerve: pudendal nerve (S2-S4), voluntary control, connection with Onuf’s nucleus, relaxation of external sphincter (skeletal muscle)
- Sensory nerve: afferent pelvic nerve, signals from detrusor muscle
Describe the nervous control centres involved with bladder control
- Cortex: voluntary initiation of voiding, sensation
- Pontine micturition centre/periaqueductal grey: co-ordination, completion of voiding, develops after potty-training
- Sacral micturition centre: S2-S4, controls reflex micturition
- Onuf’s nucleus: located in ventral horns of sacral spinal cord, controls guarding reflex
What is the guarding reflex of the bladder?
The avoidance of inappropriate voiding caused by the involuntary control of micturition
Stimulation of the hypogastric and pudendal nerve (from Onuf’s nucleus) resulting in detrusor relaxation and contraction of the external urethral sphincter
What is receptive relaxation?
Relaxation of the detrusor muscle as the volume of the bladder increases, so that the pressure remains low
How can LUTS be classified?
LUTS = lower urinary tract symptoms
Storage:
- frequency
- urgency
- nocturia
- incontinence
Voiding:
- poor flow (slow/splitting/spraying)
- hesitancy
- intermittency
- straining
- terminal dribble
Post-micturition:
- post-micturition dribble
- feeling of incomplete emptying
What are the types of incontinence?
Stress (sphincter weakness)
Urgency (overactive bladder)
Overflow
Mixed
Define urgency incontinence
Urgency incontinence or over active bladder is defined as urgency and frequency, with/without nocturia, when appearing in the absence of local pathology or metabolic factors
What are the causes of urgency incontinence?
Detrusor overactivity e.g.
- prostate enlargement
- from central inhibitory pathway malfunction
- sensitisation of peripheral afferent terminals in the bladder
- bladder muscle problem
- UTI
- organic brain damage (stroke, Parkinson’s, dementia)
What are the investigations needed for urgency incontinence?
Urodynamic study: shows detrusor overactivity - rise in detrusor pressure on filling
Urine dipstick
U&Es
What are the treatments for urgency incontinence?
- Behavioural therapy: frequency volume chart, avoid caffeine, alcohol, bladder training
- Antimuscarinics: decrease parasympathetic activity to improve frequency and urgency
- B3 agonists: increase sympathetic activity
- Botox: blocks neuromuscular junction for Ach release (parasympathetic activity)
- Sacral neuromodulation: insertion of electrode to S3 nerve root to modulate afferent signals from the bladder
- Surgery: bladder augmentation (cystoplasty)
Define stress incontinence
Leakage from an incompetent sphincter such as when the intra-abdominal pressures increase (when coughing/laughing)
What are the causes of stress incontinence
Pregnancy/birth trauma, neurogenic (e.g. faulty nerve supply to sphincter), congenital, iatrogenic (prostatectomy)
Risk factors: obesity/increasing age
What are the investigations needed for stress incontinence?
Examine for pelvic floor weakness/prolapse/masses
Urine dipstick
U&Es
What are the treatments of stress incontinence?
Pelvic floor physiotherapy (1st line)
Surgery (sling, urethral bulking, artificial sphincter)
Drugs: duloxetine (SNRI - increases contraction of external urethral sphincter)
Also: weight loss, fluid balance
Define unsafe bladder
One that puts the kidneys at risk of damage
What are the risk factors of an unsafe bladder?
Prolonged raised bladder pressure
Vesico-ureteric reflux
Chronic infection (residual urine/stones)
What are the causes of urinary retention?
Prostatic hyperplasia
Prolapse (e.g. uterine)
Pelvic mass (colon, ovarian, bladder cancers)
Faecal impaction
Urethral strictures
Infection (e.g. vulvovaginitis, prostatitis)
Drugs (e.g. anticholinergics)
Iatrogenic
Atonic/insensate bladder (non-obstructive: no contraction or sensation)
Congenital deformities
Describe the epidemiology of renal cancer
Mosley affects >50 y/o
More common in males
10 year survival = 52%
Increasing rates
90% are renal cell carcinomas
What are the risk factors for renal cancer?
