Urology Flashcards
Treatment of bladder hyperactivity (neurogenic bladder)?
Bladder hyperactivity - antimuscarinic medications to relax bladder
When should you refer to a urologist for LUTS?
o Failure of medical therapy
o UTIs
o Hematuria, Retention, Renal Compromise
o Concerns re: elevated PSA, abN DRE
o Any consecutive rise in PSA while on 5ARi
What are the side effects of vacuum erection devices?
Side effects of petechiae, numbing, trapped ejaculation.
What are the side effects of intracavernosal injections?
Priapism
Which disorders to organic causes for ED usually stem from?
Atherosclerosis or diabetes
Common causes of urinary retention in men?
Prostate abnormalities or urethral strictures causing outlet obstruction
Treatment of bladder hyperactivity if refractory to antimuscarinic medications?
o Botulinum toxin injections into bladder wall (detrusor muscle)
o Occasionally augmentation cystoplasty (enlarging bladder volume and improving compliance by grafting section of detubularized bowel onto the bladder)
o Occasionally urinary diversion (ileal conduit or continent diversion) in severe cases if bladder management unsuccessful
What should be done on physical exam for scrotal pain?
- Abdomen: tenderness and masses (including bladder distention). Flanks are percussed for costovertebral angle tenderness.
- Inguinal and genital examination should be done with the patient standing.
- Inguinal area is inspected and palpated for adenopathy, swelling, or erythema.
- Scrotal examination: asymmetry, swelling, erythema or discoloration, and positioning of the testes (horizontal vs vertical, high vs low).
- Cremasteric reflex should be tested bilaterally.
- The testes, epididymides, and spermatic cords should be palpated for swelling and tenderness.
MOA of α1-adrenoceptor-blocking agents
Hyperplasia of the prostate is primarily a phenomenon of the stromal rather than epithelial tissue in the majority of men. The smooth muscle of the stroma receives adrenergic innervation. For this reason, the selective α1-blockers may be useful for relaxing the smooth muscle of the prostate and the bladder neck.
Which medications can cause ED?
Antihypertensives, antidepressants (SSRIs – not bupriopion), dopaminergic, alcohol
What is the conservative management for BPH?
Watchful waiting (mild to moderate symptoms)
Lifestyle modification (i.e. caffeine intake, exercise)
Modification of current medications (i.e. diuretics)
What should be asked on history for scrotal pain?
o Location (unilateral or bilateral), onset (acute or subacute), and duration of pain o Important associated symptoms include fever, dysuria, penile discharge, and presence of scrotal mass o Injury, straining or lifting, and sexual contact.
Contraindications to PDE5 inhibitors
Nitrates (drops your BP too much), active MI, LV outflow obstruction.
Typical investigations for scrotal pain?
o Urinalysis and culture (all patients)
o STD testing (all patients with positive urinalysis, discharge, or dysuria)
o Color Doppler ultrasonography to rule out torsion (no clear-cut alternate cause)
Side effects of surgical penile prosthesis?
S/E: infection, perforation, urethral injury, malfunction, erosion
What do you need to r/o for priapism?
Rule out leukemia and sickle cell anemia
Two general categories of etiology for ED?
Psychologic and organic
Examples of 5 alpha reductase inhibitors?
Finasteride – type II, dutasteride – type I & II
3rd line treatment for ED?
- Surgical penile prosthesis - Need to take out cavernosal tissue so if this thing fails – no other therapy allowed!
What are the emptying symptoms of LUTS?
(WISE): Weak Stream, Intermittency, Straining, Sense of Incomplete Emptying
What are the mandatory investigations for BPH?
Mandatory: Hx including LUTS, surgery, trauma, medications (OTC and phytotherapeutic agents), impact of QOL, P/E including DRE, U/A to exclude UTI
What should be preformed on physical exam for a patient with LUTS?
o Abdominal exam – palpable masses, suprapubic tenderness
o External genitalia – obstruction, scrotal pathology
o DRE – size, texture and nodules
o Neurological Exam – walk to the bed
Treatment options for priapism?
Corporal irrigation, intracavernosal injection alpha adrenergic agonists or surgical shunt
1st line treatment for ED?
Phosphodiesterase inhibitor (sildenafil/viagra, tadalafil/cialis)
How do 5 alpha reductase inhibitors work?
Slow the rate of prostate enlargement - block conversion of testosterone to DHT
Clinical presentation of orchitis?
