Surgery - Urology Flashcards
Describe acute urinary retention and its presentation
SUDDEN inability to pass urine
complete obstruction lower abdominal pain medical emergency palpable bladder (dull to percuss) BPH on DRE May see phimosis on external genitalia examination suprapubic tenderness
Describe chronic urinary retention and its presentation
PERSISTENT inability to completely empty the bladder
there is increased post-void residual volume insidious onset partial obstruction painless Associated LUTS usually painless ?lower abdominal pass UTIs associated +/- renal failure
Describe complications of acute urinary retention
infection
AKI
post-retention haematuria
Describe complications of chronic urinary retention
hydronephrosis
CKD
bladder detrusor hypertrophy
acute on chronic retention
What are the causes of urinary retention?
POMN!
Post-op (iatrogenic)
Obstructive - BPH, constipation, stones, strictures, phimosis, infection
Medications (TCA’s opioids, antihistamines)
Myogenic (increased alcohol/anaesthesia)
Neurological - DM, stroke, GB syndrome, cauda equine syndrome
What are the investigations for urinary retention?
urine - dipstick and microscopy, culture and sensitivity
Bloods - FBC, U&E, PSA (can be falsely + in AUR)
renal USS
bladder USS
urinary catheterisation
CT (?tumour)
voiding cystourethrogram
How is acute urinary retention managed?
conservative:
- analgesia
- privacy, running water…
- walking/movement
catheter:
- urethral/suprapubic
- antibiotic cover
drugs:
alpha-1-receptor blocker (relax the internal urethral sphincter) e.g. doxazocin, tamsulosin
How is chronic urinary retention managed?
catheterise treat the cause e.g. TURP nephrostomy ureteric stent catheter (urethral/suprapubic) antibiotics 5-a-reductase inhibitors (finasteride)
Describe the risk factors for UTI development
infancy
increased bacterial inoculation (sex, constipation, incontinence)
anatomy (females)
reduced urine flow (incomplete bladder emptying)
increased bacterial growth (DM)
Describe how an upper UTI may present
upper = pyelonephritis (kidneys)
- systemic symptoms (fever, rigors)…
Describe how a lower UTI may present
lower causes = cystitis, prostatitis, orchitis, epididymitis
Present with LUTS but no systemic symptoms
What is urosepsis?
life threatening UTI
high WCC, RR, HR and temperature
What organisms commonly cause UTI’s?
E.coli
Klebsiella pneumoniae
Proteus mirablis
Enterococcus faecalis
Describe LUTS and possible systemic urinary symptoms (which you would get in an UPPER UTI)
increased frequency
dysuria
urgency
polyuria
systemic = rigors, chills, fever, flank pain
What antibiotics are used to treat an upper UTI?
IV amox and gent
What antibiotics are used to treat a lower UTI?
trimethoprim
nitrofurantoin
What are the investigations of a UTI?
Bloods - FBC, U&E, CRP, ?BM, blood cultures
Urinalysis - microscopy and culture and sensitivuty
dipstick - + nitrates and + leukocytes
Imaging - USS (cyst/drainage issues?), micturating urethrogram
What are complications of recurrent UTIs
in children, may be underlying structural abnormalities
Risk of scarring/CKD
What is the definition of haematuria?
presence of blood in the urine
>3RBC/HPF in 2 successive samples
What are the causes of true haematuria?
Glomerular (kidney)
- infarct, trauma, stones, infection, cancer, GN, IgA nephropathy, polycystic kidney
Ureter
- stones, tumour
Bladder
-infection, stones, tumour, exercise
Prostate
- BPH, prostatitis, tumour
Urethra
- infection, stones, trauma, tumour
INFECTION IS THE MOST COMMON CAUSE!
What are the causes of false haematuria?
beetroot
rifampicin
PV bleed
porphyuria
What S/Sx may present with haematuria?
LUTS Blood might be frank or microscopic 'clots' suggest extra-glomerular source infective/inflammatory signs: - frequency - dysuria - urgency - discharge
How is haematuria investigated?
Bloods - FBC, U&E, clotting Urine culture - exclude infection Urine dipstick - MC&S, cytology PR exam Imaging... -> renal USS for upper tracts flexible cystoscopy +/-biopsy for lower tracts
How are large bleeds (haematuria) managed?
Fluids Catheterise All bloods (FBC, U&E, G&S, clotting) Transfusions? Start Abx?