Smoking
Obesity
Hypertension
Dialysis
Genetic syndromes
What are the signs/symptoms of renal cell carcinoma?
Classic triad (only 10%):
- haematuria
- loin pain
- mass
*most cancer are found incidentally or with metastatic symptoms
*rarely presents with testicular varicocele (compression of left testicular vein from left renal vein)
What are the investigations needed for renal cell carcinoma?
Bloods: FBC, U&E, ESR
Urine dipstick and cytology
US of kidneys
CT renal protocol: diagnostic, staging
Biopsy: if unsure from scan
What are the treatments for renal cancer?
Active surveillance (for small tumours, asymptomatic, elderly)
Radiofrequency ablation or cryotherapy (only works on small tumours)
Partial/radical nephrectomy
Immunotherapy/chemotherapy - tyrosine kinase inhibitors
Describe the epidemiology of bladder cancer
Mostly affects >55 y/o
More common in men
10 year survival = 46%
Half are preventable
90% are transitional cell carcinomas
What are the risk factors for bladder cancer?
Smoking (45%)
Industrial exposure (dyes, rubber - aromatic amines)
Schistosomiasis (increases risk of squamous cell carcinoma)
What are the signs/symptoms of bladder cancer?
Haematuria - painless, visible in 85%
Lower urinary tract symptoms (voiding irritability)
Recurrent UTIs
What are the investigations needed for bladder cancer?
Bloods: FBC, U&E, PSA
Urine dipstick and microscopy
US
CT urogram (excretory phase)
Flexible cystoscopy + biopsy
What are the treatments for bladder cancer?
Transurethral resection of bladder tumour - TURBT (for non-muscle invasive, small tumours, diagnostic and therapeutic)
Intravesical therapy: mitomycin (reduces recurrence), BCG (reduces progression and recurrence)
Surgery: (muscle invasive or large tumours, left with stoma)
- cystoprostatectomy (bladder, prostate in men)
- anterior exenteration (bladder, uterus, ovaries in women)
Radiotherapy
Other than malignancy, what are the causes of haematuria?
Stones
Infection
Prostate (cancer or BPH)
Nephrological causes
Idiopathic
Describe the epidemiology of testicular cancer
Commonest malignancy in young men
Mostly affects 30-40 y/o
10 year survival = 91%
Most common type is seminoma
What are the risk factors of testicular cancer?
Cryptorchidism (undescended and abnormal testis)
Family history
HIV
Previous testicular cancer
Caucasian males
What are the signs/symptoms of testicular cancer?
Lump (commonly felt in self examination)
Associated pain
Urinary symptoms
Hydrocele (fluid within tunica vaginalis)
Metastatic symptoms (in chest/abdomen)
What are the investigations needed for testicular cancer?
US (same day)
Bloods: tumour markers = AFP, b-HCG, LDH
CXR if respiratory symptoms
CT: staging
What are the treatments for testicular cancer?
Radical inguinal orchidectomy
Neoadjuvant therapy: chemotherapy, radiotherapy
Retroperitoneal lymph node dissection
Sperm banking
Describe the epidemiology of prostate cancer
Most commonly diagnosed cancer in men
Mean age at diagnosis = 72
10 year survival rate = 97%
Present in 80% of men >80 in autopsy
Rising incidence
Higher risk with family history
Most commonly adenocarcinoma in peripheral prostate
What are the signs/symptoms of prostate cancer?
LUTS
- nocturia
- hesitation
- poor stream
- terminal dribble
Weight loss +/- bone pain (metastasis)
Hard irregular prostate on examination
What are the investigations needed for prostate cancer?
PSA (prostate specific antigen - responsible for liquefaction of semen, elevated in other causes)
Transrectal ultrasound + biopsy
CT/MRI (staging, using Gleason’s score)
Bone scan
What are the treatments for prostate cancer?
