Urology Flashcards
Define uncomplicated UTI
An uncomplicated UTI occurs in a nonpregnant individual with structurally and functionally normal urinary tract.
Discuss management of UTI in pregancy
Unlike bacteriuria in non pregnant females in pregancny women even if asymptomatic should be treated with antibiotics
Untreated bacteriuria is associated with
-premature labour
-LBW
-perinatal mortality
-maternal anaemia
-maternal pyelonephritis.
Hospital admission should be considered for any patient that is unwell and for those in the later stages of pregnancy
Same ABs as non pregnant
Describe prostatits
4 distinct processes
1) acute bacterial prostatis generally affects man between the age 20-40 years with a second peak in men older than 60 years of age. Common bacterial causes include E.coli, Klebsiella, Enterobacter, Proteus or pseudomonas
2) Chronic bcaterial prostatits is a persistent bacterial infection of the prsoate lasting mroe than 3 months. Appoxim 10% of acute develop into chornic bacterial prostatitis
3) Of those with chronic bacterial prostatits 10% will develop chronic pelvic pain syndrome defined as urological pain in the pelvic region associated with urinary symptoms or sexual dysfunction lasting for at least 3 of the previous 6 months
DIscuss clinical features of prostatitis
UTI symptoms: fever chills, dysuria, urinary frequency or urgency and/orperineal and low back pain.
A rectal exmaination will reveal an exquistely tender and swollen prostat gland in more than 90% of patients.
Discuss management of prostatits
Generally can be managed in an outpatient setting if not systemically unwell.
General support measures for OPD treatment inlcude analgeisa , NSAIDS, hydration and stool softeners. Aplha blockers are also recommended if any signs of voiding issues
Non severe prostatis can be treated initially with
-cephalexin 500mg QID
if resistances found
-cipro 500mg BD is a good choice
For severe-hospitalisation
Ampi + gent
Complications
- abscess
- obstruction
Discuss risk factors for the development of renal calculi
Metabolic disease or disturbance
- chron’s disease
- milk-alkali syndrome
- primary hyperparathyroidism
- hypernatriuria
- Hyperuricosuria
- sarcoidosis
- recurrent UTI
- RTA
- GOUT
- Laxative abuse
Positive family history Hot arid climate Male Gender PRevious kidney stones dehydration
Discuss briefly types of stones
Calcium oxalate or phosphate
-Hyperexcretion of calcium is a major contributor to stone formation
Magnesium ammonium phosphate (struvite)
- Seen in UTIS caused by organisms such as proteus, providencia, klebsiella, pseudomonas and staph
- these stones cause staghorns
Uric acid stones
-approximatelty 15% of patients with sympomtaic gout have uric acid calculi and in the incidence of uric acid stones increases with the use of uricosuric agents.
Discuss complications of renal calculi
Obstructive nephropathy
- Obstruction causes a rapid redistribtuion of renal bloodflow and decrease in GFR
- As glomerular and tubular function declines renal excretion switches to the unaffected kidney
- Complete obstruction of the ureter may lead to renal fucntion loss with an increased incidence of irreversible damage after 1-2 weeks including rupture of the renal calyx
Infection
- Stones behave as a foreign body and leads to stasis and obstruction decreasing host resistance and increasing the incidence of infection.
- Pyelonephritis, perinephric abscess and gram -ve sepsis are all complications of an infected stone
Discuss factors related to passage of stones
The three primary predictors of stone passage without the need for surgical intervention are calculus size, location and degree of pain .
Approximately 90% of stones that are smaller than 5mm pass spontaneously within 4 weeks. This decreases to 15% with stones 5-8mm in size
Spont passage is more frequent if the stone is located below the midureter than those located above.
There are five common sites of ureteric lodgement
1) CA stone may lodge in the calyx of the kidney
2) may pass inot the renal pelvis and get lodged in the ureteropelvic junction
3) Where the ureter crosses the pelvic brim
4) VUJ
5) vesicular orifice
Discuss IX of renal calculi
Bloods
Urine MCS – + ph PH >7.5 should raise suspicion for the presence of urea splitting organisms such as proteus.
AXR - can differentiate radioopage and radiolucent stones
IVP: Very sensitive 96%
CT: 98% sensitive and 97% specific with NPP of 97%
Discuss management of renal calculi and indications for admission
NSADIS are first line ( ketoralac, indomethacin, iburpforn)
Opiates may be required
IV fluids if dehydrated or unable to tolerate oral intake
Consider medical epulsive therapy tamsulosin 0.4mg PO
Indications for admission Absolute - obstructing stone with signs of UTI -intractable nausea or vomting -severe pain not able to be controlled with parenteral analgesics -urinary extravasation -hypercalcaemic crisis
Relative
- significant comorbid illness complicating OPD mangement
- high grade obstruction
- leukocytosis
- solitary kidney or intrinsic kidney disease
- psychosocail factors adversely affecting home mangement.