Describe testicular cancer types and their presentation
commonest male malignancy
5X>in caucasians than black ethnicity
excellent prognosis
3 types:
1) Germ cell = 80%
- seminoma = normal AFP/b-HCG, men 25-30 (older)
- teratoma = raised AFP/b-HCG, men 20-35yrs
2) Stromal cell = 10%
- leydig
- sertoli
3) Other e.g. lymphoma =10%
What are the risk factors for testicular cancer?
un/maldescended testes (cryptorchidism) atrophic testes previous testicular cancer infertility HIV infant hernia
What are the S/Sx of testicular cancer?
painless testicular mass (firm, irregular, does not transilluminate) para-aortic lymphadenopathy B symptoms haematospermia secondary hydrocoele gynaeomastia (with leydig cell tumours)
What are the differentials for a testicular lump?
hydrocoele scrotal hernia testicular torsion spermatocoele benign cyst
How is a testicular lump investigated
scrotal US tumour markers (AFP, b-HCG, LDH) CT (staging) consider sperm storage regular self-examination advised
What is the management of testicular cancer?
cryopreserve sperm if both testes abnormal
surgical -> radical orchidectomy
para-aortic node RTx
retroperitoneal LN dissection
Describe bladder cancer and its types
2nd most common uro malignancy 3M:1F average age 73yrs Types: 90% transitional cell (MIBC/NMIBC) - can affect any part of urinary system 5% squamous 2% adenocarcinoma
What are the risk factors for bladder cancer
male occupation smoker chronic inflammation (stones/infection) drugs (cyclophosphamide) race pelvic irradiation
What are the S/Sx for bladder cancer?
80% = painless frank haematuria 20% dipstick + haematuria LUTS recurrent UTIs retention obstructive renal failure anorexia confusion lower limb swelling ?abdo/DRE mass
What are the differentials for bladder cancer?
BPH haemorrgahic cystitis nephrolithiasis RCC UTI
How is bladder cancer investigated?
CT urethrogram
CT-KUB
USS renal tract
cystoscopy + cytology -> allows TNM staging
How is bladder cancer managed?
Surgery = TURBT, cystectomy... Chemotherapy = intravesicle mitomycin RTx Immunotherapy (BCG = bacille calmette guerin)
What are the complications of bladder cancer?
Bladder haemorrhage
Sexual/urinary malfunction after cystectomy
Describe prostate cancer and its risk factors
commonest urological malignancy
in 80% of 80yr old men (most die with it than of it)
> in black ethnicity
RFX: age, family history
What zone of the prostate does prostate cancer most commonly affect?
And what is the most common type of prostate cancer?
peripheral zone
adenocarcinoma is the most common
What are the S/Sx of prostate cancer?
often asymptomatic raised PSA LUTS ureteric obstruction (if advanced) if metastatic: -> bone pain, PSA, renal failure
How is prostate cancer investigated?
TRIAD: DRE, PSA, TRUS biopsy
Bloods: FBC, PSA, U&E, LFT, calcium
Imaging: MRI, CXR/spinal XR (?mets), TRUS (+ biopsy), isotope bone scan
How is prostate cancer staged?
Gleason score (2 x TRUS biopsies, each gets a score out of 5, then added together and the higher the total score the worse the prognosis)
What is the management of prostate cancer
- Conservative (close monitoring, watch and wait)
- Radical therapy (prostatectomy)
- Surgery (prostatectomy, robot assisted laparoscopic radical prostatectomy = RALRP)
- Medical (androgen deprivation therapy) = LHRH antag/agonists, radiotherapy (external beam or brachytherapy)
What is PSA and what can cause it to be raised?
A proteolytic enzyme (a glycoprotein) used to liquefy ejaculate half life is 2-3 days Screening is NOT recommended as can be raised with: - age - PR exam - sex - TURP - prostatitis
What are the causes of testicular torsion?
Can be primary but normally secondary to exertion/minor trauma
Due to an anatomical variant of testicular anatomy (tunica vaginalis invests the whole testes rather than having a bare area, this is called a ‘bell clapper’ testicle)
Means the testes can twist on its mesentery
How is testicular torsion treated (and what are the important timings?)