Surgery: radical prostatectomy
Radiotherapy
Observation: active monitoring/surveillance
Hormone therapy: treatment of metastases, palliative
Describe epididymo-orchitis
Inflammation of the epididymis and/or testis
Cause: chlamydia/N.gonorrhoea
Features: sudden-onset painful swelling, dysuria, fever
Treatment: antibiotics, analgesia, draining of abscesses
Describe hydrocele of the scrotum
Fluid within the tunica vaginalis
Cause: patent processes vaginalis, or testis trauma/tumour/infection
Treatment: usually resolves spontaneously, may need aspiration or surgery
Describe varicocele of the scrotum
Dilated blood vessels of pampiniform plexus
Features: visible as distended scrotal blood vessels that feels like ‘a bag of worms’, associated with subfertility
Treatment: surgery or embolisation
Describe testicular torsion
Common in 11-30 y/o but can be any age
Features: sudden acute pain, inflammation, tender, and warm testis
Treatment: needs prompt surgery to save testes (within 6h = 90-100% salvage rate)
Define polycystic kidney disease
The most common inherited cause of renal disease, characterised by clusters of cysts which cause the kidneys to enlarge and lose function over time
What are the causes of polycystic kidney disease?
Autosomal dominant = most common
- 85% PKD1 abnormality on chromosome 16
- 15% PKD2 abnormality on chromosome 4
Autosomal recessive = rare, more common to occur in infancy
- mutation on chromosome 6
What are the signs/symptoms of polycystic kidney disease?
May be asymptomatic unless cysts become enlarged/haemorrhage
Loin pain
Visible haematuria
Hypertension
Bilateral kidney enlargement
UTI and pyelonephritis
Renal stones
Progressive renal failure
Extra-renal: polycystic liver/ovarian disease, intracranial aneurysms, cardiac abnormalities
Recessive polycystic kidney disease: liver involvement (fibrosis, hepatomegaly, portal hypertension)
What are the investigations needed for polycystic kidney disease?
Urinalysis: check for infection, protein, haematuria
Urine microscopy and culture
Bloods: FBC (raised Hb), U&E, eGFR, bone profile
Imaging (diagnostic): US, or CT/MRI for higher sensitivity
Genetic testing
What are the treatments for polycystic kidney disease?
Lifestyle advice to reduce CVD risk
Avoid contact sports
High fluid intake may supress cyst growth
Hypertension: controlled to 130/80 using ACEi/ARB (1st), diuretics (2nd), b-blockers (3rd)
UTI: treat as normal (antibiotics)
Haematuria: analgesia for renal colic, hydration, avoid anti-coagulants
Renal pain: treat cause, analgesia
End-stage kidney disease: renal replacement therapy
Tolvaptan (vasopressin receptor antagonist): decrease kidney volume
Define glomerulonephritis
A broad term that refers to a group of immune-mediated parenchymal kidney disease, characterised by inflammation and damage to glomeruli
Define nephrotic syndrome
Glomerulonephritis with proteinuria due to podocyte pathology, such as…
- Minimal change disease
- Focal segmental glomerulosclerosis
- Membranous nephropathy
Describe minimal change disease
Nephrosis caused by fusion of podocyte foot processes seen electron microscopy (but normal on light microscopy), mostly idiopathic but can be drug associated/paraneoplastic
Presentation: proteinuria, oedema, hypoalbuminaemia, normal renal function and blood pressure (does not progress to renal failure)
Investigations: urinalysis, renal biopsy with microscopy
Treatment: usually responds to high-dose prednisolone, relapsing disease may need immunosuppression (cyclophosphamide)
Describe focal segmental glomerulosclerosis
Nephrosis caused by segmental scarring of the glomeruli with foot process fusion, primary (idiopathic) or secondary (drugs, lymphoma, other GN), at risk of progressive CKD/renal failure
Presentation: proteinuria, oedema, hypoalbuminaemia, hypertension, reduced renal function
Investigations: urinalysis, renal biopsy
