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u r o l o g y Flashcards

1
Q

what is haematuria

A

presence of blood in urine

weither visible or non-visible (confirmed by urine dip or urine microscopy)

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2
Q

what is haematuria classified into

A

visible haematuria

non-visible haematuria = symptomatic vs asymptomatic

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3
Q

what are the causes pf pseudohaematuria, what is it

A

red or brown urine not sedentary to presence of haemoglobin

caused by meds like rfampcin, methyldopa

hyperbilirubinaemia, myogloburia, certain food - beetroot or rhubarb

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4
Q

what are some urological causes of haematuria

A

Infection, including pyelonephritis, cystitis, or prostatitis

Malignancy, including urothelial carcinoma or prostate adenocarcinoma

Renal calculi

Trauma or recent surgery

Radiation cystitis

Parasitic, most commonly schistosomiasis

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5
Q

in what cases do patients required urgent referral to adult urological service

A

Aged ≥45yrs with either:

Unexplained visible haematuria without urinary tract infection

OR Visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged 60yrs with have unexplained non‑visible haematuria and either dysuria or a raised white cell count on a blood test.

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6
Q

what modalities of imaging are used in urology

A

flexible cytoscopy = lower utinarry tract

US KUB = non visible haematuria

CT urogram used in cases of visible haematuria = higher radiation exposure

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7
Q

what is urinary retention and what is divided into

A

inability to pass urine

acute vs chronic

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8
Q

what is acute urinary retention

A

Acute urinary retention is defined as a new onset inability to pass urine*,

which subsequently leads to pain and discomfort, with significant residual volumes.

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9
Q

what is acute on chronic urinary retention

A

patients with chronic retention can also enter acute retention, either as an acute deterioration of the underlying pathology causing their chronic retention

or a new aetiology superimposed on a background of chronic retention.

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10
Q

how do patients with acute on chronic retention present, what risk do they carry

A

minimal discomfort, despite very large residual volumes.

treated as per acute retention management.

may have much higher residual volumes than other acute retention patients, therefore more at risk to post-obstructive diuresis.

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11
Q

what are the causes of acute urinary retention

A
  1. BPH is commonest cause
  2. urethral structures
  3. prostate cancer
  4. UTI
  5. constipation
  6. severe pain
  7. medications
  8. neurological causes
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12
Q

how does a UTI cause urinary retention

A

urethral sphincter to close, especially in those with already narrowed outflow tracts (e.g. BPH)

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13
Q

how can constipation cause urinary retention

A

through compression on the urethra

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14
Q

which types of medication can cause urinary retention acutely, how do they do this

A

anti-muscarinics or spinal or epidural anaesthesia, can affect innervation to the bladder, resulting in acute retention.

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15
Q

what are some neuro cause of acute urinary retention

A

peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, upper motor neurone disease (such as Multiple Sclerosis Parkinson’s disease)

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16
Q

what are the clinical features of acute urinary retention

A

acute suprapubic pain and an inability to micturate

palpable distended bladder with suprapubic tenderness

fever, rigors = infective cause

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17
Q

apart from abdominal examination, which other examination should you perform in acute urinary retention, why

A

Ensure to perform a PR examination,

especially in elderly patients, to assess for any prostate enlargement or constipation.

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18
Q

what Lx are required in acute urinary retention

A

post void bedside bladder scan = volume of retained urine to confirm dx

routine bloods - FBC, CRP, UE

send post catheterisation specimen of urine = assess for presence of infection

pts with features of high-pressure retentionwill require an ultrasound scan of their urinary tract to assess for the presence of associated hydronephrosis

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19
Q

what is chronic urinary retention, what are the two forms of chronic urinary retention

A

Chronic urinary retention is characterised by being painless and insidious.

High pressure retention
impaired renal function and bilateral hydronephrosis
typically due to bladder outflow obstruction

Low pressure retention
normal renal function and no hydronephrosis

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20
Q

what is decompression haeamturia and when is it seen

A

occurs commonly after catheterisation for chronic retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment

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21
Q

in low pressure retention why is the upper renal tract unaffected

A

due competent urethral valves or reduced detrusor muscle contractility / complete detrusor failure.

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22
Q

in high pressure retention why is upper renal tract affected

A

high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract leading to hydroureter and hydronephrosis, impairing the kidneys’ clearance levels.