- Abrupt onset of testicular pain
- Nausea, fever
- Unilateral or bilateral swelling, erythema and tenderness of scrotum
Clinical presentation of strangulated inguinal hernia
o Long history of painless swelling (often known diagnosis of hernia) with acute or subacute pain
o Scrotal mass, usually large, compressible, possibly with audible bowel sounds
o Not reducible
What is priapism?
Prolonged, painful, unwanted erection >4h, emergency
Bilateral scrotal pain suggests _____
Suggests infection (eg, orchitis, particularly if accompanied by fever and viral symptoms) or a referred cause.
What referred pain could cause scrotal pain?
Abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, postherniorrhaphy pain
2nd line treatment for ED?
- Vacuum erection devices - uses VENOUS Blood (unnatural)
- Intracavernosal injections – inject prostaglandin into cavernosa – leads to involuntary erection.
- Constriction rings
Investigations to be done for a patient with LUTS?
o Uroflow/PVR
o Urinalysis +/- culture
o Creatinine + lytes
o PSA
Indications for surgery for BPH?
Bothersome symptoms despite maximal medical treatment
Inability to tolerate medical therapy
BPH-related complications: Urinary Retention (inability to void), Bladder calculi, Recurrent UTI, Recurrent hematuria from the prostate, Upper tract dysfunction (hydronephrosis, renal dysfunction)
In females, LUTS are most commonly presents in those over 40 years old and commonly associated with a
Lower urinary tract infection
What are the investigations and their findings of urethral stricture?
- Laboratory findings - flow rates <10 mL/s (normal >15 mL/s) on uroflowmetry
- Radiologic findings - RUG and VCUG will demonstrate location
Men with psychogenic ED usually have _____ nocturnal erections and erections upon awakening
Normal
What is defined as erectile dysfunction?
Consistent (>3 mo duration) or recurrent inability to obtain +/or maintain an erection sufficient for satisfactory sexual activity
What are the side effects of alpha blockers
Orthostatic hypotension, asthenia, dizziness, abnormal ejaculation, nasal congestion, headache.
Treatment of chronic urinary retention?
Chronic retention - intermittent catheterization by patient may be used; definitive treatment depends on etiology
In older men, LUTS are commonly caused b
BPH
Clinical presentation of testicular torsion?
Sudden onset unilateral scrotal pain with nausea
Gold standard surgical technique for BPH?
TURP – Gold standard if prostate moderate size
Appendiceal torsion tx?
Treat conservative + NSAIDs. Surgical exploration and excision if refractory pain
Treatment of post-operative patients with retention?
- Encourage ambulation
- α-blockers to relax bladder neck/outlet (men only)
- May need catheterization
Examples of selective α1-adrenoceptor-blocking agents
Alfuzosin, Tamsulosin
What are the optional investigations for BPH?
Optional: Cr, urine cytology, uroflowmetry, PVR, voiding diary, sexual function questionnaire, renal U/S to assess for hydronephrosis
Common causes of urinary retention in both sex?
Retention may be due to drugs (particularly those with anticholinergic effects, including many over-the-counter drugs), severe fecal impaction (which increases pressure on the bladder trigone), or neurogenic bladder in patients with diabetes, multiple sclerosis, Parkinson disease, or prior pelvic surgery resulting in bladder denervation
What is Detrusor sphincter dyssynergia (DSD) and its causes?
- Suprasacral lesion of spinal cord (e.g. trauma, MS, arteriovenous malformation, transverse myelitis)
- Loss of coordination between detrusor and sphincter (detrusor contracts on closed sphincter and vice versa)
What is a urethral stricture?
Decrease in urethral calibre due to scar formation in urethra
First steps in treating ED (including lifestyle)?
- Underlying organic disorders (eg, diabetes , prolactin-secreting pituitary adenoma , hypogonadism , Peyronie disease ) require appropriate treatment
- Drugs that are temporally related to onset of erectile dysfunction (ED) should be stopped or replaced.
- Depression may require treatment or counselling
- Lifestyle stuff: stop smoking, exercise, eat right, ↓alcohol, sleep, modify meds (e.g. aniHTN, SSRIs, antiandrogens).
Examples of the non-selective alpha blockers?
Doxazosin, terazosin
Tx of testicular torsion?
Treat with surgery in <6hrs (up to 24) - bilateral orchiopexy
What do you need to do with taking PDE5?
