MedEd urology Flashcards
What is the most common cause of epididymitis in people under 35?
Gonorrhea and chlamydia
What bacteria causes most UTIs?
E coli
What are differentials for scrotal mass?
Testicular torsion Epididymitis/ orchitis Testicuar cancer Variocele Hydrocele
What is testicular torsion?
Twisting of spermatic cord resulting in constriction of vascular supply and ischaemia of testicular tissue
What are the types of testicular torsion and which is more common? How are they differentiated?
Intravaginal- most common and within the tunica vaginalis
Extravaginal- entire testes and tunica vaginalis twists
What are RF for testicular torsion?
If intravaginal- age under 25 years and bell clapper deformity
How will someone with testicular torsion present?
Painful Swollen hot tender erythemous scrotum Unilateral Raised affected testicle Absent cremasteric reflex
How do you perform the cremasteric reflex?
Stroke the inner thigh of the affected testicle and see if it rises
How quickly do you have to treat testicular torsion?
Within 6 hrs of symptom onset
What is GS investigation for testicuar torsion? What is second line
Emergency exploration of the scrotum within 6hrs of symptom onset
Testicle twisted back and bilateral orchidopexy
second line manual de torsion if surgery is not availbale
What is epididymitis/orchitis?
Inflammation of the epididymis or testes
What are causes of epididymitis/orchitis? Describe organisms in under and over 35s
Bacterial infection- chlamydia most common or gonorrhea if under 35
If over 35 mainly klebsiella, e coli, enterococcis faecalis
Non infective= trauma, vasculitis, medication
What are RF for epididymitis/orchitis?
Unprotected sex
Bladder outflow obstruction
UTI
Immunosupressed- more likely atypicals eg candida
How does epididymitis/orchitis present?
Painful Swollen, hot tender erythemous scrotum Unilateral Presents over a few days urinary syptoms= dysuria, retention
How can you differentiate epididymitis/orchitis from testicular torsion?
Different RF
Testicular torsion usually in younger people but epidid= all ages
Cremasteric reflex painful but may be present in epidid vs absent in testicular torsion
There will be dysuria and urgency in epididymitis/orchitis
What inevstigations are done for for epididymitis/orchitis? What will be seen
Urine dip, MSU and MC&s bedside
Bloods- WCC high, UEs
Imaging- colour duplex USS
How is epididymitis/orchitis managed?
Conservative= bed rest and scrotal elevation Medical= analgesia, abx to target infection Surgical= exploration of the testes if torsion can't be excluded and abscess drainage if abscess develops
What is variocele?
Dilated veins of the pampiniform plexus forming a scrotal mass
How does variocele arise?
high hydrostatic pressure (esp left renal vein)
imcompetent veinous valves
What side is variocele more common in?
Left
How will variocele present?
Asympotmatic
Looks like a bag of worms
What investigations are done for variocele?
Examine the patient standing up
May be fertility analysis
May do ultrasound if it doesnt diminish when they lie down
In what position will variocele be less prominent? Why is this important?
Lying down
You have to examine them standing up
If it doesnt reduce when they lie down there is a problem
How is variocele managed?
Reassure and observe
If fertility is comprimised then surgery
What is hydrocele?
A collection of serous fluid in the tunica vaginalis
What are the types of hydrocele and how do they differ?
Communicating- processus vaginalis is open- peritoneal fluid flows in from abdomen
Non communicating- processus vaginalis is closed
What are RF for hydrocele?
Male
Children
Non communicating- trauma, infection, testicular torsion, testicular cancer
Communicating- increased intraperitoneal fluid eg ascites
How does hydrocele present?
Asymptomatic Scrotal swelling Possible to get above swelling Enlarges after activity eg coughing and straining Will transilluminate
What investigations are done for hydrocele? Why are they done
Clinical diagnosis
Urine dip- rule out infection
USS- exclude tumor
Bloods- exclude testicular tumor markers
How is hydrocele managed?
Observe
If too uncomfortable offer surgery
What are the types of testicular cancers?
Seminomas
Non seminomatous germ cell tumors
What are RF for testicular cancer?
Cryptorchidism
Ectopic testes
Testicular atrophy
FHX
How does testicular cancer present
Painless hard nodular unilateal testicular mass Lymphadenopathy Gynaecomastia Back ache Hydrocele
How is testicular cancer inevstigated?
FBC, UEs, LFTs
Tumor markers- alpha fetoprotein, beta HCG, LDH
Image w testicular ultrasound, CT AP, CXR
What tumor markers are checked for testicular cancer?
alpha fetoprotein, beta HCG, LDH
Where does testicular cancer metastase to and how?
Through para aortic lymph nodes to chest
How is testicular cancer managed?
Ochiectomy
Chemotherapy
What is UTI?
Presence of a pure growth of >10^5 organisms per mL of fresh MSU
What is cystitis?
Infection of bladder
What are RF for UTI?
Female Sexual intercourse Immunosupression Catheterisation Urinary tract obstruction- BPH, urinary tract calculi
Why are females at higher risk of UTI?
Urethra is way smaller in length than in a man
How will UTI present?
