Revise Notes Urology Flashcards
Acute Prostatitis
Pathophysiology
Acute infection of urinary tract and prostate
Aetiology: E.Coli most common, pseudomonas, klebsiella, enterococcus. Rarely STI (NG/CT)
Clinical features
Urinary symptoms - frequency, urgency, dysuria, fever
Perineal pain
Bladder outflow obstruction due to swelling - urinary retention, voiding symptoms (poor stream, hesitancy, intermittency, straining etc.)
Pain on ejaculation
Lower back pain
Systemic upset, fever, rigours
DRE findings
The prostate is tender on examination, and may feel swollen, warm and boggy
DRE must be performed gently and prostate massage should be avoided as it can cause abscess/sepsis.
Investigations
Urine MSU - dipstick, send for MCS
Management of acute prostatitis
Admit if severely unwell/septic/abscess etc.
Consider urgent referral if immunocompromised/diabetic/urological condition
Antibiotics
1st line: Ciprofloxacin 500mg BD OR ofloxacin 200mg BD
Initial course is 14 days
Use trimethoprim 200mg BD if cipro/oflox are unsuitable
Prostate cancer
Background
The most common cancer in men (25% of diagnoses)
Prostate adenocarcinoma accounts for the majority of cases - predominantly arising from the peripheral zone
There are two main types of adenocarcinoma:
Acinar - originates from glandular cells - most common
Ductal - originates from cells lining the ducts - more aggressive
RFs: Age, african-carribean, FHx
Clinical Features
Voiding symptoms: SHIT - poor Stream, Hesitancy, Intermittency, Terminal dribble
Other: storage symptoms (urgency, incontinence), haematuria, dysuria
Examination findings:
Enlarged, irregular, craggy/nodular, asymmetrical
Investigations
PSA
Imaging
1st Line - MRI prostate
Staging - CT TAP, PET
Biopsy - transrectal ultrasound guided (TRUS), or transperineal
Management of prostate cancer
Management of local disease is dependent on risk - which is determined by a combination of factors including PSA level, Gleason score and T staging
Low-risk - can be managed with active surveillance
Involves monitoring PSA, DRE, MRIp and biopsy
Intermediate/high risk - radical prostatectomy (alts. radiotherapy, brachytherapy)
SEs - impotence, incontinence
Metastatic disease
Hormonal treatment - androgen deprivation therapy
Bicalutamide - anti-androgen
Goserelin - GnRH receptor agonists
Chemotherapy
Benign Prostate Hyperplasia
Background
Non-cancerous hyperplasia of the of the prostate tissue
Extremely common - > 80% of men > 80 years have BPH to some extent
RFs: Age, african-caribbean ethnicity
Clinical Features
Voiding symptoms
SHIT - poor stream, hesitancy, intermittency, terminal dribble
Storage symptoms
Frequency, nocturia, urgency, incontinence
Examination findings
Enlarged, but smooth & symmetrical prostate
Irregular, craggy/nodular enlargement is suspicious for malignancy
Bph
Investigation
Investigations
PSA
The International Prostate Symptoms Score (IPSS) consists of seven questions re. urinary symptoms
0-7 Mildly symptomatic
8-19 Moderately symptomatic
20-35 Severely symptomatic
Imaging if indicated (e.g. MRI
Management
Voiding symptoms - 1st line - alpha antagonist (tamsulosin, alfuzosin)
Relax prostatic smooth muscle
If symptoms persist - consider adding an anticholinergic (oxybutynin, darifenacin etc).
Enlarged prostate, at risk of progression - 1st line - 5-alpha-reductase inhibitor (finasteride, dutasteride)
Inhibit conversion of testosterone to DHT - reduces prostate volume
For the purposes of ‘enlarged’ - NICE references estimated prostate > 30g / PSA > 1.4ng/ml.
‘Older men’ are those at risk of progression.