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23
Q

what is the treatment of urinary retention

A

immediate urethral catheterisation
ensure to measure volume drained post catheterisation

treat underlying cause = BPH tamsulosin

check CSU for infection and treat w abx

review meds if contributing

pt with large retention volume 1L or more monitor for post catheterisation for evidence of post obstructive diuresis

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24
Q

what is post obstructive diuresis, what are the complications

A

Following resolution of the retention through catheterisation, the kidneys can often over-diurese

can lead to worsening AKI

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25
why do kidneys diuresis post urinary retention resolution
due to the loss of their medullary concentration gradient, which can take time to re-equilibrate.
26
how is post obstructive diuresis managed
patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI.
27
further management of acute urinary retention, high pressure retention, why?
high pressure retention = catheter in situ until definitive management due to risk of further episodes of urinary retention leading to AKI and renal scarring and CKD if no evidence of renal impairment TWOC 24-28hrs after insertion. if TWOC fails after 2 further attempts = long catheter catheter until treat underlying cause
28
what are the complications of acute urinary retention
AKI which could lead to CKD if multiple episides of retention leading to renal scarring increased risk of UTI and renal stones due to urinary stasis
29
how is urinary retention diagnosed
bladder ultrasound should be performed. A volume of >300 cc confirms the diagnosis
30
in women what can cause chronic urine retention
pelvic prolapse (such as cystocele, rectocele, or uterine prolapse) or pelvic masses (such as large fibroids)
30
in women what can cause chronic urine retention
pelvic prolapse (such as cystocele, rectocele, or uterine prolapse) or pelvic masses (such as large fibroids)
31
what are the clinical features of chronic urinary retention
painless urinary retention associated voiding LUTS = weak stream, hesitance overflow incontinence =
32
what is overflow incontinence, when is it worse
the intra-vesical pressures rise greater than those of the urinary sphincter. T his is typically worse at night (nocturnal enuresis), when the sphincter tone is reduced
33
what is Intemittent self catheterisation, what are the pt requirements
used in patients with chronic retention, however for those who wish to avoid a long-term catheter Patients are taught how to catheterise themselves at regular intervals (e.g. every 4-6hrs), however requires good manual dexterity and patient compliance, therefore is not suited for all patients.
34
what is pyelonephritis | describe the pathophysiology
infection of renal parenchyma, ascended from lower urinary tract via blood or via lymphatics usually bacterial
35
what are the common organisms in pyelonephritis
e.coli staph aureus - catheter pseudomonas - catheter
36
what are the risk factors associated with pyelonephritis
1. obstruction of urinary tract e.g BPH 2. colonisation of Bacteria - renal stones 3. female tract which is shorter 4. immunocompromised =T2DM
37
how does pyelonephritis present
fever loin pain usually unilateral nausea and vomiting over 24-48hrs may have sx of pre existing UTI
38
ddx for pyelonephritis
AAA ruptured | renal calculi, acute cholecystitis, ectopic pregnancy, PID
39
what Lx are required in pyelonephritis
urine dip and MCS urine bHcg FBC, CRP, UE USS KUB if obstruction suspected CT KUB non contrast
40
how is pyelonephritis managed
A-E approach and resus | empirical abx, IV fluids
41
what are the complications associated with pyelonephritis
``` chronic pyelonephritis severe sepsis multi organ failure renal scarring leading to CKD pyonephritis perinephric abscess ```
42
what is urinary incontinence and what are the different types
involuntary leakage of urine ``` stress urgency overflow mixed continous ```
43
describe the lx required in urinary incontinence
post void bladder scans = esp in suspected overflow UI midurine dipstick - infection or haematuria urodynamics to assess intravesicualr and intra abdominal pressures = hyperactivity of bladder muscle may suggest UL
44
describe the management of incontinence
general = weight loss, reduce caffeine intake, smoking cessation, avoiding excessive fluid intake each day esp before bed conservative = pelvic floor muscle training for at least 3 months for urgent = anti muscranic drugs = oxybutynin or tolterodine which inhibit bladder contraction surgery = botox A injections for urge and tension free vaginal tape in stress UI
45
what is stress UI
urine leakage occurring when the intra-abdominal pressure exceeds the urethral pressure, such as coughing, straining, laughing, or lifting. The impaired urethral support is most often due to weakness of the pelvic floor muscle.
46
risk factors of stress UI
