Urology Flashcards
Why might someone with haematuria on a background of bladder cancer develop post-renal AKI?
What is the 1st line management of this?
Clot causing urethral blockage
Continuous bladder irrigation via 3-way catheter
How long must someone abstain from ejaculation/rigorous exercise before getting PSA?
48 hours
Most common cause of epidydimo-orchitis in males <35 y/o?
If >35 y/o or those who have anal sex?
What may be seen on exam?
<35: chlamydia
> 35: E coli or enterococcus
Erythematous, swollen testicle. Pain is relieved upon elevating the testicle
28 y/o man has painful testicle that came on 10 hours ago and has been getting worse. He is pyrexial, the testis is tender and there is associated hydrocele?
Acute infective epidydimo-orchitis
15 y.o boy develops acute pain in left hemiscrotum, O/E the superior pole of the testis is tender and cremasteric reflex is partially marked?
Torsion of testicular appendix (hydatid of morgagni)
Renal stone with sepsis?
IV antibiotics and renal decompression
23 y/o male with:
- 1cm stone and hydronephrosis?
- 1cm stone, no hydronephrosis?
- 2.7cm staghorn calculus?
- percutaneous nephrostomy
- lithotripsy
- percutaneous nephrolithotomy
What can cause acute urinary retention in females?
- UTI
- Neurogenic
- Neoplasm
- Fibroids
- Constipation
Management of varicoceles:
- mild?
- mod or severe?
Mild - conservative
Mod-severe:
- if asymptomatic and normal semen analysis: semen analysis every 1-2 years
- if symptomatic or abnormal semen analysis: surgery
2 year old boy with hypertension and right flank mass. CT: non-calcified, irregular lesion affecting apex or R kidney and adrenal gland?
Nephroblastoma
Communicating hydrocele?
Non-communicating?
What can they develop secondary to?
Communicating:
Patency of processus vaginalis allowing peritoneal fluid to drain down into scrotum. In 5-10% newborns
Non-communicating:
caused by excessive fluid production in tunica vaginalis
Can develop 2 to:
- epididymis-orchitis
- torsion
- tumours
Ix for hydrocele?
Management?
Ix:
usually a clinical diagnosis (non-tender swelling of hemiscrotum usually anterior and below testicle, can get above, transilluminates)
-> if any uncertainty, USS
Management:
- infantile: resolve spontaneously within 1-2 years, rarely don’t resolve and may be fixed
- adults: conservative approach if non-severe. Further investigation usually warranted to rule out cancer
What side are varicoceles most common on?
Presentation?
Ix?
Management?
Left
‘bag of worms’, may be assoc w subfertility
USS with doppler
Management:
Usually conservative
Occasionally surgery if pain or infertility
Epididymal cyst features?
Assoc w?
Ix?
Management?
Most common cause of scrotal swellings in primary care
Separate from the body of the testicle
Posterior to the testicle
Assoc:
- PKD
- CF
- von hippel-lindau
Ix: may be confirmed by USS if needed
Management:
Supportive
Surgical removal or sclerotherapy may be attempted if larger or symptomatic
Neuropathic pain:
- if drug is not working, what should you do?
- what can be used for rescue therapy?
- what can be used for localised neuropathic pain e.g. post-herpetic?
If none of this working?
Switch to another one - they are used as mono therapies, don’t add them on top of each other
Tramadol rescue
Localised: capsaicin cream
If not working - refer to pain team
Types of bladder cancer?
Ix?
Management if superficial (CIS/T1)?
Management of T2+ (invasion into muscle)?
Transitional - 90%
Squamous - schistosomiasis
Ademocarcinoma - if neobladder formed
Ix: biopsy - cystoscopy
MRI for invasion
CT/PET CT for mets
Superficial - transurethral resection
T2+ - radical cystectomy with ileal neobladder or radical radiotherapy
High risk AAA rupture, indicating need for surgery?
Preferred treatment?
5.5+cm
Enlarging >1cm/year
Symptomatic
Ideally EVAR, open repair if unsuitable
AAA size and surveillance?
<3cm, normal
3 - 4.4cm - small, USS every 12 months
- 5 - 5.4 - medium, USS every 3 months
- 5+ - large, refer to vascular surgeon within 2 weeks
Is there screening for AAA?
Yes, single USS scan for males aged 65
6P’s of acute limb ischaemia?
Pale Pulseless Painful Paralysed Paraesthetic Perishing with cold
1 or more suggests acute limb ischaemia
Initial management of suspected acute limb ischaemia?
USS doppler
Analgesia - IV opioids
IV unfractioned heparin to prevent thrombus propagation
Immediate vascular review
What suggests thrombus causing limb ischaemia?
What suggests embolus?
Thrombus:
- pre-existing claudcation with sudden deterioration
- no obvious embolic source
- Reduced/absent pulses in contralateral limb as well
Embolic:
- sudden onset with no Hx claudication
- obvious source e.g. AF, recent MI
- contralateral limb fine
- evidence of proximal aneurysm (abdo, popliteal)
Management of superficial thrombophlebitis?
Specific to long saphenous vein?
General:
NSAIDs 8-12 days
Compression stockings (after ABPI)
since thrombophlebitis gives a 4% chance of forming clot
Long saphenous:
If proximal, USS to exclude DVT
Consider LMWH/Fondaparinux for up to 45 days
Drugs given to folk with peripheral arterial disease?
Statin
Clopidogrel
Drugs given to folk with peripheral arterial disease?
Statin
Clopidogrel
Management of acute urinary retention?
USS initially to confirm
- volume >300ml confirms diagnosis - catheter
- if <200ml, not urinary retention
- If >400ml, keep catheter in place
Reversible cause - UTI, BPH, neuro
What typically causes ABPI >1.2?