If both voiding symptoms and prostatic enlargement - consider both of the above
Surgical e.g. TURP - in cases refractory to medical management
Epididymo-orchitis
Background
Epididymo-orchitis describes the inflammation of epidiymis +/- testis
Aetiology
Age < 35 - most commonly STI (CT/NG)
Age > 35 - most commonly pathogens from urinary tact - E. Coli, proteus, klebsiella, pseudomonas
RFs: Bladder outflow obstruction, recent instrumentation/catheterisation
Clinical features
Symptoms
Acute onset, unilateral scrotal pain, swelling and erythema
Fever, rigors
Symptoms of STI - urethral discharge
Symptoms of UTI - dysuria, frequency, urgency
DDx - testicular torsion - sudden, severe pain, N&V
Examination Findings
Unilateral, firm swelling, and associated tenderness of the epididymis
Scrotal erythema/oedema
Prehn’s positive - scrotal pain is relieved by elevation of the scrotum
Acute EO
Investigations
Investigations should include
First pass urine for NAAT - for detection of NG/CT
Urine dipstick / MSU for MCS
Management
Empirical treatment should be commenced as follows
Probable STI related epididymo-orchitis
Ceftriaxone 1g IM stat plus PO doxycycline 100mg BD for 14 days
Probable UTI/enteric epididymo-orchitis:
PO ofloxacin 200mg BD for 14 days or..
PO levofloxacin 500 mg OD for 10 days
For epididymo-orchitis, with risk factors for both (NG/CT) and/or enteric organisms (men who practise insertive anal sex):
Ceftriaxone 1g IM stat plus PO ofloxacin 200mg BD for 10 days
Peyronie’s Disease
Pathophysiology
Fibrosis of the tunica albuginea causes an acquired curvature of the penis, which may result in pain or impact sexual function.
Clinical Features
Abnormal curvature and shortening of the penis
Painful erections (for first 12-24 months)
Erectile dysfunction/sexual dysfunction
Management
Medical management of ED - Sildenafil (PDE5 inhibitor) etc
Surgical management - to reduce abnormal curvature
Priapism
Pathophysiology
A pathological, abnormally sustained erection, occuring in the absence of sexual stimulation/desire
Classification
Classification
High-flow priapism (non-ischaemic)
Occurs due to unregulated cavernous arterial inflow
Causes: Penile or perineal trauma, or spinal cord injury
Low-flow priapism (ischaemic) - urological emergency
Obstruction of the venous outflow of the corpus cavernosum
Results in ischaemia - therefore a urological emergency
Causes: Sickle cell disease, iatrogenic (e.g. following intracavernosal drug therapy)
Clinical Features
Abnormally sustained, unwanted erection
High-flow - non-painful (as no ischaemia), not fully erect
Low-flow - painful (due to ischaemia), fully rigid erection
Investigations
Corporal blood gas helps to differentiate between high-flow and low-flow priapism
High-flow - PO2 > 9, CO2 < 4.5, lactate normal
Low-flow (ischaemic) - PO2 < 3, CO2 > 6, lactate elevated
Management
Initial management - corporeal aspiration
Intracavernosal phenylephrine may help (sympathomimetic)
Surgical management - shunt formation
Paraphimosis
Background
The inability to pull forward a foreskin, that has already been retracted over the glans
Once occurred, the paraphimosis reduces venous return from the distal penis and glans, resulting in progressive oedema
Eventually can result in penile ischaemia and necrosis
Manual reduction is the mainstay of management - gentle constant squeezing pressure helps to reduce oedema, before pushing glans back into prepuce
Can be very painful - ensure adequate analgesia
If this fails, a dorsal incision or circumcision may be necessary
Clinical Features
Classically occurs following catheterisation in men, where foreskin is not retracted following completion of the procedure
Progressive swelling of the glans/distal penis
Unable to retract foreskin
Progressive, substantial pain
Examination findings: Congested/swollen glans, with collar of oedematous foreskin
Management
Phimosis
Background
The inability to retract the foreskin due to narrow preputial ring
Causes
Physiological
Secondary - occurs to scarring of the prepuce from:
Balanitis
STIs
Trauma
Clinical Features
Abnormal urine stream - may spray, uncontrolled, in all directions
Weak stream
Foreskin may swell/balloon during micturition
In adults may cause pain during sex
Management
Topical steroids may be beneficial, particularly in cases of scarring/secondary phimosis
Circumcision may be required
Phimosis
Background
The inability to retract the foreskin due to narrow preputial ring
Phimosis may appear as a tight ‘rubber band’/ring of foreskin at the tip of the penis, which cannot be retracted over the glans penis
At birth, the foreskin is attached to the glans, and the preputial ring is tight - so the foreskin cannot be retracted in most newborns.