Treatment: supportive (ACEi/ARB, diuretics, statins), corticosteroids (only in primary disease), plasma exchange and rituximab (for recurrence in transplants/resistance)
Describe membranous nephropathy
Nephrosis with thickening of the glomerular basement membrane and deposition of IgG and complement causing a leaky glomerulus, primary (idiopathic) or secondary (malignancy, infection, drugs, immunological conditions e.g. SLE)
Presentation: proteinuria, oedema, hypoalbuminaemia, hypertension, reduced renal function
Investigations: urinalysis, anti-phospholipase A2 receptor antibody, renal biopsy (IgG deposits)
Treatments: supportive - remission in 30% (ACEi/ARB, diuretics, statins), immunosuppression for high risk (corticosteroids + cyclophosphamide)
Define nephritic syndrome
Glomerulonephritis with haematuria due to inflammatory damage, such as…
- IgA nephropathy
- Post-strep glomerulonephritis
- Goodpasture’s syndrome (anti-GMB disease)
- SLE nephropathy
Describe IgA nephropathy
The commonest nephritic syndrome, where abnormal IgA glycosylation leads to deposition in the mesangium and cause kidney injury
Presentation: variable, non-visible/visible haematuria, may be proteinuria, hypertension, upper respiratory tract infection
Investigations: urine dipstick, IgA in renal biopsy
Treatment: ACEi/ARB lowers BP and proteinuria, corticosteroids for persistent proteinuria
Describe post-streptococcal nephritis
Occurs after a throat (~2 weeks) or skin (~3-6 weeks) infection, more common in children, antigen deposits in glomerulus leads to immune complex formation and inflammation
Presentation: ranges from haematuria to acute nephritis (+oedema, hypertension, oliguria)
Investigations: evidence of strep infection, raised autoantibodies
Treatments: supportive, antibiotics to clear nephritogenic bacteria
Describe anti-GBM disease
Anti-glomerular basement membrane /Goodpasture’s disease is where auto-antibodies to type 4 collagen damage the glomerular and alveolar basement membranes
Presentation: renal - haematuria, AKI, failure, lung - haemorrhage, dyspnoea, haemoptysis
Investigations: anti-GBM in circulation/kidney, FBC: anaemia, urinalysis
Treatment: plasma exchange (remove antibodies), corticosteroids + cyclophosamide (immunosupression)
Describe SLE nephritis
Systemic lupus erythematous is a multisystem autoimmune disease, which can present as nephritis (or nephrosis)
Presentation: kidney failure, + rash, arthralgia, CNS effects
Investigations: urinalysis, anti-nuclear antibodies, anti-dsDNA, renal biopsy
Treatment: ACEi/ARB (renal protection), steroids + cyclophosphamide (immunosuppression), rituximab
Define erectile dysfunction
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
What are the causes of erectile dysfunction?
Neurogenic - failure to initiate
Arteriogenic - failure to fill
Venogenic - failure to store
Others:
- hypogonadism
- trauma
- drugs (anti-androgens, alcohol)
- psychosomatic
- associated diseases (DM, CVD, obesity )
What are the treatments for erectile dysfunction?
Treat underlying condition
Lifestyle advice (weight loss, physical activity, alcohol reduction)
Psychological therapy
PDE-5 inhibitors (Viagra) - improves smooth muscle relaxation in corpus cavernosa
Testosterone replacement (if hypogonadism cause)
Intraurethral suppository or intracavernosal injections- improves vascular flow
Vacuum assisted device - increased blood flow, constriction band to maintain erection
Penile implant
Define UTI
A urinary tract infection is a combination of clinical features and the presence of bacteria, classified as lower/upper and complicated/uncomplicated
Describe the categorisation of lower/upper UTIs
Lower: cystitis, urethritis, epididymo-orchitis, prostatitis
Upper: pyelonephritis, ureteritis
Describe the classification of uncomplicated/complicated UTIs
Uncomplicated: non-pregnant women
Complicated: pregnant, men, children, catheterised, immunocompromised, structural abnormalities, recurrent/persistent infection
What are the most common pathogens to cause UTIs?
