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Y3 Renal and Uro > Testicular cancer - Varicocoele > Flashcards

Testicular cancer - Varicocoele Flashcards

1
Q

RF of testicular cancer (7)

A
  • Maldescended Testes
  • Ectopic Testes
  • Atrophic Testes
  • Family history/past medical history of testicular cancer
  • HIV
  • White Ethnicity
  • Inguinal Hernia
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2
Q

Types of testicular cancers (4)

A

o Seminomas - 50%
o Non-seminomatous germ-cell tumours and teratomas - 30%
o RARE: gonadal stromal tumours (Sertoli and Leydig cell tumours) and non-Hodgkin’s lymphoma

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3
Q

Age of onset of testicular cancers

A

18-35 yrs

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4
Q

S/s of testicular cancer (6 and 3 due to metastases)

A
  • Swelling or discomfort of the testes
  • Bone Pain (skeletal metastasis)
  • Lumbar Back Pain (involvement of Psoas Muscles and Nerve roots)
  • Shortness of breath (lung metastases)
  • Haemoptysis (lung metastases)
  • Painless, hard testicular mass (may be a secondary hydrocele)
  • Lymphadenopathy (e.g. supraclavicular, para-aortic)
  • Gynaecomastia (tumour produces hCG)
  • Lower extremity swelling (venous occlusion)
  • Signs of hyperthyroidism
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5
Q

Ix for testicular cancer

A 
•	Bloods
o	FBC
o	U&Es
o	LFTs 
o	Tumour Markers
•	a-fetoprotein
•	b-hCG
•	LDH
•	Urine Pregnancy Test - will be positive if the tumour produces b-hCG
•	CXR - show lung metastases 
•	Testicular Ultrasound
o	Allows visualisation of the tumour 
o	Can see associated hydrocoele 
•	CT Abdomen and Thorax - allows staging
o	Staging System: Royal Marsden Hospital Staging
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6
Q

Differentials of testicular cancer (4)

A
  1. Testicular Torsion
  2. Scrotal Hernia
  3. Hydrocele
  4. Epididymal Cyst
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7
Q

Define testicular torsion and what it results in

A

A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of the vascular supply and time-sensitive ischaemia and/or necrosis of testicular tissue. Twisting or torsion of the spermatic cord results, initially, in venous outflow obstruction from the testicle, progressing to arterial occlusion and testicular infarction if not corrected.

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8
Q

RF of testicular torsion (2)

A

o Imperfectly descended testes

o High investment of the tunica vaginalis

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9
Q

Epidemiology of testicular torsion

A
  • Most common cause of acute scrotal pain in 10-18 yr olds

* Most commonly occurs in 11-30 year olds

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10
Q

Explain the 2 types of testicular torsion

A

• Intravaginal (MOST COMMON)
o The spermatic cord twists within the tunica vaginalis
• Extravaginal (usually in neonates)
o The entire testis and tunica vaginalis twist in a vertical axis on the spermatic cord
o Due to incomplete fixation of the gubernaculum to the scrotal wall allowing free rotation

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11
Q

S/s of testicular torsion

A

• Swollen, erythematous scrotum on the affected side – tender, hot and swollen
• Swollen testicle will lie slightly higher than the unaffected one
• Testicle might lie horizontal
• Thickened cord
• Testicular Appendix
o There may be a visible necrotic lesion on transillumination

  • Sudden-onset severe hemiscrotal pain – in one testis
  • Makes walking uncomfortable
  • Abdominal pain
  • Nausea and vomiting
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12
Q

Ix for testicular torsion

A

Doppler/Duplex Imaging of the Testes
• Do NOT delay surgery
• Arterial inflow REDUCED in testicular torsion and INCREASED in epididymo-orchitis

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13
Q

How to differentiate between epididymo-orchitis and torsion

A

Via Doppler/duplex imaging

• Arterial inflow REDUCED in testicular torsion and INCREASED in epididymo-orchitis

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14
Q

DDx of testicular torsion

A

o Epididymo-orchitis – tends to affect older, more gradual onset
o Incarcerated inguinal hernia

