Urogenital Flashcards
what scrotal masses can you not get above
inguinoscrotal hernia or hydrocele extending proximally
Separate and cystic scrotal mass
epididymal cyst
separate and solid scrotal mass
epididymitis/ varicocele
testicular and cystic scrotal mass
hydrocele
5 testicular and solid masses
tumour, haematocele, granuloma, orchitis, gumma.
epididymal cyst
Benign cyst lesion of the epididymis.
pathology of epididymal cyst
Possibly due to obstruction of the epididymis.
2 clinical maifestations of epididymal cysts
Usually presents as a small paratesticular swelling which may be tender
Grossly appears as a thin-walled, translucent cystic lesion
management of epididymal cyst
Remove if symptomatic
hydrocele
An abnormal accumulation of fluid in the space between the two layers of the tunica vaginalis.
2 causes of hydocele
Usually caused by trauma (primary), or
A reaction to an underlying pathology such as epididymitis, orchitis or a tumour (secondary cause)
clinical manifestation of hydrocele
Scrotal swelling
3 management options for hydrocele
Can resolve spontaneously
Aspiration
Surgery: placating the tunica vaginalis/ inverting the sac
varicocele
A persistent abnormal dilation of the pampiniform venous plexus in the spermatic cord.
4 clinical manifestations of varicocele
Usually presents with nodularity on the lateral side of the scrotum
Some cause a dull ache, especially after prolonged standing or towards the end of the day
May contribute to male subfertility, as the increased flow raises the scrotal temperature and impairs spermatogenesis
Often visible as distended scrotal blood vessels.
management of varicocele
Surgery to remove if symptomatic
If left untreated can lead to infertility
what is Adenomatoid tumour
The most common benign paratesticular neoplasm.
possible locations for adenomatiod tumour
Can occur in epididymis, spermatic cord, and tunica albuginea
appearance of Adenomatoid tumour
Grossly, they are small solid, firm, grey/ white tumours which are usually <3cm
6 causes of UT obstruction
Urinary stones
Urothelial tumours
Extrinsic compression by abdominal/ pelvic masses
Prostatic hyperplasia
Urinary tract malformations
Strictures
3 common clinical manifestations of UT obstruction
Symptoms directly suggestive of obstruction (e.g. ureteric colic)
Impaired renal function
Recurrent UTIs
specific symptoms of Acute upper tract obstruction
Loin pain radiating to the groin. There may be superimposed infection, loin tenderness, enlarged kidney.
specific symptoms of chronic upper tract obstruction
Flank pain, renal failure, superimposed infection.
specific manifestations of Acute lower tract obstruction
Acute urinary retention, severe suprapubic pain, acute confusion.
specific manifestations of Chronic lower tract obstruction
Urinary frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence
4 investigations for UT obstructions
Blood: U&E, creatinine, FBC and prostate-specific antigen
Urine: dipstick and MC&S
Ultrasound: hydronephrosis (swelling of the kidney due to a build-up of urine) or hydroureter = CT scan
CT scan: determines level of obstruction
treatment of Upper tract obstruction
nephrostomy or ureteric stent.
treatment of lower tract obstruction
urethral or suprapubic catheter.
complications of UT obstructions
Obstruction increases the risk of infection, stone formation, and renal damage
classification of haematuria
Visible: previously known as macroscopic, frank
Non-visible: found on dipstick/ microscopy, previously known as microscopic.
4 causes of haematuria
Malignancy (kidney, ureter, bladder)
Calculi
IgA nephropathy
Polycystic kidney disease
what causes a false haematuria positive
myoglobin triggers same dipstick reaction
investigations into cause of haematuria
Undergo urological assessment, imaging, and cystoscopy to exclude renal tract malignancy and calculi.
symptoms of testicular torsion
Sudden onset of pain in one testis, which makes walking uncomfortable
Pain in the abdomen, nausea, and vomiting are common
signs of testicular torsion
Inflammation of one testis – very tender, hot and swollen.