Need sexual stimulation to activate the NO pathway! Won’t work without it. Onset 15-30min, can last for 6-24 hrs. Cialis lasts longer – helps erectile function, but does not cause erection
Clinical features of urinary retention?
Suprapubic pain (with acute retention), incomplete emptying, weak stream
Possible purulent/bloody meatal discharge (with UTI)
Increased size of prostate or reduced anal sphincter tone on DRE
Neurological: presence of abnormal or absent deep tendon reflexes, reduced “anal wink”, saddle anesthesia
Severe, sudden onset of scrotal pain suggests _____ or ______
Testicular torsion or renal calculus.
What is the pathophysiology behind OSA resulting in nocturnal polyuria?
o Increased airway resistance - Hypoxia
o Pulmonary Vasoconstriction
o Increased Right Atrial Pressure = Atrial Naturetic Peptide = Na and H2O excretion
S/E of 5 alpha reductase inhibitors?
S/E – decreased libido, ED, ejaculatory dysfunction, gynecomastia
Clinical presentation of epididymitis?
o Acute or subacute onset of pain in the epididymis and sometimes also the testis
o Possibly urinary frequency, dysuria, recent lifting or straining
o Cremasteric reflex present
o Often scrotal induration, swelling, erythema
o Sometimes penile discharge
Ddx of LUTS in men?
Prostate: BPH, prostate cancer, prostatitis
Bladder: cystitis, bladder tumour, bladder or ureteric stone, overactive bladder
Urethra: urethral stricture, urethritis (STI), meatal stenosis, phimosis, foreign body
Neurologic: Neurogenic bladder: Parkinson’s disease, stroke, Alzheimer’s disease, spinal cord disease
Other: Obstructive sleep apnea, medication side effect (anticholinergics, opioids), dietary irritant, external compression from pelvic mass or constipation, polydipsia, congestive heart failure, DM
What is the neuro-urologic evaluation for neurogenic bladder?
- Hx and P/E (urologic and general neurologic)
- Voiding diary
- Catheterization volumes in patients with CIC
- U/A, renal profile
- Imaging - U/S to rule out hydronephrosis and stones; occasionally CT scanning with or without contrast
- Cystoscopy
- Urodynamic studies
Risk factors for ED?
Risk factors for ED are basically the same as that of CV disease – they are related! Include: HTN, obesity/sedentary, smoking, heart disease, diabetes, hyperlipidemia, BPH, vascular disease
A vesicular nonpedunculated structure attached to the cephalic pole of the testis
Appendix testis
Investigations for epididymitis?
Urinalysis and culture – likely to be abnormal, Nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis
o Severe pain, fever, toxic appearance, erythema, blistering or necrotic lesions
o Sometimes palpable subcutaneous gas
o Sometimes history of recent abdominal surgery
o More common in older men with diabetes, peripheral vascular disease, or both
Fournier gangrene
Name two other potential causes of ED (other than meds, organic or psychological)?
Pelvic radiation and testosterone deficiency
Clinical findings + signs of testicular torsion?
o Asymmetric, transversely oriented, high-riding testis on affected side
o Cremasteric reflex absent
Deficient bladder sensation - Increasing residual urine - decompensation (e.g. DM, neurosyphilis, herpes zoster)
Peripheral autonomic neuropathy
What risk can alpha blockers pose for cataract surgery
Intraoperative floppy iris syndrome
Treatment for epididymitis?
Treatment: ceftriaxone (200 mg IM) AND doxycycline (100 mg PO bid) x14d, bedrest, scrotal support, and NSAIDs.
Important things to ask about on history for ED?
- History of drug (including prescription drugs and herbal products) and alcohol use, pelvic surgery and trauma, smoking, diabetes, hypertension, and atherosclerosis and symptoms of vascular, hormonal, neurologic, and psychologic disorders.
- Satisfaction with sexual relationships
Psychologic causes of ED?
Include guilt, fear of intimacy, depression, or anxiety. In secondary ED, causes may relate to performance anxiety, stress, or depression. Psychogenic ED may be situational, involving a particular place, time, or partner.
When should open prostatectomy be considered for BPH?
Gland Size > 80cc, Urethral Stricture, Hip contractures, Need for concomitant bladder surgery (diverticulum, big stones)
Treatment of neurogenic bladder
- Clean intermittent catheterization (CIC) (if there is associated inability to void)
- Bethanechol is a parasympathomimetic choline carbamate that selectively stimulates muscarinic receptors without any effect on nicotinic receptors.