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15
Q

Mx for testicular torsion

A

• Exploration of the scrotum within 6 hrs of onset of symptoms – if performed in <6h, salvage rate is 90-100%. If >24h, it is 0-10%.
• After the testicle is twisted back into place, a bilateral orchidopexy is performed
This involves suturing both the testicles to the scrotal tissue to prevent recurrence
• If the testicle is necrotic, orchidectomy may be performed (surgical removal of one or both testes)

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16
Q

Complications of testicular torsion (4)

A
  • Testicular infarction
  • Testicular atrophy
  • Infection
  • Impaired fertility (due to production of anti-sperm antibodies)
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17
Q

Prognosis of testicular torsion

A

• From the onset of torsion, a testicle may only survive 4-6 hrs. With prompt surgical intervention, most testicles are salvaged

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18
Q

Where do urinary calculi typically deposit

A

Can be anywhere from renal pelvis to urethra but typically:
Renal pelviureteric junction
Pelvic brim where the ureter crosses over the iliac vessels
Vesicoureteric junction

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19
Q

Types of urinary tract calculi (5)

A 
o	Calcium oxalate - MOST COMMON
o	Struvite - quite common
o	Urate - 5% 
o	Hydroxyapatite (5%)
o	Cysteine - 2%
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20
Q

Causes of urinary tract calculi (6 metabolic, 1 infectious, 4 drugs, 3 urinary tract abnormalities. 2 foreign bodies)

A 
•	Many cases are IDIOPATHIC
•	Metabolic Causes
o	Hypercalciuria
o	Hyperuricaemia 
o	Hypercystinuria
o	Hyperoxaluria
o	Hyperparathyroidism 
o	Renal tubular acidosis 
•	Infection
o	Hyperuricaemia
o	Recurrent UTIs 
•	Drugs
o	Indinavir 
o	Diuretics
o	Antacids
o	Corticosteroids 
•	Urinary tract abnormalities
o	Pelviureteric junction obstruction
o	Hydronephrosis 
o	Ureteral stricture
•	Foreign bodies
o	Stents
o	Catheters
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21
Q

Which types of stone are found in acidic urine (2)

A

Cystine and Uric acid stones

22
Q

Which types of stone are found in alkaline urine (3)

A

calcium oxalate, calcium phosphate and Struvite stones

23
Q

RF of urinary tract calculi (10)

A

High Protein and/or salt intake, male, dehydration, obesity, crystalluria, occupational exposure to dehydration, warm climate, family history, precipitant drugs (i.e. antacids)

24
Q

What drugs cause urinary tract calculi (4)

A

o Indinavir
o Diuretics
o Antacids
o Corticosteroids

25
Q

Epidemiology of urinary tract calculi

A
  • COMMON
  • 2-3% of general population
  • 3 x more common in MALES
  • Age group affected: 20-50 yrs
  • Bladder stones more common in developing countries
  • Upper urinary tract stones more common in industrialised countries
26
Q

S/s of urinary tract calculi

A
  • Often ASYMPTOMATIC
  • SEVERE loin to groin pain – renal colic
  • Nausea and vomiting
  • Unable to lie still
  • Urinary urgency, frequency or retention
  • Haematuria
  • Loin to lower abdominal tenderness – usually no tenderness on palpation
27
Q

Which renal stones are frequently associated with fever

A

Struvite

28
Q

Ix for urinary tract calculi (13)

A 
Bloods
•	FBC: high WCC if infection
•	U&amp;Es: check renal function
o	Calcium: if elevated, may suggest hyperparathyroidism
o	Urate: if elevated, may suggest gout
•	Other: TFTs, Albumin, PTH, Vitamin D

Urinalysis
• Dipstick: haematuria (COMMON), leucocytes, nitrates
• MC&S: WBCs, RBCs or bacteria
• 24-hour collection: creatinine clearance, calcium, phosphate, oxalate and urate

X-Ray KUB
• Calcium Oxalate stones are radio-Opaque
• Cystine Stones are semi-Opaque
• Urate Stones are radio-lucent (white)
• NOTE: Pregnancy Test to EXCLUDE ECTOPIC prior to ionising radiation