Testis may lie high and transversely
differential diagnoses for testicular torsion
The main one is epididymo-orchitis, and there will be symptoms of urinary infection, and more gradual onset of pain.
investigations for testicular torsion
Doppler US may demonstrate lack of blood flow to testis.
Do not delay surgical exploration
management of testicular torsion
Ask consent for possible orchidectomy + bilateral fixation
At surgery expose and untwist the testis
Benign prostatic hyperplasia
Enlargement of the prostate gland due to an increase in cell number.
pathology of Benign prostatic hyperplasia
Androgens are critical in the development of BPH, more specifically increased levels of dihydrotestosterone locally in the prostate.
Current evidence suggests that increased oestrogen levels in blood induce androgen receptors in prostate tissue and stimulate hyperplasia
6 symptoms of Benign prostatic hyperplasia
Frequency
Urgency
Nocturia
Hesitancy
Poor flow
Terminal dribbling
4 differential diagnoses for BPH
Overactive bladder
Prostatitis
Prostate cancer
UTI
4 investigations for BPH
GS+ FL= digital rectal exam
PSA test
Frequency chart
Urine dipstick
lifestyle changes for BPH
Avoid caffeine, alcohol, to reduce urgency.
Void twice in a row to aid emptying
drugs for BPH
useful in mild disease, and while awaiting surgery
α-blockers are 1st line e.g. Tamsulosin
surgery for BPH
Transurethral resection of prostate
Transurethral incision of the prostate
Retropubic prostatectomy
4 complications of BPH
Urinary retention
Recurrent UTIs
Bladder stones
Obstructive nephropathy
renal carcinoma
A malignant epithelial tumour arising in the kidney.
5 symptoms of renal carcinoma
Loin pain
Abdominal mass
Anorexia
Malaise
Weight loss
how are renal carcinoma cases usually picked up
About half of all cases present with painless haematuria
Most of the remained is picked up incidentally on imaging
A small proportion presents with metastatic disease
investigations for renal carcinoma
FL=
Abdominal/pelvis ultrasound, bloods: raised RBC, raised calcium, raised LDH
GS=
CT chest/abdo/pelvis
management of renal carcinoma
Radical nephrectomy.
Cryotherapy and radiofrequency ablation is an option for patients unfit or willing to undergo surgery
what is Nephroblastoma
AKA Wilm’s tumour
A malignant childhood renal neoplasm
presentation and prognosis of nephroblastoma
Presents with abdominal mass and haematuria
Most tumours are of low stage with an excellent prognosis with treatment
what are urothelial carcinomas
A group of urothelial neoplasms arising in the urothelial tract.
clinical manifestations of bladder cancer
Haematuria – painless
LUTS
Recurrent UTIs
Voiding irritability
4 investigations for bladder cancer
FL=
urinalysis for microscopy and culture (haematuria), bladder USS
GS=
Flexible cystoscopy and biopsy
management of T1 bladder cancer
Diathermy via transurethral cystoscopy/ transurethral resection of bladder tumour
management of T2-3 bladder cancer
Radical cystectomy is the gold standard.
Radiotherapy gives worse survival rates than surgery but preserves the bladder.
management for T4 bladder cancer
Palliative chemo/radiotherapy.
Chronic catheterisation and urinary diversions may help to relieve pain
pathology of prostate cancer
Arise from a precursor lesion known as prostatic intraepithelial neoplasia, characterised by neoplastic transformation of the epithelium lining of the prostatic ducts and acini.
Harbour mutations in a number of genes.
3 clinical manifestations of prostate cancer
The vast majority of prostate cancers are asymptomatic.
LUTS may be present
Patients may present with symptoms of metastatic disease
differential diagnoses for prostate cancer
Benign prostatic hyperplasia
Prostatitis
investigations for prostate cancer
FL= Prostate exam and digital rectal exam (firm, hard, asymmetrical, rough), prostate specific antigen (raised), multiparametric MRI
GS=
Transrectal USS and biopsy
4 management options for prostate cancer
Prostatectomy
Radiotherapy
Analgesia
Treat hypercalcaemia
seminoma
germ cell tumour of the testicle.
teratoma
non-germ cell tumour of the testicle.
