surgery - urology Flashcards
what is paraphimosis?
- commonly affects uncircumsized males
- when foreskin can no longer be pulled forward over tip of penis
- foreskin becomes swollen and stuck
- may stop blood flow to tip of penis
what is phimosis?
inability to retract foreskin
what is balanitis?
- pain and inflammation (swelling and irritation) of the glans (head) of penis
hydrocele is a collection of fluid in the…
tunica vaginalis
surrounding the testis
cystic or fluctuant in nature
would not be distinguishable from the testis itself
testicular malignancy is always treated with…
orchidectomy via an inguinal approach
management of varicoceles…
conservatively
the following points to what diagnosis?
- inguinoscrotal swelling, cannot get above it
- cough impulse may be present
- may be reducible
inguinal hernia
the following points to what diagnosis?
- discrete testicular nodule
- symptoms of metastatic disease
testicular tumours
- USS scrotum
- serum AFP and beta HCG
the following points to what diagnosis?
- single or multiple cysts
- may contain clear or opalescent fluid
- usually occur over 40 years of age
- painless
- lie above and behind testis
- usually possible to get above the lump on examination
epidiymal cysts
the following points to what diagnosis?
- non-painful, soft fluctuant swelling
- can get above it
- transilluminate
- usually contain clear fluid
hydrocele
the following points to what diagnosis?
- severe, sudden onset testicular pain
- risk factors include abnormal testicular lie
- typically affects adolescents and young males
- on examination testis is tender
- pain not eased by elevation
testicular torsion
brainstorm some possible reasons for acute urinary retention in males?
- secondary to BPH
- urethral strictures, calculi, cystocele, constipation or masses
- medications affecting nerve signals to bladder: anticholingerics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines
investigations for acute urinary retention:
- urinalysis and culture
- serum U&Es and creatine to assess kidney injury
- FBC and CRP for infection
- PSA not appropriate as typically elevated
- USS to confirm
how is acute urinary retention managed?
- decompressing bladder via catheterisation
what is epididymo-orchitis ?
- infection of the epididymis and testes
- pain and swelling
- due to local spread of infections from genital tract such as chlamydia trachomatic and neisseria gonorrhoeae
- E-coli in males with low STI risk
important differential for epididymo-orchitis?
- testicular torsion
45 y/o female
- fluctuating loin to groin pain
- visible haematuria
- unable to get comfortable
indicative of:
renal stones
- CT KUB gold standard investigation for suspected urolithiasis
calculi or stones that form in the urinary tract:
- urolithiasis
initial management of renal colic?
- NSAID
initial investigations for patients with renal colic?
- urine dipstick and culture
- serum creatinine and electrolytes to check renal function
- FBC and CRP to look for associated infection
- calcium/urate: look for undelrying causes
three treatment options for renal stone?
- shockwave lithotripsy: uncomfortable
- ureteroscopy: retrograde through ureter into renal pelvis, if pregnant
- percutaneous nephrolithotomy
51 y/o male
- swelling L testicle
- OE: unilateral swelling of L side of scrotum
- feels separate to testicle itself
- does not trans-illuminate
- no superior border
- can’t be felt in top of scrotum
most likely
inguinoscrotal hernia
- swelling you can’t get above
Often history of dysuria and urethral discharge
Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
likely to be:
acute epididymorchitis
This is a gentleman presenting with macroscopic haematuria, dysuria and weight loss.
- known to have had malaria and schistosomiasis
describe thought process to differential
- source of urinary blood: bladder, prostate, ureters or kidneys
- combination or dysuria with haematuria points to bladder
- weight loss suggests malignancy
- 90% of bladder cancers are transitional cell carcinoma
- schistosomiasis is a major risk factor for development of squamous cell carcinoma of the bladder
what is the most effective management option in renal cell carcinoma?
- radical nephrectomy
- RCC often resistant to radiotherapy or chemotherapy
renal cell carcinoma typically presents with a triad of:
- haematuria
- abdominal mass
- loin pain
describe the two different types of hydrocele?
- communicating: caused by patency of processus vaginalis allowing peritoneal fluid to drain into scrotum
- non-communicating: caused by excessive fluid production within the tunica vaginalis
56 y/o male
- lethargy, haematuria and haemoptysis
- OE: hypertensive and has right loin mass - CT shows lesion affecting upper pole of right kidney
- small cystic centre
likely diangosis?
- renal adenocarcinoma
- most common renal tumours
- typically affect renal parenchyma
why might renal adenocarcinoma cause haemoptysis?
- cannon ball metastasis in lung
- may cause haemoptysis
management for metastatic prostate cancer disease?
synthetic GnRH agonist
- e.g. goserelin
- cover initially with anti-androgen to prevent rise in testosterone
anti-androgen
orchidecotmy
management for localised prostrate cancer T1/T2
- conservative
- radical prostatectomy
- radiotherapy
management for localised advanced prostate cancer T3/T4
- hormonal therapy
- radical prostatecotmy: erectile dysfunciton common complication
- radiotherapy
57 y/o male
- 3 day hx lower back pain, pain on urination, low grade fever
- tender boggy prostate
- diffuse lower abdo pain
Urine dip: 2+ of blood in urine
suspected diangosis?
prostatitis
- urine sample should be sent for culture
most common pathogen associated with acute bacterial prostatitis?