OTHER:
• Intravenous Urography (IVU): Allows visualisation of the kidneys and ureters
• Ultrasound: May show hydronephrosis and hydroureter
• Non-enhanced Spiral CT: Can also be used to image stones
• Isotope Radiography: Used to assess kidney function

29
Q

Main differential to consider in older men presenting with s/s consistent of urinary tract calculi

A

Leaking AAA

30
Q

DDx of urinary tract calculi

A
  1. Acute Appendicitis
  2. Ectopic Pregnancy
  3. Ovarian cysts
  4. Acute Pancreatitis
  5. Diverticular Disease
31
Q

Mx of acute presentation of renal tract calculi (6)

A

• ACUTE PRESENTATION
o Analgesia – diclofenac 75mg IV/IM or 100mg PR (IN OSCE SAY PR DICLOFENAC). If contraindicated: opioids
o Bed rest
o Fluid replacement – IV if unable to withstand PO
o Urine collection to try and retrieve any stone that has passed
o An obstructed, infected kidney is an EMERGENCY and should be treated as soon as possible to relieve the obstruction (e.g. by placing a percutaneous nephrostomy)
o Antibiotics – cefuroxime or gentamicin IV

32
Q

Removal of chronic renal tract calculi (5)

A

o Stones <5mm in lower ureter: 95% pass spontaneously with increased fluid intake. For stones >5mm OR if pain not resolving:
o Medical expulsive therapy – nifedipine (CCB) or alpha blockers (tamsulosin) promote expulsion and reduce analgesia requirements
If this does not work within 48h, try ESWL ( Extracorporeal Shock-Wave Lithotripsy) or urethroscopy
- Percutaneous Nephrolithotomy (PCNL): for large, complex stones

33
Q

Complications of renal stones (3) ureteroscopu (2) lithotripsy (2)

A 
•	Of Stones
o	Infection (PYELONEPHRITIS)
o	Septicaemia 
o	Urinary retention 
•	Of Ureteroscopy
o	Perforation
o	False passage 
•	Of Lithotripsy
o	Pain
o	Haematuria
34
Q

Prognosis of urinary tract calculi

A
  • GOOD
  • However, infection of the calculus could lead to irreversible renal scarring
  • Recurrence of about 50% over 5 yrs
35
Q

Define UTI (differentiate upper and lower)

A
  • The presence of a pure growth of > 105 organisms per mL of fresh MSU
  • Lower UTI: affecting the urethra (urethritis), bladder (cystitis) or prostate (prostatitis)
  • Upper UTI: affecting the renal pelvis (pyelonephritis)

• NOTE: the laboratory classification mentioned above isn’t a complete necessity for the diagnosis of UTI - 1/3 women with symptoms of UTI will have negative MSU (abacterial cystitis)

36
Q

Causative organisms of a UTI (at least 3)

A
  • MOST UTIs are caused by Escherichia coli
  • Other causative organisms: Staphylococcus saprophyticus, Proteus mirabilis, Enterococci
  • Atypical organisms that can cause UTI (usually in immunocompromised individuals):
    o Klebsiella
    o Candida albicans
    o Pseudomonas aeruginosa
37
Q

RF of a UTI (7

A
  • Female
  • Sexual intercourse
  • Exposure to spermicide
  • Pregnancy - usually asymptomatic until serious pyelonephritis or premature delivery supervenes so must do routine dipstick
  • Menopause
  • Immunosuppression
  • Catheterisation
  • Urinary tract obstruction or malformation
38
Q

Epidemiology of UTI

A
  • VERY COMMON
  • 1-3% of GP consultations
  • The majority of women will have a UTI in their lifetime
  • MUCH more common in FEMALES
39
Q

S/s of UTI (5 general signs, cystitis 5, prostates 4, acute pyelonephritis 5)