SURGERY - try to untwist but consent for possible orchidectomy
4-6hr salvageable window
Carry out orchidopexy on the opposite testes
IV access
Bloods (FBC, U&E, G&S, clotting)
What are the risk factors for renal stones?
male 20-40yrs caucasian dehydrated hypercalcaemia tea, chocolate, strawberries (high in oxalate) UTI gout diuretics (furosemide, thiazide)
What are the three causative factors of renal stones
1) Infection (proteus mirablis -> has urease enzyme and increases formation of struvite stones e.g. Ca/Mg/NH3 components)
2) Abnormal urine (high oxalate, low citrate, dehydration)
3) Urinary obstruction (congenital (PUJ) or acquired obstructions (e.g. strictures))
What are the 5 types of renal stones?
CatSlidUptheColourfulXylophone
Calcium stones (e.g. calcium oxalate, calcium phosphate) -increased risk in Crohn's disease
Struvite stones (ass. with proteus mirablis infection) - triple stones: Ca/Mg/NH3 components
Uric acid/urate stones (common in gout, radiolucent)
Cysteine stones (associated with Fanconi syndrome)
Xanthine stones (radiolucent)
What are the S/Sx of renal stones?
colicky pain, loin -> groin associated N&V patient CANNOT LIE STILL LUTS UTI haematuria fever pyuria urinalysis ?anuria
What are the three common sites where stones can become stuck?
PUJ
pelvic brim
VUJ
What are the differentials of renal stones?
UTI gynae pathology pyelonephritis lower lobe pneumonia acute abdomen testicular torsion radicular pain (shingles, sciatica)
What investigations would you carry out for renal stones?
Hx and Ex
Urine -> dipstick, MC&S, pH (alkaline - infection stone, acidic = uric acid stone), B-HCG!!!
Bloods -> FBC, U&E, CRP, Ca, PO4, urate
Imaging: CT-KUB, X-ray, USS (?hydronephrosis), IV urogram, functional scans (DMSA)
What is the normal diameter of the ureter?
5-7mm
What is the management of renal stones?
Analgesia (diclofenac, morphine) Fluids and Abx 1) Conservative and leave to pass 2) Medical expulsive therapy: - nifedipine (relaxes smooth muscle) - tamsulosin (alpha 1 blocker) 3) temporary relief - nephrostomy - stents 4) active stone removal - ESWL - ureteroscopy +/- laser, pneumatics, electrohydraulics - cystoscopy - PNL (percutaneous nephrolithotomy) - open/lap (nephrolithotomy, ureterolithotomy, cystolithotomy)
How can renal stones be prevented?
hydration
treat UTIs rapidly
low oxalate (less strawbs, chocolate and tea)
urine alkalisation (sodium bicarbonate)
thuazide diuretics (for idiopathic hypercalcaemia)
What is BPH and its two components?
BPH = LUTS caused by bladder outlet obstruction due to BPH
2 components:
- static: increased mass of benign prostatic tissue which narrows urethral lumen
- increased prostatic smooth muscle tone (due to stimulation of a-adrenergic receptors)
Pathophysiology: testes, prostate and seminal vesicles make 5-a-reductase which converts testosterone -> DHT (DHT is more potent and induces growth of prostate)
What zone of the prostate does BPH most commonly involve?
transitional zone
What are the signs/symptoms of BPH
Storage symptoms: nocturia, frequency, urgency, overflow incontinence
Voiding symptoms: hesitancy, straining, poor flow, strangulatory (urinary tenesmus)
2o to urinary stasis: UTI, bladder stones
What are the differentials for BPH?
Prostate cancer prostatitis UTI Overactive bladder Bladder cancer Neurogenic bladder Urethral stricture
What investigations should be carried out for BPH?
Bloods: PSA, U&E Urine: dipstick, MC&S Imaging: TRUS and biopsy Urodynamics -> pressure flow cytometry Voiding diary
What is the management of BPH?
Conservative: less caffeine and alcohol, bladder training, double voiding
Medical: useful for mild disease when awaiting TURP
- alpha-blocker (tamsulosin)
- finasteride (5-a-reductase inhibitor) = takes 6/12 to work
Surgical: TURP, laser prostatectomy, open prostatectomy
What are complications of TURP?
bleeding infection retrograde ejaculation ED incontinence urethral stricture BPH recurrence
Define erectile dysfunction
inability to achieve/maintain an erection which is satisfactory for sexual intercourse
Describe causes of erectile dysfunction:
Drugs - antihypertensives, alcohol, recreational drugs
Psychological - anxiety, depression
Vascular - hypercholesterolaemia, atheroma, DM
Penile - cavernositis, previous priapism, peyronies disease
Endocrine - hyperthyroid, DM, hypogonadism…
Neurological - parkinson’s, spinal injury autonomic neuropathies
How is erectile dysfunction investigated?
