Miscellaneous Urology Flashcards
Acute bacterial prostatitis
E. coli
Recent UTI, catheterisation, prostate biopsy
Painful rectum, voiding symptoms, fever, rigors, DRE- tender, boggy prostate
14-day course of quinolone eg. Ciprofloxacin, screen for STI
Causes of acute urinary retention
BPH
Urethral strictures, calculi, constipation, pelvis masses (NB- not ureters, we have two, so both need compressing to cause AUR)
Drugs- anticholinergics, TCA, opioids, benzodiazapenes, antihistamines
Neurological- MS, PD, spinal cord lesion
UTI
Postoperative
Features of AUR
Inability to pass urine
Lower abdominal discomfort
Considerable pain or distress
Delirium (esp. elderly)
AUR vs CUR
Typically painless and overflow incontinence (nocturia)
Investigations for AUR
Urinalysis, microscopy culture and sensitivities
UE, FBC, CRP
Bladder USS (volume of greater than 300cc)
Subtypes of CUR
High pressure- impaired renal function and bilateral hydronephrosis (due to bladder outflow obstruction)
Low pressure- normal renal function and no hydronephrosis
Decompression haematuria commonly occurs after catheterisation for CUR due to rapid decrease in pressure. Requires no treatment.
Medical indications for circumscision
Phimosis
Recurrent balantitis
Balantitis xerotica obliterans
Paraphimosis
NB- must exclude hypospadias prior to circumscion
Epididymal cysts
Most common cause of scrotal swelling seen in primary care
Separate from body of testicle
Posterior to testicle
Associated- PKD, CF, Von hippel lindau syndrome
USS diagnosis
Epididymo-orchitis
Infection of epididymis or testes resulting in pain and swelling- usually due to spread of infection from genital tract or bladder
20’s and sexually active- chlamydia trachomasis, (Neisseria gonnorhoea less so)
Over 35’s- E coli
Features of EO
NB- need to exclude testicular torsion
Unilateral testicular pain and swelling
Urethral discharge
If organism unknown, ceftriaxone 500mg IM once, plus doxycycline 100mg BD for 10-14 days
Factors favouring an organic cause of ED
Gradual onset of symptoms
Lack of swelling
Normal libido
NB- vascular are the most common organic causes of ED
Factors favouring a psychogenic cause of ED
Sudden onset
Decreased libido
Spontaneous or self stimulated erections
Major life events
Problems or changes in a relationship
Previous psychological problems
History of premature ejaculation
Risk factors for ED
Advancing age
CVD- obesity, DM, smoking, dyslipidaemia, HTN
Alcohol use
Drugs- SSRI, beta blockers
NB- vascular are the most common organic causes of ED
Investigations for ED
Calculate 10 year cardiovascular risk
Testosterone (between 9 and 11am)
Management of ED
PDE5 inhibitors (slidenafil, viagra)
Vacuum erection devices if people cannot take PDE5 inhibitor (ie. recent MI)
Hydrocele
Accumulation of fluid in the tunica vaginalis
Communicating- peritoneal fluid enters scrotum (common in newborn males and resolve within first month of life)
Non communicating- excess production
They can develop secondary to- epididymo-orchitis, testicular torsion, testicular tumours
Features and management of hydrocele
Soft non tender swelling of the scrotum (anterior and below scrotum usually)
Transillumimates
May be difficult to palpate if hydrocele is large
USS to rule out underlying pathology (although can be clinical)
Children- repaired if don’t resolve by 1-2 years
Adults- conservative. USS to rule out underlying pathology
Causes of hydronephrosis
Unilateral- PACT
Pelvic ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Bilateral- SUPER
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro peritoneal fibrosis
Investigation and management of hydronephrosis
USS
CT KUB
Remove obstruction and drain urine
Acute- nephrostomy tube
Chronic- ureteric stent or pyleoplasty
Renal cell carcinoma
Most common is clear cell
Associations- middle aged men, smoking, Von hippel lindau syndrome, tuberous sclerosis, slight increase with ADPKD (not much)
Features of renal cell carcinoma
Triad- haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Endocrine effects- EPO (polycythaemia), PTH (hypercalacemia), ACTH
Paraneoplastic hepatic dysfunction syndrome
Varicocele (left sided, tumour suppresses veins)
NB- varicocele can be a testicular tumour or a renal one
Management- nephrectomy, alpha interferon and IL2
NB- patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy (more= radical nephrectomy)
Risk factors for renal calculi
Dehydration
Hypercalcuria, hypercalcaemia, hyperparathyroidism
Cystinuria
High dietary oxalate
Rental tubular acidosis
PKD
Drugs- calcium stones: loop diuretics (furosemide, bumetinide), steroids, acetazolamide, theophylline (thiazides (indapamide, bendroflumethazide), prevent calcium stones by causing hypocalcuria)
Urate stones- gout, ileostomy (acidic urine, bicarbonate lost)
Potassium sparing diuretics
Aldosterone antagonists
Spironalactone, eplenrone
Varicocele
Abnormal enlargement of testicular veins (associated with infertility)
Commonly on left side
Look and feel like a bag of worms
Subfertility
Diagnose with Doppler
Usually conservative management, occasionally surgery if pain
Testicular cancer
95% are germ cell tumours (seminomas and non seminomas (embryonal, yolk sac, teratoma etc.)