A
  • Fever
  • Abdominal or loin tenderness
  • Foul-smelling urine
  • Distended bladder (occasionally)
  • Enlarged prostate (if prostatitis)
•	Cystitis
o	Frequency 
o	Urgency
o	Dysuria
o	Haematuria
o	Suprapubic pain 
•	Prostatitis
o	Flu-like symptoms 
o	Low backache
o	Few urinary symptoms 
o	Swollen or tender prostate on PR 
•	Acute Pyelonephritis
o	High fever 
o	Rigors 
o	Vomiting 
o	Loin pain and tenderness 
o	Oliguria (if AKI)
40
Q

Ix for UTI (9)

A

• Urine dipstick (FIRST LINE) – positive leucocyte esterase and nitrites – treat empirically whilst waiting for MSU (GOLD STANDARD)
• If dipstick –ve but patient symptomatic, send MSU for lab MC&S.
• Always send MSU for lab MC&S for male, child, pregnant, immunosuppressed or ill.
• Urine Microscopy
o Presence of leucocytes indicates infection
• Urine Culture
o To exclude diagnosis or if the patient failed to respond to empirical antibiotics
o A pure growth of >10^5 organisms/mL is diagnostic
• Some may have sterile pyuria – treat if symptomatic
• Ultrasound
o Rule out obstruction
o If fail to respond to treatment
• Bloods
o FBC
o U&Es - check renal function
o CRP
o Blood cultures - if systemically unwell and risk of urosepsis

41
Q

DDx for UTI

A
  1. Over-active bladder
  2. Urothelial carcinoma of the bladder
  3. Non-infectious urethritis
  4. Benign prostatic hyperplasia (men)
  5. Prostatitis (men)
42
Q

Mx for UTI (2 first line Abx 2 second line, and prophylactic use indication)

A

• Empirical treatment of uncomplicated presumed E. Coli lower UTI in otherwise healthy women: TRIMETHOPRIM or NITROFURANTOIN
o Treat for 3-6 days
o NOTE: men with UTI may need a longer course of antibiotics
• Alternative Treatments: Co-amoxiclav or Cefalexin
• Prophylactic antibiotics may be used in certain circumstances (e.g. recurrent cystitis associated with sexual intercourse)
• In non-pregnant women with upper UTI, take urine culture and treat with co-amoxiclav IV then oral when afebrile for 7 day course.

43
Q

Complications of UTIs (5)

A 
•	Ascending infection can lead to:
o	Pyelonephritis 
o	Perinephric and intrarenal abscess 
o	Hydronephrosis or pyonephrosis 
o	AKI
o	Sepsis 
•	Prostatic involvement (e.g. prostatitis) in men with UTIs is common
44
Q

Prognosis of UTI

A

• GOOD prognosis with appropriate treatment

45
Q

Define varicocoele

A

A varicocele is the abnormal dilation of the internal spermatic veins and pampiniform plexus that drain blood from the testis.

46
Q

Which side is a varicocele more common and why (3)

A

More common on the LEFT (80-90%) because of:

  • Increased hydrostatic pressure due to the angle at which the left testicular vein meets the left renal vein
  • Incompetent valves between the left testicular vein and left renal vein
  • Increased reflux from
47
Q

Why do varicoceles occur

A

Venous incompetence

48
Q

Epidemiology of varicocele

A
  • Incidence increases after puberty
  • 10% of Varicoceles are bilateral
  • Occurs in 25% of adolescent boys and adult men
49
Q

RF of varicocele (2)

A
  • Somatometric Parameters (Taller and heavier, low BMI)

- Family history of varicocele

50
Q

S/s of varicocele

A 
•	Usually ASYMPATOMATIC
o	Only 2-10% have symptoms 
•	Scrotum feels like a bag of worms
•	Scrotal heaviness 
•	Incidental finding at examination 
•	Often visible as distended scrotal blood vessels
•	May feel dull ache
  • Patient must be STANDING for examination
  • The side of the scrotum with the varicocoele will hang lower
  • The swelling may reduce when lying down
  • Valsalva manouevre whilst standing will increase dilatation
  • Cough impulse
51
Q

Ix for varicocele

A
  • Sperm count - done as part of fertility investigation

* Colour Doppler scan

Y3 Renal and Uro (3 decks)

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