post partum constipation due to recurrent straining obesity pelvic surgery - TURP leading to external sphincter damage
47
what is urger UI
overactive bladder - detrusor hyperactivity which leads to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.
48
cause of urge UI
infection, malignancy | meds = cholinesterase inhibitors
49
what is mixed UI
stress UI and urge UI
50
what is overflow UI
compilation of chronic urinary retention progressive stretching of bladder was = damages efferent fibres of the sacral reflx and loss of bladder sensation most common in BPH
51
what is continuous UI
constant leakage of urine pt always wet due to anatomical abnormality or bladder fistulae or due to overflow incontinence
52
in urinary incontience what should you examine for
BPH prolapse fistula opening ask pt to keep bladder diaries = help to find precipitating factors
53
what are the causes of ED
psychological = anxiety, stress HTN, hypercholesteremia hormone deficient = testosterone side effect of meds
54
management of ED
CBT manage underlying cause = stop causative problems, manage HTN or cholesterol viagra - sildenafil PDE inhibitor
55
how does sildenafil
blocking phosphodiesterase 5 (PDE5), an enzyme that promotes breakdown of cGMP, which regulates blood flow in the penis. It requires sexual arousal, however, to work. It also results in dilation of the blood vessels in the lungs.
56
what are the potential causes of LUTS
``` BPH UTI Bladder cancer prostate cancer pelvic floor dysfunction urethral stricture ```
57
what lifestyle factors can exacerbate LUTS
drinking fluids late at night excess alcohol intake excess caffeine intake
58
how are LUTS classified
storage vs voiding sx
59
describe storage sx
increase urinary frequency nocturia increased sense of urgency to urinate urge incontinence
60
describe sx for voiding
hesitancy or straining in micturition poor floor post micturition or terminal dribble feeling of incomplete emptying
61
features to ask about in history in pt with LUTS
associated symptoms, such as visible haematuria, suprapubic discomfort, or colicky pain, and their medication history, as certain medication, including anticholinergics, antihistamines and bronchodilators, are known to exacerbate LUTS
62
what tool would you use to assess LUTS impact on life in men
initially and though out treatment course IPSS = international prostate symptom score
63
what examinations would be useful in pt with LUTS
DRE examination of external genitalia abdominal examination
64
what initial investigations would necessary in LUTS
post void bladder scan and flow rate = help distinguish causes bladder diary = highlight behavioural patterns which may be contributing to sx urinalysis + urine culture routine bloods = FBC, U+E PSA may be useful in some conditions
65
what specialist Lx can be used in LUTS
urodynamics = assess flow rate, detrusor pressure and storage capacity - neurogenic bladder also for women with OAB or stress urinary incontincen being conducer for invasive treatment options cystoscopy = gold stands for assess the LUT upper urinary tract - CT or USS
66
describe the conservative management of LUTS
regulating fluid intake - times and volumes and reduce caffeinated and alcoholic beverages in evenings voiding sx = urethral milking techniques = manually emptying bulbar urrethra of residual urine or double voiding pelvic floor exercises = stress and post micturition dribble bladder training technique in overactive bladder
67
describe the pharmacological management of LUTS
anticholinergics = oxybutynin = for overactive bladder - relax bladder muscle by opposing parasympathetic cholinergic control of contraction alpha blockers - tamsulosin and 5-reductase inhibitors - finasteride for BPH to reduce prostate size by relaxing prostate muscle loop diuretics - furosemide, bumetanide - prevent nocturia
68
what are the complications of LUTS
increased risk of infection formation of renal and bladder calculi due to stagnation of urine renal failure and bilateral hydronephrosis acute urinary retention
69
ddx for scrotal pain
testicular torsion, epididymitis
70
what are the features to ask about in pt presenting with scrotal pain
onset, course, and duration of pain, any associated urinary symptoms, relevant sexual history, and history of previous surgery.
71
what is the cremasteric reflex
cremasteric reflex is elicited by stroking the proximal and medial aspect of thigh; a normal response is contraction of the cremaster muscle causing retraction of testes upwards on the ipsilateral side Absence of the cremasteric reflex is a potential sign for testicular torsion
72
what is Prehn's sign
alleviation of scrotal pain by lifting of the testicle and is suggestive of the diagnosis of acute epididymitis
73
lx required in scrotal pain
urrine dipstick/ urinalysis urine for MCS urethral swab if STI suspected bloods - FBC, UE, CRP doppler USS of scrotum
74
blood tests for testicular cancer
AFP LDH bets hCG
75
what is a hydrocele
abnormal collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis enveloping the testis
76
how do hydrocele present