Questionnaires -> international index of erectile dysfunction BP glucose lipids serum electrolytes hormones TFTs
Describe renal cell carcinoma and the two main types
Any cancer affecting the kidneys
Due to imaging advances, the number of cancers being diagnosed incidentally is increasing!
1) renal cell carcinoma = 80% (5 subtypes)
2) transitional cell carcinoma = 20%
What are the S/Sx of renal cancer?
Usually asymptomatic and picked up on imaging!
- haematuria
- palpable abdominal mass
- flank pain
What is the link between varicocoeles and renal cancer?
Often a renal cancer can cause gonadal vein compression and so anyone presenting with varicocoele gets a kidney scan
Where do the L and R renal veins drain into?
L gonadal vein -> L renal vein
R gonadal vein -> straight into IVC
How is renal cancer investigated?
Bloods: FBC, LDH, U&E, a+, LFT
Urine: dipstick and MCS
Examination: abdo mass/lymphadenopathy/varicocoele/lower limb oedema
Imaging: pelvic USS, CT/MTI, bone scan, biopsy, PET scan
Flexible cystoscopy
How is renal cancer treated?
Medical - temsirolismus (mTOR inhibitor)
Surgery - radical nephrectomy, partial nephrectomy, nephron-sparing surgery
Chemo/immunotherapy (usually very angiogenic so respond well to VEGF inhibitors)
Palliative if mets
What is the definition of prostatitis/orchitis/epididymo-orchitis?
Epididymitis = inflammation of the epididymis, causing pain and swelling (usually unilateral, develops over a few days and lasts ~6 weeks)
Orchiditis = inflammation of the testes
Acute epididymo-orchiditis = inflammation of both (most commonly used term!)
What is the cause of epididymo-orchiditis and its pathophysiology
Usually BACTERIAL
Younger men = chlamydia, gonorrhoea
Older men = enteric pathogens e.g. E.coli
Retrograde ascent of pathogens from urethra/bladder via ejaculatory ducts and vans deferens which colonise the epididymis leading to infection
What are the risk factors for epididymo-orchiditis
Sex (STDs)
Anal intercourse (enteric organism infection)
UTIs
Bladder outlet obstruction
What are the S/Sx of epididymo-orchiditis
Urethral discharge Fever LUTs Unilateral scrotal swelling and pain Tenderness Hot, erythematous, swollen hemiscrotum
What are the differentials of epididymo-orchiditis
Torsion scrotal oedema infected hydrocoele strangulated inguinal hernia testicular tumour
How is epididymo-orchiditis investigated?
Urethral swab urine dipstick urine microscopy urine culture and sensitivity NAAT test of urethral discharge (for chlamydia/gonorrhoea)
How is epididymo-orchiditis treated?
Supportive measures
Antibiotics
What are the causes of urethral strictures?
Trauma (surgery, instruments)
Infection (STIs)
Chemotehrapy
Balantitis xerotica obliterans
What are the complications of urethral strictures
voiding difficulties: hesitancy, strangury, poor stream, terminal dribbling, pis en deux (need to pee immediately after peeing)
What is the treatment of urethral strictures?
Internal urethrotomy (surgery to remove a narrowed section of the urethra)
Stent
Dilatation
What is the definition of a hernia and what are its contents?
protrusion of viscus beyond the coverings of the viscus in which it is contained
Contents: sac, covering and contents
Name 5 types of hernia
Which one is most likely to strangulate?
epigastric incisional umbilical inguinal (direct and indirect) femoral -> more likely to strangulate as borders are 70% none
What is the pathophysiology of a hernia?
Increased intra-abdominal pressure (exercise, coughing, straining, sneezing)
+
weakened abdominal wall (older age, malnutrition, muscle/nerve paralysis)
How are hernias investigated?
Examination -> reducible?, N&V (obstructed?), severe pain (strangulated?)
Hernigram (CT + contrast)
USS (used with scrotal lumps to exclude hydrocoeles)
What is the difference between an incarcerated and strangulated hernia>
Incarcerated - a hernia that is irreducible but not strangulated
- The lumen of the hernia has become obstructed but the blood supply is intact
- Can cause bowel obstruction
Strangulation - the blood supply to the hernia contents are cut off
- Tissue undergoes ischaemic necrosis
- Perforation and septic shock can result
What are the 9 layers of the abdominal wall?
skin subcut fat fascia -> campers and scarpas external oblique internal oblique
