Surgery - Urology Flashcards
Testicular torsion
- Cause
- Typical presentation
Cause:
Often triggered by activity, cause twisting of spermatic cord
Bell-Clapper deformity: fixation between testicle and tunica vaginalis absent, testicles lie horizontally, prone to torsion
acute rapid onset of unilateral testicular pain abdominal pain and vomiting swollen testicles Retraction of testicles Absent cremasteric reflex
Management of testicular torsion
Is imaging necessary?
UROLOGICAL EMERGENCY
Nil by mouth, in preparation for surgery
Analgesia as required
Surgical exploration of the scrotum**
Orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
scrotal ultrasound can confirm the diagnosis, but delay surgery is contraindicated
Characteristic imaging sign of testicular torsion
Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.
Causes of epididymo-orchitis
Causes Escherichia coli (E. coli) Chlamydia trachomatis Neisseria gonorrhoea Mumps
(Think of mumps in patients with parotid gland swelling and orchitis. Mumps can also cause pancreatitis)
Typical presentation of epididymo-orchitis
over minutes to hours, with unilateral:
Testicular pain Dragging or heavy sensation Swelling Tenderness on palpation Urethral discharge (should make you think of chlamydia or gonorrhoea)
Systemic symptoms such as fever and potentially sepsis
Investigations for epidydymo-orchitis
Urine microscopy, culture and sensitivity (MC&S)
Chlamydia and gonorrhoea NAAT testing on a first pass urine
Charcoal swab of purulent urethral discharge for gonorrhoea culture and sensitivities
Saliva swap for PCR testing for mumps
Serum antibodies for mumps
Ultrasound may be used to assess for torsion or tumours
Management of epidydymo-orchitis
Analgesia
Supportive underwear
Reduce physical activity
Abstain from intercourse
Antiobiotics:
Ofloxacin*/Levofloxacin / ciprofloxacin
Doxycycline
Co-amoxiclav
Complications of epidydymo-orchitis
Chronic pain Chronic epididymitis Testicular atrophy Sub-fertility or infertility Scrotal abscess
Prostatitis:
- Typical presentation
Pelvic pain, which may affect the perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention
Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)
Pain with bowel movements
Investigations for prostatitis
Urine dipstick testing can confirm evidence of infection.
Urine microscopy, culture and sensitivities (MC&S) can identify the causative organism and the antibiotic sensitivities.
Chlamydia and gonorrhoea NAAT testing on a first pass urine, if sexually transmitted infection is considered.
Management of acute prostatitis
Hospital admission for systemically unwell or septic patients (for bloods, blood cultures and IV antibiotics)
Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim)
Analgesia (paracetamol or NSAIDs)
Laxatives for pain during bowel movements
Management of chronic prostatitis
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
Analgesia (paracetamol or NSAIDs)
Psychological treatment, where indicated (e.g., cognitive behavioural therapy and / or antidepressants)
Antibiotics if less than 6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks)
Laxatives for pain during bowel movements
Complications of chronic prostatitis
Sepsis
Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
Acute urinary retention
List lower urinary tract symptoms (LUTS)
Hesitancy – difficult starting and maintaining the flow of urine
Urgency – a sudden pressing urge to pass urine
Frequency – needing to pass urine often, usually with small amounts
Intermittency – flow that starts, stops and varies in rate
Straining to pass urine
Weak flow
Terminal dribbling – dribbling after finishing urination
Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night
5 assessments for LUTS
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Causes of raised PSA
Prostate cancer Benign prostatic hyperplasia Prostatitis Urinary tract infections Vigorous exercise (notably cycling) Recent ejaculation or prostate stimulation
Describe cancerous prostate on palpation
cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
Medical treatment of BPH
Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
Surgical treatment for BPH
Transurethral resection of the prostate (TURP) **
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision
5 types of urinary catheters
Intermittent catheters – simple catheters used to drain urine, then immediately removed
Foley catheter (two-way catheter) – the “standard” catheter with an inflatable balloon to hold it in place
Coudé tip catheter – has a curved tip to help navigate it past an obstruction during insertion
Three-way catheter – has three tubes used for inflating the balloon, injecting irrigation and drainage
Suprapubic catheters
Indications for urinary catheter insertion
Urinary retention due to a lower urinary tract obstruction (e.g., enlarged prostate)
Neurogenic bladder (e.g., intermittent self-catheterisation in multiple sclerosis)
Surgery (during and after)
Output monitoring in acutely unwell patients (e.g., sepsis or intensive care)
Bladder irrigation (e.g., to wash out blood clots in the bladder)
Delivery of medications (e.g., chemotherapy to treat bladder cancer)
Obstructive uropathy
- Upper urinary tract causes
Kidney stones
Tumours pressing on the ureters
Ureter strictures (due to scar tissue narrowing the tube)
Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)
Bladder cancer (blocking the ureteral openings to the bladder)
Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)
Obstructive uropathy
- Lower urinary tract causes
Benign prostatic hyperplasia (benign enlarged prostate)
Prostate cancer
Bladder cancer (blocking the neck of the bladder)
Urethral strictures (due to scar tissue)
Neurogenic bladder
Obstructive uropathy
- functional causes
Neurogenic bladder:
Multiple sclerosis Diabetes Stroke Parkinson’s disease Brain or spinal cord injury Spina bifida
Management of obstructive uropathy
Nephrostomy
Urethral/ suprapubic catheter