Non germ cell tumours include leydig cell tumours and sarcomas
Risk factors for testicular cancer
Infertility
Cryptorchidism
FH
Kilenfelters syndrome
Mumps orchiditis
(Teratoma-25 years, seminoma- 35 years)
Features of testicular cancer
Painless lump is most common presentation
Pain in minority
Hydrocele
Gynaecomastia (increased oestrogen to androgen ratio)
Germ cell tumours release hCG
Tumour markers
Germ cell tumours
Seminoma- hCG elevated
Non-seminomas- AFP/beta hCG elevated
LDH elevated
USS first line
Refer to urology, then chemo, radio, and orchidectomy
NB- non-seminoma is 2 words, so 2 markers are raised
Features of testicular torision
Pain is severe and sudden onset
Pain may be referred to lower abdomen
Nausea and vomiting may be present
Swollen, tender testis retracted upwards
Red skin
Cremasteric reflex lost
Elevation of testes doesn’t ease the pain (Prehns sign)
Urgent surgical exploration (if tortes testes identified them both testes fixed as condition of a bell clapper testes is often bilateral)- never elective (even if patient has had episodes before and not presented)
NB- USS is imaging modality of choice (whirlpool sign)
TURP syndrome
Large volumes of glycine absorbed during TURP procedure, causes hyponatrameia, hyper ammonia (get CNS, respiratory and systemic Sx)
Causes of urethral stricture
Iatrogenic (traumatic placement of indwelling catheter lines)
STI (gonorrhoea)
Hypospadias
Lichen sclerosus
Vasectomy
More effective than female sterilisation
Contraception until semen analysis reveals azoospermia twice before unprotected sex (usually 16/20 weeks- doesn’t work right away)
Chronic testicular pain, bruising, hameatoma, infection, sperm granuloma
Which testicular cancer is associated with cystic lesions containing heterogeneous solid echoes?
Teratoma
Complication of goserelin treatment (GnRH analogue)
During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer. This is known as the ‘flare effect’ and is caused by an initial increase in luteinizing hormone production prior to receptor down-regulation.
Flutamide, a synthetic antiandrogen, can be used pre-emptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
Paediatric phimosis
In children less than 2 years of age, phimosis (a non-retractable foreskin) is normal and will most likely resolve with time
Vesicovaginal fistulae
Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.
Investigating UTI’s in children
All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks (or during the illness if there are recurrent UTIs or atypical bacteria)- send for MCUG if recurrent UTI’s under 6 months
Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks
Children with atypical UTIs should have an abdominal ultrasound during the illness
Mnemonic for LUTS
FUN WISE (storage and voiding)
Frequency
Urgency
Nocturia
Weak stream
Intermittency/hesitancy
Straining
Emptying incomplete
PDE5 inhibitors
eg. sildenafil (viagra)
Contraindications
patients taking nitrates and related drugs such as nicorandil
hypotension
recent stroke or myocardial infarction (NICE recommend waiting 6 months)
Side effects
visual disturbances ie. blue discolouration/ischaemic neuropathy
nasal congestion
flushing
gastrointestinal side-effects
headache
priapism
NB- blue tablet for blue discoloration
Varicocele that doesn’t dimmish when lying down
This patient has signs and symptoms consistent with a varicocele (subfertility and a testicular mass similar in feeling to a ‘bag of worms’) that does not diminish when lying down. This should raise suspicion of compression of the renal vein which suggests the presence of an abdominal or retroperitoneal mass, such as malignancy. As well as this, right-sided varicoceles alone are rare and should further raise suspicion of this, therefore necessitating an urgent referral for suspected malignancy. It is important to note that this may be a sign of renal cell carcinoma, and up to 50% of cases are diagnosed incidentally.
Preservation of cremaster reflex in testicular torsion
The cremasteric reflex is usually preserved when the torsion affects the appendage only.
Phimosis management
Under 2- conservative