DIscuss DDX of acute scrotal swelling
Infant
- hernia
- hydrocele
Child
- Hernia
- Torsion
- epididymitits
Adolescent
- epididymitis
- torsion
- trauma
Adult
- epididymiti
- torsion
- trauma
- tumor
- torsion
- Fournier’s gangrene
Describe testicular torsion
Bimodal incidence in the first year of life and at puberty when the rapid increase in testicular volue predisposes the testis to torsio
Up to 40% of cases occur in adutls and it is more common in the winter months
With torsion a congenital defect of the testis results in the abnormal testicualr rotation during crmasteric contraction. This leads to twisting of the spermatic cord resulting in obstruction of venous outflow, subsequent compromised arterial flow and testicular ishcaemia.
Salvage hinges on the degree of torsion and duration of ischaemia. Torsion presenting within 6 hours is associated with salvage rates of 80-100% whereas symptoms persisting for longer than 6 hours are as low as 44%
Discuss clinical features of torsions
Sudden onset of radpidly escalating pain in the scrotum lower abdomen or inguinal area that awakens them from sleep.
Up 29% of patient with torsion describe similar pain in the past caused by previosu intermittent torsion
A history of scrotal trauma
Exam
- absence cremasteric reflex
- tender firm high riding testicles
- transverse position
- scrotum is wollen and tender making exam difficult
Discuss IX of torsion
Urinalysis
Imaging
US -sensitivity between 64-100% and spec 97-100%
-the torsed testicle typically will be hypoechoic and enlarged. -False -ve finding occur when the testicel is examined early in the course when blood flow is still present.
-examination of the spermatic cord for twisting instead of the testicle itself has been shown to reduce the frequency of these false -ve results.
-colour doppler improve specificty to 100%
-dopple in young children is more difficult with as many as 50% of boys younger than 8 years of age not showing intratesticular flow.
MRI can be used
Discuss management of Torsion
Exploration detorsion and orhciopexy
Discuss torsion of the appendages of the testis
The paramesonephric duct is present in 92% of patients. It is located on the superior aspect of the testicle between the testis and epididymis.
This appendage is prone to torsion.
After several days of ischaemia from torsion it will undergo necrosis with eventural reabsoprtion.
Patient will usually seek attention alter than patients with torsion generally after 49 hours of symptoms. Reported as milder pain with a more gradial onset.
If torsion has been ruled out surgical excision of the appendix is rarely necesary. Treatment consists of scrotal support ice and NSAIDS. REsolultion of symptoms can be expected within 7-10days
Describe epididymitis
Most common intrascrotal inflammatory disease
Most commonly seen in men between the ages of 18 and 35
If untreated it can lead to orchitis testicular abscess and rarely sepsis
Main route of infection is local extension mainly due to infection spreading from the urethra (STI) or from the bladder (UTI)
Older man are more likley to have bladder source due to increase rates of cocommitant prostatis, BPH, immunosupression or systemic disease.
Discuss clinical signs of epididymits
Gradual onset of pain. May reside in hte lower abdomen or flank caused by inflammation of the vas deferens.
Prehn’s sign a decrease in pain on elevation of the scortum has both low sensitivty and specificity.
Discuss IX
Urine MCS for UTI – mid stream
Urine first pass and swab for STI
FBC
US
Discuss DDX of acute urinary retention
Obstruction Men
- BPH
- prostatitis
- phimosis
- paraphimosis
Obstruction women
- Pelvic masses
- prolapse of pelvic organs such as the bladder, rectum or uterus
obstruction both
- Meatal stenosis
- tumor
- foreign body
- calculus
- stricture
- haemtoma
- cardinoma
Infectious
- urethritis
- UTI
- prostatitis
- severe vulvovaginitis
- genital herps
Neuro (motor)
- Spinal shcok
- cord syndrome
Neuro (sensory)
- Tabes dorsalis
- t2dm
- MS
- syringomyelia
- spinal cord syndrome
- herpes zoster
Drugs
- antishitamines
- anticholinergic
- antispasmodic
- TCA
- a adrengergic stimulators
- cold tablet
- amphetamines
Discuss management of epididymitis
Mainstay is antibiotics
If STI suspected
IM ceftriaxone 500mg + doxy 100mg BD or azithromycin 1g repeated in a week
If UTI suspected treat as per cystitis
Discuss DDX of haematuria in the adult
Renal:
- Benign renal mass (abscess, angiomylipoma)
- Malignant renal mass (RCC, TCC)
- Glomerular bleeding (IGA nephropathy, thin basement membrnae disease, alport)
- Structure disease ( polycycstic kidney)
- Pyelonephritis
- hydronephrosis/distension
- hypercaclicura
- malignant hypertension
- renal vein thrombus/ renal artery embolism
- AVM
- Papillary necrosis
Ureter -malignancy -stone -stricture 0post surgical
Renal and or uppr or lower collecting system
- infeciton
- malignancy
- urolithiasis
- trauma
- recent instrumentation
- exercise induced haematuria
Bladder
- malignancy(TCC, squamous cell carcinoma)
- radiation
- cystitis
- bladder stones
Prostate/urethra
- BPH
- prostate cancer
- prostatic procedures
- traumatic catheterization
- urethritis
- urethral diverticulum
