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
Complications of obstructive uropathy
Pain
Acute kidney injury (post-renal)
Chronic kidney disease
Infection (from bacteria tracking up urinary tract into areas of stagnated urine)
Hydronephrosis (swelling of the renal pelvis and calyces in the kidney)
Urinary retention and bladder distention
Overflow incontinence of urine
Treatment of hydronephrosis
Percutaneous nephrostomy – inserting a tube through the skin and kidney into the ureter, under radiological guidance
Antegrade ureteric stent – inserting a stent through the kidney into the ureter, under radiological guidance
Risk factors of prostate cancer
Symptoms
Increasing age Family history Black African or Caribbean origin Tall stature Anabolic steroids
Symptoms: LUTS Haematuria Erectile dysfunction Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)
Options for prostate biopsy
Transrectal ultrasound-guided biopsy (TRUS)
Transperineal biopsy
Histological grading system for prostate cancer
Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy
A Gleason score of:
6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk
Treatment options for prostate cancer
Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy ( implanting radioactive metal “seeds” into the prostate)
Hormone therapy
Surgery - Radical prostatectomy
Hormone therapy options for prostate cancer
Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)
Ddx of scrotal lump
Hydrocele Varicocele Epididymal cyst Testicular cancer Epididymo-orchitis Inguinal hernia Testicular torsion
Causes of hydrocele
idiopathic, with no apparent cause, or secondary to:
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
Causes of varicocele
Swollen pampiniform plexus due to:
Obstruction in left testicular vein (e.g. by RCC)
Incompetent valves in testicular vein
Complications of varicoceles
impaired fertility
testicular atrophy
Typical presentation of varicoceles
Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility
Examination findings are:
A scrotal mass that feels like a “bag of worms”
- More prominent on standing
- Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
Investigations for varicoceles
Ultrasound with Doppler imaging can be used to confirm the diagnosis
Semen analysis if there are concerns about fertility
Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
Epididymal cyst
- Presentation
Soft, round lump Typically at the top of the testicle Associated with the epididymis Separate from the testicle May be able to transilluminate large cysts (appearing separate from the testicle)
3 main types of testicular cancers
Seminoma
Non-seminomas (mostly teratomas)
Leydig cell tumor (gynaecomastia)
Investigations for testicular cancer
Scrotal ultrasound
Tumour markers for testicular cancer are:
Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)
Beta-hCG – may be raised in both teratomas and seminomas
staging CT scan - Royal Marsden Staging system (extent of metastasis)
Management of testicular cancer
Surgery to remove the affected testicle (radical orchidectomy) with prosthesis
Chemo and radiotherapy
Sperm banking
Lower UTI presentation
Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Frequency Urgency Incontinence Haematuria Cloudy or foul smelling urine
Pyelonephritis symptoms
Fever
Loin/back pain
Nausea/vomiting
Renal angle tenderness on examination
Investigation for UTI
Dipstick: nitrites, leukocyte esterase, RBC
MSU for culture and sensitivity testing
Typical pathogens causing UTI
E.coli***
Klebsiella pneumoniae (gram-negative anaerobic rod)
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans (fungal)
Antibiotics for lower UTI
Trimethoprim (often associated with high rates of bacterial resistance)
Nitrofurantoin (avoided in patients with an eGFR <45)
Pivmecillinam
Amoxicillin
Cefalexin
Interstitial cystitis
- Presentation
- Investigation
typical presentation is more than 6 weeks of:
- Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
- Frequency of urination
- Urgency of urination
IX:
- Hunner lesions and granulations (tiny bleeds) seen during cystoscopy
- Urinalysis for urinary tract infections
- Swabs for sexually transmitted infections
- Cystoscopy for bladder cancer
Prostate examination for prostatitis, hypertrophy or cancer
Bladder cancer
- Major risk factors
- Histological types
- Presentation
Risk factors:
- Aromatic amines in dye and rubber and cigarettes
- Schistosomiasis
Histological types:
Transitional cell carcinoma (90%)
Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma
Painless haematuria
Investigation for bladder cancer
Cystoscopy under GA or LA
TNM staging with CT
Treatment options for bladder cancer
Transurethral resection of bladder tumour (TURBT) Intravesical chemotherapy (chemotherapy given into the bladder through a catheter)
Intravesical Bacillus Calmette-Guérin (BCG) (BCG vaccine into bladder to stimulate immune attack of cancer)
Radical cystectomy with ileal conduit*** or Ureterosigmoidostomy (ureters connect to sigmoid colon)
5 types of kidney stones
Calcium oxalate (more common)
Calcium phosphate
Uric acid – these are not visible on x-ray
Struvite – produced by bacteria, therefore, associated with infection
Cystine – associated with cystinuria, an autosomal recessive disease
Renal stone presentation
Unilateral loin to groin pain that can be excruciating (“worse than childbirth”)
Colicky (fluctuating in severity) as the stone moves and settles
Haematuria
Nausea or vomiting
Reduced urine output
Symptoms of sepsis, if infection is present
Investigation for renal stones
Urine dipstick for exclusion of haematuria and infection
Blood test: serum calcium
Abdominal X-ray
Non-contrast CT KUB
Ultrasound KUB
Cause of calcium renal stones and associated symptoms
Calcium supplements
Hyperparathyroidism
Cancer: Myeloma, breast or lung cancer with PTHrP
Management of renal stones
NSAID: Intramusclular diclofenac
Antiemetics
Antibiotics
Tamsulosin - spontaneous passage
Extracorporeal shock wave lithotripsy (ESWL)
Ureteroscopy and laser lithotripsy
Percutaneous nephrolithotomy (PCNL) under GA
Lifestyle modifications for calcium and uric acid renal stones
calcium stones – reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
uric acid stones – reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
Increase oral fluid intake (2.5 – 3 litres per day)
Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
Reduce dietary salt intake (less than 6g per day)
Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)
Risk factors for RCC
Smoking Obesity Hypertension End-stage renal failure Von Hippel-Lindau Disease Tuberous sclerosis
Presentation of RCC
classic triad of presentation is haematuria, flank pain and a palpable mass
Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
Paraneoplastic syndrome associated with RCC
Polycythaemia – due to secretion of unregulated erythropoietin
Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
Surgical options for RCC
Partial nephrectomy (removing part of the kidney) Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)
- Arterial embolisation
- Percutaneous cryotherapy
- Radiofrequency ablation
Immunosuppressants for kidney transplant
life-long immunosuppression to reduce the risk of transplant rejection. The usual regime is:
Tacrolimus
Mycophenolate
Prednisolone
Or Cyclosporine
Sirolimus
Azathioprine
Complications of immunosuppressants for kidney transplant
- Immunosuppressants often cause seborrhoeic warts and skin cancers (look for scars from skin cancer removal)
- Tacrolimus causes a tremor
- Cyclosporine causes gum hypertrophy
- Steroids cause features of Cushing’s syndrome
General: Ischaemic heart disease Type 2 diabetes (steroids) Infections Non-Hodgkin lymphoma Skin cancer (particularly squamous cell carcinoma)