E.coli: > 50% = most common
Proteus: 10-15% (associated with renal stones)
Klebsiella: 10% (hospital/catheter associated)
Staph. saprophyticus: 5-8% (young women)
Pseudomonas: 4% (recurrent UTI/underlying pathology)
What are the risk factors for UTIs?
Recent instrumentation of the renal tract
Abnormality of the renal tract
Incomplete bladder emptying (prostatic obstruction)
Sexual activity
Diabetes
Pregnancy
Immunocompromised
Describe the pathophysiology of UTIs
Catheterisation allows colonisation
Bowel flora (common in females due to shorter urethra)
Obstruction (prostate enlargement, bladder/ureteric stones or tumour)
Low urinary volume
Stasis during pregnancy
What are the sings/symptoms of upper and lower UTIs?
Lower: dysuria, frequency, suprapubic pain
Upper: loin pain, fever, pyuria (WBC in urine)
What are the investigations needed for lower UTIs
Urine dipstick: leukocytes, nitrates, may be haematuria
Urine microscopy, culture, and sensitivity: identify pathogen, WBC, pathological casts
What are the treatments of uncomplicated lower UTIs?
Not always necessary to send sample and treat
If treated… 3 day course of antibiotics (nitrofurantoin)
Adjunctive advice:
- simple analgesia
- increase fluid intake
- void pre – post intercourse
- hygiene
What are the treatments for complicated lower UTIs?
7 day course of antibiotics
1st line = nitrofurantoin (cannot be used in pregnancy at term, low renal function, and has side effects, alternative = amoxicillin)
What are the investigations needed for an upper UTI?
Abdominal examination (+PV to rule of tubal/ovarian/appendix pathology)
Bloods (including cultures)
US scan (rule out obstruction)
MSU
What are the treatments for upper UTIs?
Fluid replacement
IV antibiotics, 7-14 day course (broad spectrum - co-amoxiclav +/- gentamicin)
Drain obstructed kidney
Catheter
Analgesia
Define urolithiasis and renal colic
Urolithiasis is the formation of stones anywhere in the urinary tract (mostly commonly the kidney)
Renal colic is the acute and severe loin pain caused when a urinary stone moves from the kidney or obstructs the flow of urine
Describe the epidemiology of stones in the urinary tract
Commonest age 30-50 but decreasing
Unusual in children
More common in males
What are the causes of stones in the urinary tract?
Anatomical:
- congenital (e.g. horseshoe, duplex causing stasis)
- acquired (obstruction, trauma, reflux)
Urinary factors:
- metastable urine, promoters/inhibitors
- abnormal calcium, urate, cystine, oxalate levels
- dehydration
Infections
What are the risk factors for developing stones in the urinary tract?
Age
Sex
Ethnicity (more common in whites)
Diet (excessive oxalate, urate, sodium, and animal protein)
Chronic dehydration
Obesity
High ambient temperatures
Family history
Anatomical abnormalities of urinary tract
Describe the pathophysiology of stones in the urinary tract
Nucleation theory: stones form from crystals in supersaturated urine
Most stones are formed of crystals of normal urinary constituents: 80% Ca2+ based ( + oxalate or phosphate)
Can also be crystals of uric acid, struvite, cystine
Common locations: pelvo-ureteric junction, pelvic brim, vesico-ureteric junction
What are the signs/symptoms of stones in the urinary tract?
Often asymptomatic
Pain
- loin radiating to groin
- unilateral or bilateral
- colicky
- acute onset
- associated nausea/vomiting
UTI symptoms
- dysuria
- urgency
- frequency
Haematuria
What are the investigations needed for stones in the urinary tract?
Urinalysis (+ve blood)
FBC
U&E
Calcium, phosphate
Imaging:
- KUB-XR (1st line, not very sensitive)
- non-contrast CT = gold standard
- US (in pregnancy - no radiation)
What are the treatments for stones in the urinary tract?