- acute bacterial prostatitis
- caused by gram negative bacteria entering the prostate gland via the urethra
- E.coli
management for acute bacterial prostatitis?
- 14 day course of a quinolone
- consider STI screening
what is a varicoele?
abnormal enlargement of testicular veins
diagnosis: doppler
management: conservative
Lower urinary tract symptoms in men
VOIDING:
- hestitancy
- poor or intermittent stream
- straining
- incomplete emptying
- terminal dribbling
Lower urinary tract symptoms in males:
STORAGE:
Frequency
Urgency
Urinary incontinence
Nocturia
management for predominantly voiding symptoms?
- conservative: pelvic floor, bladder training
- ‘moderate or severe symptoms’ - alpha blocker
- if prostate enlarged, high risk of progression - 5-alpha reductase inhibitor
management for predominantly overactive bladder?
- conservative: moderating fluid intake
- bladder retraining
- anti-muscarinic drugs
Management of nocturia
- conservative: moderating fluid intake at night
- furosemide 40mg in late afternoon
- desmopressin
36 y/o builder
- 1 day hx pain in his groin on right side
- intermittent
- extremely severe
- radiates across from flank
- ? dehydrated
dipstick
- ++ blood
could be:
ureteric calculus
- right sided loin to groin pain
- with microscopic haematuria
70 y/o male
- 6 week hx of increased urinary frequency and urgency
- feeling of incomplete emptying
- OE DRE: enlarged prostate, feels hard and craggy, raised PSA
what type of cancer is this?
adenocarcinoma often in 95% of cases
in the acute management of renal colic what is the recommended choice of analgesia?
IM diclofenac
causes of unilateral hydronephrosis?
4
PACT
- pelvic ureteric obstruction
- aberrant renal vessels
- calculi
- tumours of renal pelvis
causes of bilateral hydronephrosis?
5
SUPER
- stenosis of urethra
- urethral valve
- prostatic enlargement
- extensive bladder tumour
- retro-peritoneal fibrosis
investigation of hydronephrosis?
- USS first line
- IVU assess position of the obstruction
- CT is renal colic sus
management of hydronephrosis?
- remove obstruction and drainage of urine
- acute upper urinary tract obstruction: nephrostomy
- chronic upper urinary tract obstruction: ureteric stent or pyeloplasty
most common organism causing staghorn calculus?
- proteus mirabilis
4 complications of TURP : transurethral resection of the prostate
T- transuretral resection of the prostate syndrome
U - urethral stricture
R - retrograde ejaculation
P - perforation of the prostate
A 20-year-old complains of severe pain and swelling of the scrotum after a cystoscopy. He had mumps as a child. The testis is tender. The urine dipstick is positive for leucocytes.
epidiymo-orchitis
- to differneitate from testiular torision do dipstick
An 8-year-old presents with scrotal swelling. He has just recovered from an acute viral illness with swelling of the parotid glands. On examination both testes are tender and slightly swollen.
orchitis
may be associated with mumps viral infection
what investigation of choice in diagnosing bladder cancer?
cystoscopy
The first-line investigation of a testicular mass
USS
A 34-year-old man presents in general practice with a painful right scrotal swelling. He has a past medical history of von Hippel-Lindau syndrome. On examination, a 4mm lump can be felt posterior to and separate to the right testicle. There is no erythema, gross scrotal enlargement, or dysuria. The patient is apyrexial with normal vital signs. Tumour markers are normal.
epididymal cyst
- cause of scrotal swelling which can be palpated as separate from body of testicle
would not be epididymo-orchitis
- cause of unilateral testicular pain and swelling
68 y/o male
- nocturia sometimes with urgency
- finding it difficult to begin urinating
- poor stream
DRE: enlarged but smooth prostate
what may be given to relieve symptoms?
BPH
Alph a-1 antagonist: promotes relaxation of the smooth muscle of prostate and bladder to reduce LUTS
such as tamsulosin
A 31-year-old man presents as he and his partner have been having problems conceiving. On examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which can be felt separately, is normal.
varicocele
A 62-year-old man presents with nocturia, hesitancy and terminal dribbling. Prostate examination reveals a moderately enlarged prostate with no irregular features and a well defined median sulcus.
benign prostatic hyperplasia
- alpha-1 antagonist is first line
tumour marker in pancreatic cancer
CA 19-9
tumour marker in ovarian cancer
CA125
tumour marker in testicular cancer
beta HCG
common presentation of testicular cancer?
painless testicular lump in a 27 year old male
Testicular torsion can involve testicular appendage or spermatic cord.
in which type is the cremasteric reflex preserved?
- cremasteric reflex preserved when torsion affects the appendage only
Urine culture shows a Proteus infection. An x-ray demonstrates a stag-horn calculus in the left renal pelvis. What is the most likely composition of the renal stone?
struvite
- stag horn calculi are composed of struvite and form in alkaline urine
- ammonia producing bacteria therefore predispose
A 69-year-old male presents with haematuria. He worked in the textile industry. He has a left flank mass. A CT IVU shows a lesion of the left renal pelvis.
renal transitional cell carcinoma
- rare form of renal cancer
- risk factors include exposure to chemicals in the textile, plastic and rubber industry
first-line investigation in suspected prostate cancer
multiparametric MRI