Calcification e.g. in advanced age, PAD or diabetes
Where may people be tender with AAA?
Abdo and loin (aorta is right sided)
SE tamsulosin?
How long does it take finasteride to work? SE?
What does it do to PSA?
Talsulosin:
- dizziness, postural hypotension, dry mouth, depression
Finasteride:
- takes up to 6 months to work
- SE: erectile dysfunction, reduced livido, ejaculation problems, gynaecomastia (prevents conversion of testosterone to DHT)
- Can raise PSA by up to 50%
What can raise PSA levels that’s not cancer? (5)
BPH Prostatitis/UTI Ejaculation/vigorous exercise in 48 hours prior Urinary retention Catheterisation
Age peaks of priapism?
Causes?
Bimodal - 5-10 and 20-50 years
Causes: idiopathic, sickle cell, sildenafil, anti-hypertensives, antcoagulants, antidepressants, recreational drugs
Presentation of priapism?
Persistent erection for >4 hours
Pain localised to penis
If not fully erect/not painful or Hx of trauma this suggests non-ischaemic
Ix:
- Cavernosal blood gas - differentiate between ischaemic (low O2 and pH) and non-ischaemic
- Doppler as alternative to assess blood flow in penis
- FBC/toxicology for underlying cause
Management of priapism if ischaemic and non-ischaemic?
Ischaemic is a medical emergency - can lead to permanent damage
If >4 hours - aspiration of blood from cavernous - combined with saline flush
If this fails - injection of vasoconstrictive agent e.g. phenylephrine
Surgery last resort
If non-ischaemic - not an emergency - suitable for observation
Ix for intermittent claudication?
Duplex USS 1st line
MR angiography if surgery is planned
What type of renal stones are radio-lucent?
Urate and xanthine - radio-lucent
Cystine - semi-opaque (1%)
Calcium oxalate (40%), mixed calcium oxalate/phosphate (25%), triple phosphate (struvite - 10%) and calcium phosphate (10%) all radio-opaque
Indications for circumcision?
What must be ruled out before circumcision?
Phimosis
Recurrent balanitis
BXO
Paraphimosis
Hypospadias - foreskin used in repair
Intermittent testicular torsion management?
Emergency fixation as prophylaxis
Management options of prostate Ca if T1/T2?
Management options for T3/T4?
Hormonal options available? (3)
T1/T2: Conserative - watchful waiting, radical prostatectomy or radiotherapy
T3/T4: hormonal therapy, radical prostatectomy, radiotherapy
Hormonal therapy:
- Goserelin (GnRH agonist) - provides negative feedback to ant pit - cover with cyproterone at start
- Cyproterone (anti-androgen) - prevents DHT binding to intracytoplasmic protein complexes
- orchidectomy
SE of radical prostatectomy?
Of radiotherapy?
Surgery: ED
Radio: bladder, colon or rectal cancer
Things that suggest an organic cause of erectile dysfunction?
Gradual onset Normal ejaculation Normal libido (unless hypogonadism) Cardio/endocrine/neuro disease Operations/radiotherapy Drug use or PED's Smoking, alcohol
Ix for erectile dysfunction?
Free testosterone in morning
If low, repeat along with FSH/LH and PRL
Refer to endocrinology if abnormal
Also calculate QRISK and measure lipids and fasting glucose
Management of ED?
Sildenafil - useful in ED of all aetiologies
Vacuum erection device - 1st line in those who don’t want viagra
Refer to urology if young
If keen cyclist tell them to cut down
Obese 77 y/o with T2DM has leg pain at rest, it is worse at night and sometimes improves during the day, no ares of ulceration. What is likely ABPI?
> 1.2
Typical of diabetic ulceration
What is the only testicular/scrotal problem that causes a lump and difficulty conceiving?
Varicocele
Ix for hydronephrosis?
Management?
Management if hydronephrosis assoc w acute or chronic upper UTI?
1st line - USS
IVU - assess position of obstruction
If suspected renal colic - CTKUB
Management:
- remove obstruction
- acute upper UTI - nephrostomy
Chronic upper UTI - ureteric stent or pyeloplasty
What type of cancer is a renal cell carcinoma?
How might it appear under imaging?
Ix?
Where do they metastasise to?
Adenocarcinoma, most common subtype is clear cell - may appear multifocal, calcified, and/or cystic
Ix:
- CT CAP 1st line
First line for any renal mass as benign masses rare
Met: lung, bone, brain
Can hernias transilluminate?
If there is a thin walled bowel rarely they can e.g. in newborn
What are high and low pressure chronic urinary retention?
High pressure - impaired renal function and bilateral hydronephrosis, typically due to bladder outflow obstruction
Low pressure - normal renal function and no hydronephrosis
What drugs can cause urinary retention?
TCA e.g. amitriptyline Anticholinergics Opioids NSAIDs Disopyramide
Complication after relieving acute urinary retention?
Chronic urinary retention?
Acute - post-obstructive diuresis
- Kidneys lose medullary concentration gradient so lose ability to concentrate urine
- can lead to volume depletion and AKI - fluids
- Will re-equilibriate on its own
Chronic - decompression haematuria
- commonly occurs after catheterisation due to rapid decrease in bladder pressure
- Just monitor, requires no further treatment
What can cause intermittent claudication type symptoms of the buttocks?
Iliac stenosis
At what stage will most people with renal cell cancer present?
Stage 4
Test to assess if bladder is leaking after partial cystectomy?
Cystogram
Painful mid-calf ulcer with mild pitting oedema - what type?
Arterial - oedema likely from heart failure