Analgesia:
- NSAID (suppository, e.g. diclofenac)
- opiates
Antiemetics
Fluids (if needed - may make pain worse)
If septic:
- IV antibiotics (emergency)
- drainage
Treatment of stone:
- small/asymptomatic/safe location = conservation and observation
- ESWL (extracorporeal shock wave lithotripsy - fragments stones to facilitate passage)
- PCNL (percutaneous nephrolithotomy - extraction of larger stones)
- ureteroscopy
- nephrectomy (rare)
Define AKI
Acute kidney injury is a syndrome characterised by a decline in renal excretory function over hours or days, defined as…
- rise in creatinine >26umol/L within 48hrs
- rise in creatinine >1.5 x baseline within 7 days
- urine output <0.5mL/kg/h for >6hrs
Describe the epidemiology of AKI
18% of emergency hospital admissions
50% of ICU admissions
What are the risk factor for AKI?
Pre-existing CKD
Age
Male sex
Nephrotoxic drug use
Comorbidity (CVD, diabetes, malignancy, chronic liver disease, complex surgery)
What are the causes of AKI?
Pre-renal:
- hypovolaemia (bleeds, D&V, burns)
- reduced cardiac output (heart failure, MI, liver failure, sepsis)
- drugs that reduce blood pressure and renal blood flow (ACEi, ARBs, NSAIDs
Renal:
- toxic drugs (antibiotics, contrast, chemotherapy)
- glomerular (GN)
- vascular (vasculitis, thrombosis)
- interstitial (infection, infiltration)
- tubular (necrosis)
Post-renal:
- obstruction within tract: stone, malignancy, stricture, blocked catheter, clot
- extrinsic compression: enlarged prostate, pelvic malignancy
What are the signs/symptoms of AKI?
Nausea, vomiting, diarrhoea
Signs of dehydration
Reduced urine output
Change to urine colour
Confusion, fatigue, drowsiness
Hypertension
Large painless bladder on palpation
Fluid overload (raised JVP, oedema)
What are the investigations needed for AKI?
Urine dipstick (haematuria/proteinuria suggests intrinsic renal disease)
FBC: may have low platelets
U&E and creatinine
LFTs
Coagulation studies
CRP
Immunology: autoantibodies, immunoglobulins, paraprotein
Ultrasound: check obstruction, structure
What are the treatments for AKI?
Treat underlying cause (e.g. infection)
Stop nephrotoxic drugs where possible
Fluid resuscitation
Correct electrolyte imbalance (calcium carbonate + insulin for hyperkalaemia)
Relief of urinary tract obstruction
RRT if not responding
What are the complications for AKI?
Hyperkalaemia
Metabolic acidosis
Uraemia
Volume overload
CKD
Renal failure
Define CKD
Chronic kidney disease is a reduction in kidney function and/or structure present for more than 3 months, with associated health implications
Describe the classification of CKD
Stage 1: eGFR >90 with other evidence of kidney damage*
Stage 2: eGFR 60-89 with other evidence of kidney damage*
Stage 3a: eGFR 45-59
Stage 3b: eGFR 30-44
Stage 4: eGFR 15-29
Stage 5: eGFR <15 (established renal failure)
*other evidence = microalbuminuria, proteinuria, haematuria, abnormalities on ultrasound/biopsy
Describe the epidemiology of CKD
Prevalence increases with age
Higher prevalence in women
What are the causes of CKD?
Hypertension
Diabetes mellitus
Glomerular disease (GN)
Current/history of AKI
Nephrotoxic drug use (ACEi, NSAIDs etc.)
Urinary tract obstruction
Cardiovascular disease
Multisystem disease with renal involvement (SLE, vasculitis, myeloma)
What are the signs/symptoms of CKD?
Fluid overload (SOB, peripheral oedema)
Anorexia
Weight loss
Nausea
Vomiting
Fatigue
Itching
Bone pain
Sleep disturbance
Muscle cramps
Sexual dysfunction
Abnormal urine output
Pallor (due to anaemia)
Cognitive impairment
Hypertension (primary or secondary)
What investigations are needed for CKD?