With age, the ring widens, allowing retractability in:
10% boys by 12 months
50% boys by 10 years
99% boys by 17 years
So in most cases, unless symptomatic/pathological, no treatment is required.
Scrotal Problems
Epididymal cysts
Pathophysiology
A fluid-filled sac (cyst) at the head of the epididymis
Spermatocele: A variant of epididymal cysts, which contain sperm
Most common around age of 40 - so later than most testicular cancers (20-40)
Examination Findings
A soft, round/oval lump which is separate from the body of the testicle
Commonly posterior or at the top of the testicle
Diagnosis
USS
Hydrocele
Pathophysiology
An accumulation of fluid within the tunica vaginalis, which surrounds the testes
Most commonly idiopathic, but can also occur due to cancer, epididymo-orchitis etc
Clinical features
Symptoms: Painless, soft scrotal swelling
Examination findings:
Soft, fluctuant, non-tender swelling
Transilluminates when light shone through skin
Testes can be palpated within the swelling
Diagnosis
USS
Management
Normally conservative
Varicocele
Pathophysiology
Clinical Features
Symptoms: Aching discomfort, dragging sensation
Examination findings:
Scrotal mass, classically with a “bag of worms” feel
Can disappear on lying down, or become larger when standing due to increased venous pressure
Diagnosis
US doppler
Management
Most varicoceles do not require treatment.
NICE advises the following referrals:
Urgent: if a varicocele is sudden onset or remains tense when lying down.
Routine: if the varicocele is causing symptoms such as pain or discomfort.
Varicocele
Pathophysiology
Increased resistance in the testicular vein results in abnormal swelling of the pampiniform plexus of veins, found within the spermatic cord (responsible for venous drainage of testicles).
90% of varicocels are left-sided
Right sided varicoceles should prompt suspicion of an obstructive process, such as renal cell carcinoma. Left sided varicoceles may also present in this way.
Associated with subfertility, likely due to temperature dysregulation
Renal Stones
Background
Urolithiasis occurs due to over-saturation of urine with components such as calcium, urate, oxalate etc
This leads to precipitation, and
formation of stones within the kidneys. Stones can subsequently migrate into the ureters.
Types of stones
Calcium oxalate - 85% of stones
Struvite
Composed of magnesium/ammonia/phosphate
RF: chronic proteus infection
Urate - 10% of stones
Radiolucent - diagnosis requires non-contrast CT-KUB or US KUB
Risk factors
Risk factors for renal stones include the following:
Drugs: Loop diuretics, acetazolamide, steroids, theophylline
Nb. Thiazides reduce the risk of renal stones (inc. calcium reabsorption)
Hypercalcaemia - e.g. patients with hyperparathyroidism
Others: Renal tubular acidosis type 1, Cystinuria
Clinical Features
Renal/ureteric colic
Sudden, severe, loin to groin pain
Associated vomiting
Haematuria > 90% (microscopic usually)
Imaging renal stones
Imaging
Diagnosis: Non-contrast CT KUB is gold standard
Should be performed within 24 hours of presentation..
Perform immediately if single kidney/ evidence of infected/obstructed kidney (pyrexia, elevated inflammatory markers etc.)
If a woman is pregnant, or in children and young people - 1st Line: USKUB instead
Measure calcium in patients with renal/ureteric stones, consider stone analysis
Management renal stones
Analgesia
1st Line: Classically PR Diclofenac in exam Qs, though NICE advise an NSAID by any route
Medical expulsive therapy
Distal ureteric stones < 10mm
Consider alpha blockers (tamsulosin, alfuzosin) to aid expulsion
Surgical treatments (including shockwave lithotripsy) - Adults
Renal Stones
Consider watchful waiting for asymptomatic renal stones if the stone is < 5mm / patient expresses preference for this.
Most stones < 5 millimetres (majority) pass spontaneously
If surgical treatment is required (e.g. stone unlikely to pass, > 5 mm etc)
< 10 mm - 1st Line: Shockwave lithotripsy
Consider ureteroscopy (URS) if SWL is contraindicated/ prev. Failed
10-20mm - consider SWL or URS
If stone > 20mm - offer percutaneous nephrolithotomy (PCNL)