5 clinical manifestations of testicular tumours
Typically, painless testis lump, found after trauma/infection
Secondary hydrocele
Pain
Dyspnoea
Abdominal mass
3 differential diagnoses for testicular tumours
Hydrocele
Abdominal hernias
Orchitis
investigations for testicular tumours
GS= urgent doppler USS of testes
FL= α-FP and β-hcg and lactacte dehydrogenase raised tumour markers
urgent doppler USS of testes
staging of testicular tumours
1 – no evidence of metastasis
2 – infradiaphragmatic node involvement
3 – supradiaphragmatic node involvement
4 – lung involvement (haematogenous)
management of testicular tumours
Radical orchidectomy
Seminomas are exquisitely radiosensitive
Chemotherapy - teratoma
Radiotherapy - seminoma
what is urolithiasis
The formation of stony concretions in the bladder or urinary tract.
pathology of urolithiasis
Calculi form that cause symptoms by blocking and abrasing structures. Renal stones consist of crystal aggregates, stones form in collecting ducts and may be deposited anywhere from the renal pelvis to the urethra.
3 classical narrowings where UT calculi are found
Pelviureteric junction, pelvic brim, vesicoureteric junction.
6 risk factors for urolithiasis
High protein/ high salt intake
Male, white
Obesity
Dehydration
Medications – antacids, carbonic anhydrase inhibitor
Crystal urea
what can UT calculi be formed from
Calcium oxalate/ calcium phosphate
Magnesium ammonium phosphate
Uric acid
Struvite – common in chronic UTI
Cystine stones
what are urinary calculi
crystal aggregates which form in the renal collecting ducts but may become deposited anywhere in the urinary tract.
anatomical factors causing urinary calculi
Congenital (horseshoe, duplex, PUJO spina bifida)
Acquired (obstruction, trauma, reflux)
urinary factors causing U calculi
Metastable urine, promoters and inhibitors
Calcium, oxalate, urate, cystine
Dehydration
traditional triad of presentations for U calculi
fever, vomiting, flank pain
behaviour of large U calculi
Large stones tend to remain confined to the kidney – asymptomatic or recurrent UTIs
behaviour of smaller U calculi
Smaller stones may pass into the ureter and become impacted, causing ureteric colic
what is hydronephrosis
a combination of obstruction and dilation of renal pelvis that often causes lasting damage to the kidney
typical pain of U calculi
spasms of renal colic ‘loin to groin’, with nausea/ vomiting
pain for Obstruction of the kidney
felt in the loin
pain for obsruction of mid-ureter
may mimic appendicitis
pain for Obstruction lower ureter
may lead to symptoms of bladder irritability and pain in scrotum, penile tip or labia majora
pain for obstuction in bladder or urethra
causes pelvic pain, dysuria
3 possible presentations in the urine of a patient with U caliculi
Haematuria
Proteinuria
Sterile pyuria
5 investigations for U caliculi
GS= CT – helps exclude differential causes
FL= Urine dipstick: haematuria, leukocytes, nitrates. FBC, CRP (infection), U&Es (hypercalcaemia). Abdominal x-ray (will show calcium stones but not uric acid stones as they are radiolucent)
management of acute urolithiasis
NSAIDs for pain, antiemetics for vomiting and nausea
Allow stones to pass spontaneously (<5mm)
IV fluids
surgical intervention
what is percutaneous nephrostomy
catheter placed through the skin and into the kidney to drain urine directly from the kidney
surgical intervention for stone in the ureter
Ureteric stent insertion – stent passed through bladder through ureter into kidney, bypassing the blockage and draining the urine into the bladder
surgical intervention for stone in the kidney
percutaneous nephrolithotomy – remove the stone from the kidney by a small puncture wound in the skin
what is extracorporeal shock wave lithotripsy
uses shock waves to break down stones that form in the kidneys to unable easy passage of these fragments out of the body within urine
6 prevention methods against urolithiasis
Overhydration
Low salt diet
Normal dairy intake
Healthy protein intake
Reduce BMI
Active lifestyles
cause of UTIs
Caused by the presence and multiplication of microorganisms in the urinary tract.