U&Es
FBC: shows anaemia
Glucose: detect or asses DM
Biochemistry: low calcium, high phosphate, high PTH
Autoantibodies
Urine dipstick
Urine MC&S (rule out UTI)
Ultrasound: size (usually small), symmetry, anatomy
Biopsy (progressive disease)
What are the treatments for CKD?
Lifestyle advice to slow disease progression (weight loss, exercise, smoking cessation)
Blood pressure control: <140/90 (ACEi/ARB)
Glycaemic control (for diabetics)
Avoid nephrotoxic drugs
Treat complications:
- iron for anaemia
- sodium bicarbonate for acidosis
- fluid/salt restriction or diuretics for oedema
- vitamin D/dietary restriction/phosphate binders for bone-mineral disorders
- antiplatelets/statins for CVD risk
RRT
Define benign prostatic hyperplasia
An increase in the size of the prostate gland due to nodular or diffuse proliferation of the musculofibrous and glandular layers (mostly commonly in the transitional zone), without malignancy
Describe the epidemiology of benign prostatic hyperplasia
Men aged 40-60 = 25%
Men aged 60-90 = 50%
Man aged over 90 = 80%
More common in Afro-American origin that white
What are the signs/symptoms of benign prostatic hyperplasia
LUTS:
- nocturia
- frequency
- urgency
- hesitancy
- poor flow
- incomplete bladder emptying
Bladder stones
Haematuria
UTIs
What are the investigations needed for benign prostatic hyperplasia?
Urine dipstick (check haematuria)
MSU for microscopy and culture
PSA
Imaging: US (urinary tract obstruction, or transrectal +/- biopsy)
DRE exam
What are the treatments of benign prostatic hyperplasia?
Watching and waiting
Lifestyle advice (avoid caffeine and alcohol, bladder training)
Drugs:
- 1st line = a-blockers (e.g. tamsulosin) decrease smooth muscle tone of prostate and bladder (SE: hypotension, ejaculatory failure
- 5a-reductase inhibitors (e.g. finasteride) blocks synthesis of dihydrotestosterone to reduce symptoms (SE: impotence, low libido)
Surgery:
- TURP = transurethral resection of the prostate
- TUIP = transurethral incision of the prostate (less destruction and risk than TURP, used for smaller glands)
- open prostatectomy = retropubic, for larger glands
Describe chlamydia
Sexual transmission of Chlamydia trachomatis
Presenting as…
- often asymptomatic
- women: dyspareunia, dysuria, post-coital/inter-menstrual bleeding, increased vaginal discharge
- men: dysuria, urethral discharge
Tested by…
- nucleic acid amplification test, NAAT
- women = vulvovaginal swab, endocervical swab, urine sample
- men = first-pass urine
Treated with…
- azithromycin (PO, single dose), or doxycycline (BD, 7 days)
- partner tracing, screening, treatment
- avoid sexual intercourse
Describe gonorrhoea
Sexual transmission of Neisseria gonorrhoeae
Presenting as…
- vaginal/urethral discharge, dysuria
- asymptomatic in 50% of women, and 10% or men
- most are pharyngeal or rectal infection
Tested by…
- nucleic acid amplification test, NAAT
- women: vaginal or endocervical swab, urine sample (less sensitive)
- men: first-pass urine
Treated with…
- ceftriaxone IM + azithromycin PO
- partner tracing, screening, treatment
- avoid sexual intercourse
Describe genital herpes
Sexual transmission or herpes simplex virus
Presenting as…
- flu-like symptoms, vesicles/papules around genitals/anus/throat which burst and form painful shallow ulcers
- urethral discharge, dysuria, urinary retention
Tested by…
- PCR
Treated with…
- analgesia (topical lidocaine)
- antivirals
Describe syphilis
Sexual transmission of treponema pallidum
Presenting as…
- primary: genital ulcers (usually painless), highly infectious
- secondary: rash, flu-like illness
- tertiary: meningitis, seizures, cardiovascular complications
Tested by…
- PCR
- serology
Treated with…
- parenteral benzylpenicillin
