UROGENITAL Flashcards
What does the upper urinary tract consist of?
Kidneys
Ureters
What does the lower urinary tract consist of?
Bladder
Urinary sphincter
Urethra
Prostate (in men)
What is mictruition?
urination
What are the two phases of mictruition?
Storage/continene phase
Voiding phase
What controls continence?
Continence centres in the brain
What does storage of urine require the bladder to do?
Relaxation of the detrusor muscle and simultaneous contraction of the internal and external urethral sphincters.
What nervous system are the bladder and IUS under the control of?
The sympathetic nervous system
What is the sympathetic pathway to stimulate urinary storage?
Impulses travel from the cerebral cortex to the pons (pontine continence centre)–> Sympathetic nuclei in spinal cord–> detrusor muscle + internal urethral sphincter. (travel from spinal cord via hypogastric nerve T10-L2)
At how many ml does the bladder wall signal the need to void?
400ml
Under what nervous control is mictruition?
Parasympathetic
How does the bladder signal that it is time to void?
The cells sense increased pressure, and send afferent signals up through the spinal cord to the pontine micturition centre and cerebrum.
What triggers voiding?
Voluntary decision to urinate causes neurones of the pontine mictruition centre to fire, exciting the sacral ganglionic neurones and causing stimulation of the pelvic nerve (S2-4), causing the detrusor muscle to contract.
What happens to the urethral sphincters during urination?
Pontine micturition centre inhibits Onuf’s nucleus, reducing sympathetic stimulation to the IUS causing it to relax.
Conscious reduction in voluntary contraction of the EUS allows for distention and the passing of urine.
Overview of voiding?
Parasympathetic nervous system send cholinergic (ACh) signals to cause contractio of the detrusor muscle.
Which spinal nerves are involved in voiding?
S3,S4,S5
Overview of storage?
Sympathetic nervous system sends noradrenergic (noradrenaline) signals, causing urethral contraction and detrusor muscle relaxation.
Which spinal nerves are involved in urine storage?
T10, L1, L2
What is the epithelium of the bladder and what is special about it?
Urothelium:
3-7 cells thick and highly specialised so that it is completely impermeable
What is receptive relaxation?
The ability of the bladder’s pressure to remain low despite increasing volume
What is the guarding reflex?
Voluntary control of micturition
What is the action of the testes?
Site of sperm production and hormone synthesis
What is the action of the epididymis?
Stores sperm
Where are the testes located?
Within the scortum
Where is the epididymis located?
Posterolateral aspect of each testicles
What do the testes contain?
Semineferous tubules
What are the important cells located in the testes and what are their actions?
Sertoli cells–> Produce sperm under the influence of FSH
Leydig cells–> Produce androgen and testosterone under the influence of LH
Where are spermatozoa produced?
In the semineferous tubules.
Where do the developing sperm travel from after leaving the seminiferous tubules of the testes?
The rete testes
Where do sperm travel to after leaving the rete testes?
The epididymis
What does the epididymis turn into?
Vas Deferens
What does the scrotum contain?
Testis
Epididymis
Spermatic cord
What is the prostate and what is its action?
Gland that secretes proteolytic enzymes into the semen, breaking down clotting factors in the ejaculate and allowing it to remain fluid.
What is the action of the bulbourethral glands?
Produce lubricating mucus secretion
What is the function of the seminal vesicles and where are they?
Located between the bladder fundus and rectum, produce 70% of semen volume.
What is the tunica vaginalis?
The pouch of serous membrane that covers the testes
What is obstructive uropathy?
Obstruction of the urinary tract resulting in problems passing urine
How does obstruction of the upper urinary tract (e.g. ureters) present?
Loin to groin/ flank pain on affected side
Reduced urine output
Non-specific symptoms (e.g. vomiting)
Reduced renal function on bloods
How does obstruction of lower urinary tract present?
Acute urinary retention (unable to pass any urine)
Poor flow/ difficulty initiating urination/ dribbling
Reduced renal function on bloods
What are the most common causes of upper urinary tract obstruction?
Kidney stones
Cancer mass pressing on ureters
Ureter strictures (scar tissue narrowing tube)
What are the most common causes of lower urinary tract obstruction?
Benign prostatic hyperplasia
Prostate cancer
Ureter/ urethra strictures
Neurogenic bladder
What is neurogenic bladder?