Storage symptoms (bladder doesnt want to store urine as its inflammed): Increased frequency Urgency Dysuria Foul smelling
How does pyelonephritis present?
Flank pain
Fever
Malaise
What is GS investigation for UTI? What else will you do and what will you see?
MSU for MC&s
first line Urine dip- +nitrates and WC
What is the most common abx for UTI
Nitroflurotonin
What are the 3 points of urinary tract calculi commonly?
Ureteropelvic junction
Pelvic brim where ureters cross iliac vessels
Ureterovesical junction
How do kidney stones arise?
Urinary solutes are high in the urine- they supersaturate and precipitate out of the solution
What are RF for kidney stones?
Dehydration high protein intake High salt structural abnormality PMHx FHx
How is more likely to get kidney stones?
Males
30-50 y/o
Hot and dry countries (causes dehydration)
How will kidney stones present?
Intially sympotatic If it gets stuck: Acute severe loin to groin pain= renal colic Nausea and vomitting Unable to lie still, writhing in pain Urgency, frequency and haematuria Heamaturia is usually microscopic
What are investigations for kidney stones? What is GS imaging? What will you see?
First line urine dip
Pregnancy test if female to rule out ectopic pregnancy
Bloods- FBC, WCC to rule out UTI, UEs/Cr/Ca to check kidney function
GS imaging- non contrast CT KUB
How are kindey stones managed?
Acute= fluids, analgesia (diclofenac), anti emetics (ondansetron), urine collection to collect and analysed passed stone <5mm= leave to pass <10mm= alpha blocker (tamsulosin), if not passed in 4-6 weeks surgery >10mm= surgery first line extracoroporeal shock wave lithotripsy
What are complications of kidney stones?
Pyelonephritis Septicaemia Obstruction Urinary retention Hydronephrosis
What is BPH?
Diffuse hyperplasia of the periurethral zone
Who is more likely to get BPH?
Increasing age
Afro carribeans
How does BPH present?
Lower urinary tract symptoms:
Storage= urgency, frequency
Voiding= hesitancy
Bone pain
FLAWS
What acronym is used to remember storage and voiding symptoms
FUND HIPS:
Fund= storage symptoms= frequency, urgency, nocturia, dysuria
Hips= voiding= hesitency, incomplete voiding, poor stream
How is BPH investigated? What will you see? What is GS imaging
Urinalysis to exclude UTI
DRE- smoothly enlarged palpable midline grooce
PSA- high
UEs to check renal function
GS imaging- transrectal US guided needle biopsy
What is used to check for mets in prostate cancer?
Isotope bone scan
CXR
How is BPH managed?
Lifetsyle adv= avoid caffeine
Review thier medications- anticholinergics cause it
1st line= alpha tamsulosin (a1 blocker)
2nd line= 5a reductase inhib= finasteride
surgery= transurethral resection of prostate
What are the 2 main types of bladder cancer? Which is more common
urothelial carcinoma- most common
squamous cell carcinoma
What are RF for bladder cancer
General: males, over 55 years
Urothelial- smoking, carcinogen exposure, aromatic amines, arsenic, painters and hairdressers
How will bladder cancer present?
Painless macroscopic haematuria
FLAWS
Storage and voiding problems- FUND HIPS
What are investigations for bladder cancer?
1st line= urinalysis FBC ALP- high if bone mets UEs GS imaging- cystoscopy and biopsy Also do MRI, to check mets isotope bone scan and CXR
What type of testicular torsion is more common in neonates?
Extravaginal
What is the difference between intravaginal and extravaginal testicular torsion?
Intravaginal= twisting is within the tunica vaginalis Extravaginal= twisting is of the entire testes and tunica vaginalis
What deformity increases risk of intravaginal testicular torsion?
Bell clapper deformity
What bacterial organisms cause epdidymitis/orchitis in under 35s?
Chlamydia most commonly
Gonorrhea
What bacterial organisms cause epdidymitis/orchitis in over 35s?
Klebsiella
E coli
What should happen in variocele when you get the patient to lie down?
The vessels should disappear
What lymph nodes are involved with metastasis of testicular cancer?
Para aortic
What will you see on MC&S and MSU in pyelonephritis?
White cell casts
What are the types of urinary tract calculi and which is most common?
Calcium oxalate is most common
Struvite
Urate/uric acid
Hydroxyapatite
What urinary tract calculi is not visible on x ray?
Urate or uric acid
What are some causes of urinary tract calculi?
High Ca, uric acid, oxalate or Na
Metabolism eg hyperparathyroidism causing high ca
Infection
Drugs
What is the difference between BPH and prostate cancer on DRE?
BPH= smoothly enlarged prostate with palpable midline groove
Prostate cancer= asymmetrical hard nodular prostate with loss of midline sulcus
What is the difference between PSA levels in BPH and prostate cancer?
Levels are high in both (>4)
What is the GS ix for prostate cancer and BPH?
Transrectal US guided needle biopsy
If cancer then isotope bone scan to check for mets
What professions are more likely to have bladder cancer?
Painters
Hairdressers
What type of kidney stones are patients predisposed to if they have recurrent UTIs with recurrent urease positive bacteria?
Struvite