clinical syndromes of lower tract UTIs
Cystitis
Prostatitis
Epididymitis/ orchitis
Urethritis
clinical syndrome of upper tract UTIs
pyelonephritis
3 classifications for UTIs
Asymptomatic bacteriuria
Uncomplicated (normal renal tract structure and function)
Complicated (structural/ functional abnormality of genitourinary tract e.g. obstruction
main causitive organism for UTIs
Escherichia coli
transmission of UTIs
Ascending spread of endogenous gut bacteria into the urethra
The shorter urethra of women and its closer proximity to the anus are thought to be the main reason why females are more susceptible.
5 risk factors for UTIs
Bacterial inoculation: sexual activity, urinary incontinence, faecal incontinence
Binding of uropathogenic bacteria: spermicide use, menopause
Decreased urine flow: dehydration, obstructed urinary tract
Bacterial growth: diabetes mellitus, immunosuppression, obstruction, stones, catheter, pregnancy
Female
presentations of UTIs caused by bladder infection
frequency, urgency, dysuria, haematuria and suprapubic pain
presentation of UTIs caused by acute pyelonephritis
acute pyelonephritis (Ascending spread into the kidneys)
causes a more severe illness with fever, rigors, vomiting and loin pain
investigations for UTIs
Urinalysis showing leucocytes or nitrites is a useful quick screening test
Look for blood, protein, pH, ketones, glucose, leucocytes, nitrates
Microscopy: WBCs, RBCs, casts (can be indicative of infection), bacteria
Microbiological culture is gold standard
Should be a midstream urine specimen
A pure growth of >105 organisms/mL of urine is diagnostic
management of uncomplicated UTIs
treat empirically with antibiotics 3 days
management of non-pregnant women with UTIs
If 3+ symptoms of cystitis and no vaginal discharge, treat empirically with 3-day course of antibiotics
If first-line empirical treatment fails, culture urine and treat according to antibiotic sensitivity
management of men with UTIs
Treat lower UTI with a 7-day course of antibiotics
If symptoms suggest prostatitis, consider a course of ciprofloxacin due to ability to penetrate prostatic fluid.
management of complicated UTIs
Longer antibiotic course required – 7 days
treatment of pregnant women with UTIs
Asymptomatic bacteriuria should be confirmed on a second sample. Treat with antibiotics.
Prostatitis
Inflammation/ swelling of the prostate gland.
pathology of prostatitis
ascending infection from the urinary tract, haematogenous spread.
5 clinical presentations of prostatitis
Pain: perineum, rectum, scrotum, penis, bladder, lower back.
Fever
Malaise
Nausea
Urinary symptoms
treatment of acute prostatitis
Start antibiotic treatment immediately for 28 days
Treat the pain
treatment of chronic prostatitis
Pain relief
Stool softener
Antibiotics 4-6 weeks
cystitis
Inflammation of the bladder caused by a bladder infection.
6 symptoms of Cystitis
Frequency
Dysuria
Urgency
Suprapubic pain
Polyuria
Haematuria
what is pyelonenephritis
Infection of the renal parenchyma and soft tissues of renal pelvis/ upper ureter
symptoms of pyelonephritis
Loin pain
Fever
Pyuria (pus in the urine)
Vomiting
Associated cystitis symptoms
Septic shock
investigations for pyelonephritis
FL=Urine dipstick (leucocytes, nitrites, maybe haematuria), FBC (raised WCC, CRP)
GS= Mid-stream urine microscopy and cultures (confirm UTI and identify pathogen)
4 treatment options for pyelonephritis
Fluid replacement – increased losses
Broad spectrum IV antibiotics e.g. c-amoxiclav
Drain obstructed kidney
Analgesia
pathology of urethritis
predominantly sexually transmitted
Gonococcal vs non gonococcal (gonorrhoea)
Chlamydia trachomatis
Requires sexual health referral
presentation of urethritis
painful/difficult urination
treatment of urethritis
Dependent on what has caused it
Ceftriaxone – gonorrhoea
Oflaxacin - bacteria
Doxycycline – chlamydia
what is Epididymo-orchitis
Inflammation of the epididymis +/- testes.