When there is no neurological signal telling the bladder to contract.
What are the key complications of urinary tract obstruction?
Post-renal AKI–> (Chronic kidney disease)
Infection
Dilated kidneys/ ureters/ bladder
Pain
What is the most common type of kidney tumour?
Renal cell carcinoma
What is the prognosis with renal cell carcinoma?
50% alive at 10 years
What are the common metastases of renal cell carcinoma?
‘cannon ball metastases’ in the lungs
How does renal cell carcinoma present?
Often asymptomatic
Haematuria
Vague loin pain
Non-specific cancer symptoms (weight loss, fatigue, anorexia, night sweats)
What are the different types of renal cell carcinoma?
Clear cell (75-90%)
Papillary (10%)
Chromophobe (5%)
Collecting duct carcinoma (1%)
What are the risk factors for renal cell carcinoma?
Smoking Obesity Hypertension Long-term dialysis Von Hippel-Lindau disease
How is renal cell carcinoma treated?
Surgery–> partial nephrectomy
Radiotherapy/ chemotherapy depending on disease stage
What are paraneoplastic disorders?
Group of rare disorders triggered by an abnormal immune response to a neoplasm
What are the paraneoplastic features of renal cell carcinoma?
Polycythaemia (RCC secretes unregulates erythropoietin)
Hypercalcaemia (RCC secretes a hormone that mimics action of PTH)
Stauffer syndrome
What are the two most common types of bladder cancer?
90% transitional cell carcinoma
10% squamous cell carcinoma
Where does bladder cancer arise from?
The urothelium
What is the typical presentation of bladder cancer?
Painless haematuria
How is bladder cancer diagnosed?
Cystoscopy and biopsy
What are the risk factors associated with bladder cancer?
Smoking
Workplace carcinogens–>Aromatic amines, hydrocaarbons, arsenic, tetrachloroethylene (Found in hair dyes, industrial paint, rubber, motor, leather, rubber workers, blacksmiths e.t.c. )
Schistosomiasis (parasitic worm infection)
How is non muscle-invading bladder cancer treated?
Transurethral resection of bladder tumour (TURBT)
Chemo into bladder after surgery
What is given after the non-invasive bladder tumour is removed and why?
Weekly treatments of BCG vaccine into bladder for 6 weeks, followed by every 6 months for 3 years–> stimulates the bladder to cause the immune system to remove cancer cells
How is muscle-invasive bladder cancer treated?
Radical cystectomy (removal of part/ all of bladder) with ileal conduit (urinary drainage system created) Radiotherapy/ chemotherapy
What is the most common cancer in men?
Prostate cancer
What are the risk factors for prostate cancer?
Increasing age Family history Being balck Tall Use of anabolic steroids
How does prostate cancer present?
- Haematuria
- Erectile dysfunction
- General signs of cancer (weight loss, fatigue, bone pain)
Same lower urinary tract symptoms as in BPH:
- Hesitancy
- Urgency
- Frequency
- Intermittency
- Straining to urinate
- Terminal dribling
- Incomplete emptying
How is prostatic cancer diagnosed?
PSA–> Prostate specific antigen levels
DRE–> Digital rectal exam (finger in rectum to feel for enlarged/ hard, asymmetrical prostate)
Prostate biopsy–> most definitive method
What are the two options when taking a prostate biopsy?
Transrectal ultrasound-guided biopsy–> Ultrasound inserted into rectum and a needle biopsy taken through the rectal wall into prostate (10 samples taken)
Transperinieal–> Around 35 biopsys taken.
What is the grading system specific to prostate cancer?
Gleason score:
1: Well differentiated (look more like normal cells and tend to grow/ spread more slowly)
2: Moderately differentiated
3: Moderately differentiated
4: Poorly differentiated
5: Anaplastic (poorly differentiated–> Cells have lost their specialised features)
What are the management options in prostate cancer?
Watch+ wait Radiotherapy Brachytherapy Hormonal treatment Surgery (total prostatectomy)
What is Brachytherapy?
When radioactive seeds are implanted into the prostate, delivering continuous targeted radiotherapy
What is the aim of hormonal therapy in the treatment of prostate cancer?
Blocking androgens (e.g. testosterone) to slow or stop the cancer growth.
What are the side effects of hormonal treatment (antiandrogen therapy) when treating prostatic cancer?
Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis
What are the complications of radical prostatectomy/ radiotherapy?
Erectile dysfunction
Urinary incontinence
Radiation induced enteropathy
Urethral strictures
What is the prognosis of prostate cancer?
Very slow growing. Most men die with prostate cancer than of it.
What is benign prostate hyperplasia?
Hyperplasia (enlargement) of the stromal and epithelial cells of the prostate
How does BPH present?
- Difficulty starting urination
- Frequency
- Difficulty fully emptying
- Urgency
- Straining
- Terminal dribbling
How is BPH diagnosed?
Urine dipstick (to exclude infection) PSA done to asses for prostate cancer Rectal exam
How is BPH managed?
None/ lifestyle changes if symptoms manageable Medications: - Alpha blockers (relax smooth muscle) - 5-alpha reductase inhibitors (block testosterone and therefore growth) Surgery: - Transurethral resecion of prostate - Transurethral electrovaporisation - Holmium laser enucleation -Open prostatectomy
What lifestyle changes may help in managing BPH symptoms?
Drinking less alcohol
Limit sweeteners
Regular exercise
Drink less in the evening
What is TURP?
Transurethral resection of the prostate–> Removal of prostate tissue via the urethra
What are the main complications of TURP?
FIRES: Failure to resolve symptoms Incontinence Retrograde ejaculation Erectile dysfunction Strictures
How do you differentiate between different causes of testicular/ scrotal lumps?
Ultrasound scan
What are the different causes of a testicular/ scrotal lump?
Testicular cancer Hydrocele Varicocele Epididymal cyst Epididymo-orchitis Inguinal hernia Testicular Torsion
What kind of lump will testicular cancer produce?
Non tender, irregular, hard lump arising from testicle No fluctuance (pus) or transillumination (bright light shined through to see structures)
What age does testicular cancer usually present?
15-40
What is a hydrocele?
Scrotal swelling that occurs when fluid collects in the tunica vaginalis (sac surrounding the testes).
How does can a hydrocele be differentiated (what does it look/ feel like)?
Soft, fluctuant, may be large.
Irreducible
Transilluminated (can shine torch into fluid)
What is a varicocele?
Enlargement of the veins in the scrotum.
What does a varicocele look/ feel like?
Swollen pampinform (convoluted) venous plexues (bag of worms)
What causes varicoceles?
Defective valves in the veins within the scrotum
What is an epididymal cyst?
Sac of fluid at the epididymis (top of testicle)
What does an epididymal cyst look/ feel like?
Soft, fluctuant lump at top of testicle. (may be multiple)
Will transluminate.
What is epididymo-orchitis?
Inflammation of the epididymis and/or testicle, usually due to infection (e.g. UTI, STI)
What does epididymo-orchitis look/ feel like?
Tender, swollen scrotum
What is an inguinal hernia?
When part of the bowel/ tissue pushes through the inguinal canal
How does an inguinal hernia look/ feel?
Soft, reducible bulge
Bowel sounds may be heard
What is testicular torsion?
When the testicle rotates, twisting the spermatic cord that brings blood to the scrotum.
How does testicular torsion present?
Sudden and severe pain, tenderness and swelling (caused by reduced blood flow)
What are the two most common testicular cancers?
Germ cell cancers:
Seminoma (50%)
Teratoma (50%)
What is a seminoma?
Germ cell tumour of the testicle
What is a teratoma?
Rare type of tumour that can contain fully developed tissues and organs e.g. hair, teeth, muscle,
What tumour markers are presents in testicular cancers?
Alpha-fetoprotein
Beta-hCG
Lactase dehydrogenase
What is the prognosis for testicular cancer?
Good (>90%)
How is testicular cancer treated?
Orchidectomy (removal of one/both testicles)
Chemo/ radiotherapy
What is orhcitis?
Inflammation of the teste
What causes Epididymo-orchitis?
Infection: E.coli Chlamydia trachomatis Neisseria gonorrhea Mumps
How does epididymo-orchitis usually present?
Gradual onset over minutes/ hours, usually unilateral Testicular pain/ tenderness Dragging/ heavy sensation Urethral discharge Swelling
How is epididymo-orchitis treated?
Antibiotics
Tight underwear for scrotal support
When does testicular torsion typically occur?