painless fluctuating swelling transilluminates uni or bilateral
77
what are the causes of hydroceles
primary/ idiopathic trauma, infection, malignancy if 20-40yrs with hydrocele whorls under go urgent USS
78
what is a varicocole
abnormal dilatation of pampiniform venous plexus within the spermatic cord
79
how does a varicocele present
bag of worms with a dragging sensation may disappear on lying flat
80
which side are varicoceles typically on
left side as spermatic veins drain directly into L renal vein compared to IVC on right
81
varicoceles can cause
infertility, testicularr atrophy by increasing intra scrotal temperature
82
red flag signs with a varicoceles include
acute onset right sided remain when lying flat
83
what is the surgical management of varicocole
embolisation by international radiologist surgery = can be open or laparoscopic for ligation of spermatic veins
84
what are epidydmal cysts
benign fluid filled scars arising from epididymis
85
how do epidydimal cysts present
smooth fluctuant nodule found above and separate from the testis transilluminate often multiple common in middle ages men no treatment required unless painful and large = prevent infertility
86
what are the causes of epididymitis and treatment
bacterial origin - STI in sexually active younger males or enteric organisms in older males treat with oral abx and analgesia
87
what is testicular torsion, how does it present
twisting of testis on spermatic cord leading to ischaemia severe unilateral scrotal pain, N+V, loss of cremasteric reflex
88
management of testicular torsion
surgical emergency = for scrotal exploration and fixation of both testes prevent irreversible damage
89
ddx for benign testicular lesions
lipomas fibromas leydig cell tumours
90
what is orchitis and how is managed
inflammation of the testis. It is rare in isolation*, with the main cause being the mumps virus, which often is preceded with a history of parotid swelling. Treatment is typically rest and analgesia.
91
BPH, PROSTATE Ca, prostatitis, phimosis, paraphimosis
92
what is BPH
enlargement of the prostate gland which is most often due to benign prostatic hyperplasia (BPH). BPH is a histological diagnosis and is characterised by non-cancerous hyperplasia of the glandular-epithelial and stromal tissue of the prostate leading to an increase in its size.
93
what are the risk factors associated with BPH
increasing age, fhx,obesity, african or caribbean ethncity
94
pathophysiology behind BPH
the prostate converts testosterone to dihydrotestosterone (DHT) using the enzyme 5α-reductase. DHT is more potent and accounts for 90% of androgen in the tissue
95
cwhat are the clinical features of BPH
lower urinary tract symptoms (LUTS), often predominantly voiding symptoms (hesitancy, weak stream, terminal dribbling, or incomplete emptying), accompanied by storage symptoms (urinary frequency, nocturia, nocturnal enuresis, or urge incontinence). Other less common symptoms can include haematuria and haematospermia
96
IN BPH DRE what features are seen
A firm, smooth, symmetrical prostate is a reassuring sign (a more rounded prostate of greater than two finger widths may indicate enlargement)
97
what assessment score is used in BPH
ipsss | Scores of 0-7 are mild, 8-19 moderate and 20+ severe.
98
ddx for BPH
Proaste Ca UTI oab bcc
99
Lx in BPH
urinary frequency and volume chart post void bladder scan PSA in men 50 or older or 40 in black USS KUB = hydronephrosis urodynamics if dx not certain
100
Lx in BPH
urinary frequency and volume chart post void bladder scan PSA in men 50 or older or 40 in black USS KUB = hydronephrosis urodynamics if dx not certain
101
management of BPH
sx diary = meds review, suitable lifestyle advice meds = a- adrenoreceptorr antagonist - tamsulosin, relax prostate smooth muscle via blocking adrenoreceptors = reducing dynamic component add 5-a reductase inhibitors - finasteride = prevent conversion of testosterone to DHT, reducing prostate volume (can take up to 6 onthd to see sx benefit) surgery = TURP - remove obstructive prostate tissue and increase urethral lumen size
102
complications of turp
TUR syndrome, haemorrhage, sexual dysfunction, retrograde ejaculation, and urethral stricture.
103
BPH complications
high pressure retention UTI haematuria
104
what is paraphimosis
inability to pull forward a retracted foreskin over the glans penis.
105
complication of paraphimosis
may lead to penile ischaemia and worsening infection, including Fournier’s gangrene. Consequently, it is a urological emergency
106
rx for paraphimosis
Phimosis, indwelling urethral catheter (due to non-replaced foreskin), poor hygiene, and prior paraphimosis.
107
management of paraphimosis
reduction - manual pressure analgesia - penile block without adrenaline outpatient circumcision
108
scale used for prostate Ca staging
Gleason grading
109
DRE findings in prostate Ca
evidence of asymmetry, nodularity, or a fixed irregular mass.
110
rx of prostate Ca
age, ethnicity - afro caribbean, fhx of disease, genetic BRCA1 or BRCA 2

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