4 causes of Epididymo-orchitis
Chlamydia
E.coli
Mumps
N. gonorrhoea
pathology of Epididymo-orchitis
sexually transmitted pathogens ascending from the urethra or non-sexually transmitted uropathogens spreading from the urinary tract.
signs and symptoms of Epididymo-orchitis
Sudden-onset tender swelling, dysuria, sweats/ fever.
UTI symptoms
Unilateral swelling and tenderness of epididymis +/- testes
Urethral discharge
4 treatment points for Epididymo-orchitis
Doxycycline
If gonorrhoea is suspected, doxycycline and ceftriaxone.
Analgesia, scrotal support, drainage of any abscess
Sexual abstinence and contact tracing
male symptoms of STIs
Urethral discharge, dysuria, genital skin problems, testicular pain/ swelling, peri-anal or anal symptoms.
female symptoms of STIs
unusual vaginal discharge, vulval skin problems, abdominal pain, unusual vaginal bleeding.
exposure factors of STIs
Sexual contacts within last 3 months incl. sex of partners, type of contact (oral/vaginal/anal), contraceptive method, type and duration of relationship, symptoms in partner.
male STI examination
retract foreskin, inspect urethral meatus for discharge, scrotal contents/tenderness/swelling.
female examination for STIs
vulval examination, speculum of vagina/ cervix, bimanual examination for adnexal tenderness
presentation of HSV
flu-like prodrome, vesicles/papules around genitals, anus, throat. These burst, forming painful shallow ulcers. Urethral discharge, dysuria, urinary retention, proctitis.
Investigation for HSV
PCR.
treatment of HSV
analgesia, topical lidocaine.
primary presentation of syphilis
Primary chancre – genital skin, nipples, mouth
Incubation 9-90 days, usually 21-35 days
Dusky macule – papule – indurated clean based non-tender ulcer
secondary presentation of syphilis
Onset after infection
May present with skin rash
Other manifestations e.g. mucous membrane lesions, generalised lymphadenopathy, alopecia, hoarseness, bone pain, hepatitis
investigations for syphilis
Antibody testing for T. pallidum: dark field microscopy, serum treponema assay/agglutination, or PCR
treatment of syphilis
Penicillin by injection
Efficient follow up and partner notification essential
male presentation of chlamydia and gonorrhoea
Asymptomatic
Dysuria
Urethral discharge
female presentation of chlamydia and gonorhoea
Asymptomatic
Discharge
Menstrual irregularity
Dysuria
investigations for chlamydia
GS= Nucleic acid amplification tests (NAAT)
High specificity and sensitivity
Negative test does not mean not infected
Male – first void urine
Female;
Self-collected vaginal swab
Endocervical swab
chlamydia treatment
Partner management
Azithromycin or doxycycline for 7 days
community screening for chlamydia
Asymptomatic carriage of chlamydia for a number of years is well described
Community screening aims to reduce complications by reducing the prevalence of asymptomatic infection
patient test for gonorrhoea
Microscopy of gram stained smears of genital secretions look for gram negative diplococci within cytoplasm
Male urethra
Female endocervix
Rectum
Culture on selective medium to confirm diagnosis
investigations for gonorrhoea
Patient test
Sensitivity testing
NAAT
treatment for gonorrhoea
Partner notification
Continuous surveillance of antibiotic sensitivity
Single dose treatment preferred
Ceftriaxone with azithromycin