In teenage boys, often triggered by activity (e.g. playing sports)
What is the time window before testicular torsion causes irreversible damage?
6 hours after onset before ischaemia is irreversible.
What is the cremasteric reflex?
When the inner thigh is stroked, the cremaster muscle contracts and pulls up the testicle.
How would you examine for testicular torsion?
Acutely tender testicle
Firm testicle
Absent cremasteric reflex
Abnormal lie –> Testicle is horizontal and elevated
What is the ‘Bell-clapper deformity’?
When the testicle is no longer fixed posteriorly to the tunica vaginalis, allowing it to twist
How is testicular torsion treated?
Immediate surgical scrotal exploration–> untwist and fix into correct position.
(Orchiectomy is necrotic testicle present)
What is pyelonephritis?
Inflammation of the renal pelvis and parenchyma (UPPER UTI)
What are the risk factors for pyelonephritis?
Female
Structural urological abnormalities
Diabetes
What organisms are the most common causes of pyelonephritis?
E.Coli
Klebsiella
Enterococcus
Pseudomonas
How does pyelonephritis present?
High fever, rigors Loin to groin pain Dysuria (painful/ difficult urination) Haematuria Urinary frequency Non-specific symptoms (vomiting) Pain when palpating kdiney
How is Pyelonephritis diagnosed?
Urine dipstick
CT scan
Ultrasound
DMSA scan
What is looked for on a urine dipstick to diagnose pyelonephritis?
Blood
Protein
Leukocyte esterase
Nitrite
How is pyelonephritis managed?
Antibiotics–> Broad spectrum then more specific after blood/ urinary cultures
IV rehydration, analgesia and antipyretics (anti-fever) as required
What can chronic pyelonephritis lead to?
Scarring of renal parenchyma
Chronic kidney disease
Abscess/ pus around kidney
What is cystitis?
Infammation of the bladder
What are urinary tract infections?
Infections anywhere along the urethra, bladder, ureters and kidneys.
What is the main symptom of a UTI?
Fever
What are the main symptoms of UTI’s in babies?
Fever Lethargy Irritability Vomiting Poor feeding Urinary frequency
What are the main symptoms of UTI?
Pain/ burning when peeing (dysuria) Nocturia Increased frequency/ urgency Haematuria Pain Fever Incontinence Confusion (espeically in older patients)
What is the most common cause of UTI’s and why?
E.coli from the faeces, usually spread during sexual activity
What are the main sources of infection in a UTI?
Sexual activity
Urinary catheters
Incontinence
Lack of hygeine
What is looked for in a urine dipstick to diagnose a UTI?
Nitrites
Leukocytes
Blood
What do nitrites indicate on a urine dipstick?
Gram negative bacteria (e.g. E.coli) breakdown nitrates (urine waste product) into nitrites, suggesting their presence.
How are different UTI’s treated?
Antibiotics–>
- Simple lower UTI in women: 3 days
- Immunosuppressed/ abnormal anatomy or impaired kidney function: 5-10 days
- Men/ pregnant women/ catheter related UTI: 7 days
What are LUTS (lower urinary tract symptoms) caused by storage problems?
Frequency
Urgency
Nocturia
Overflow incontinence
What are LUTS caused by voiding problems?
Poor intermittent stream Hesitancy Incomplete emptying Dribbling Straining Haematuria Dysuria
What is PSA and what do high levels indicate?
Prostate specific antigen–> Glycoprotein expressed by normal and neoplastic prostate tissue.
Levels are raised in BPH and prostate cancer.
What is acute urinary retention?
Sudden onset of painful inability to pass urine with over 500ml in the baldder
What causes acute urinary retention?
Prostatic obstruction (BPH, prostate cancer) Urethral strictures Anticholinergics Alcohol Constipation Post-op Infection Neurological
What investigations are done in acute urinary retention?
Examine abdomen, prostate and perineum.
Normal renal biochemistry
Renal ultrasound
PSA test
How is acute urinary retention treated?
Catheter
Alpha-1 blocker to relax smooth muscle in bladder
What causes chronic urinary retention?
Prostatic enlargement (BPH or prostate cancer)
Pelvic malignancy
Rectal surgery
Diabetes
How does chronic urinary retention present and what can is cause?
Overflow incontinence (leaking) Loss of appetite, constipation, distended abdomen, increased risk of UTI.