What are the clinical features of urethral stricture?
- Voiding and storage symptoms
- Urinary retention
- Hydronephrosis
- Related infections: recurrent UTI, secondary prostatitis/epididymitis
What are the storage symptoms of LUTS?
(FUUND): frequency, urgency, urgency incontinence, nocturia and dysuria
_____ can be a useful tool for assessing and monitoring the impact of LUTS on quality of life in men
International Prostate Symptom Score
Fournier gangrene treatment
Treatment: Immediate debridement and broad-spectrum antibiotics, with hemodynamic support
What are the recommended investigations for BPH?
Recommended: symptom inventory (IPSS), PSA if >10yr life expectancy or if it changes management of voiding symptoms
On ROS for scrotal pain what information should you gather?
Review of systems should seek symptoms of causative disorders, including purpuric rash, abdominal pain, and arthralgias (immunoglobulin A–associated vasculitis [Henoch-Schönlein purpura]); intermittent scrotal masses, groin swelling, or both (inguinal hernia); fever and parotid gland swelling (mumps orchitis); and flank pain or hematuria (renal calculus).
What is Detrusor atony/areflexia?
- Lesion of sacral cord or peripheral efferents (e.g. trauma, DM, disc herniation, MS, congenital spinal cord abnormality, post abdominoperineal resection)
- Flaccid bladder which fails to contract
o Subacute onset of pain over several days
o Pain in the upper pole of testis
o Cremasteric reflex present
o Typically occurs in boys aged 7–14 years
Appendiceal torsion
Organic causes of ED?
Neurologic:
- Include stroke, partial complex seizures, multiple sclerosis, peripheral and autonomic neuropathies, and spinal cord injuries. Diabetic neuropathy and surgical injury are particularly common causes.
Vascular:
- The most common vascular cause is atherosclerosis of cavernous arteries of the penis (decreases capacity to dilate), often caused by smoking, endothelial dysfunction, and diabetes.
Treatment for urethral stricture?
Urethral dilatation - temporarily increases lumen size by breaking up scar tissue
Visual internal urethrotomy (VIU) - endoscopically incise stricture
Open surgical reconstruction (urethroplasty) - complete stricture excision with anastomosis depending on location and size of stricture
What are the causes behind urethral stricture?
- Congenital - failure of normal canalization (i.e. posterior urethral valves)
- Trauma - instrumentation/catheterization (most common), external trauma (e.g. burns, straddle injury)
- Infection - long-term indwelling catheter, STI (gonococcal or chlamydial disease)
- Inflammation - balanitis xerotica obliterans (BXO; lichen sclerosus or chronic progressive sclerosing dermatosis of the male genitalia) causing meatal and urethral stenosis, radiation
- Malignancy (urothelial carcinoma) - most urethral cancers in men are squamous
What typically causes epididymitis?
- UTI – E.coli, pseudomonas – Most common cause among older men and children
- STI – chlamydia, gonorrhoeae
For best results what should you start men with BPH on?
Usually start men on combo of alpha block and 5ARI
What is neurogenic detrusor overactivity?
- Lesion above PMC (e.g. stroke, tumour, MS, Parkinson’s disease)
- Loss of voluntary inhibition of voiding
- Intact pathway inferior to PMC maintains coordination of bladder and sphincter
Investigations for ED?
- Morning testosterone level; if the level is low or low-normal, prolactin and luteinizing hormone (LH) should be measured.
- DIABETES (Hb1Ac or urinalysis for glucose). TSH, lipid panel if indicated
Treatment of acute urinary retention?
Acute retention - immediate catheterization to relieve retention; leave Foley in to drain bladder; follow-up to determine cause; closely monitor fluid status and electrolytes (risk of POD)
Conservative management options for a patient with LUTS?
- Regulating fluid intake
- Urethral milking techniques* (manually emptying the bulbar urethra of residual urine) or double voiding (passing urine and then remaining for a short time before passing urine again)
- Pelvic floor exercises to strengthen the pelvic floor are useful in cases of stress incontinence or post-micturition dribble.
- Bladder training techniques, which aim to increase the duration between the urge to void and micturition, when done properly (under supervision) these may be useful in overactive bladder.
What should you ask on history for LUTS?
o Whether symptoms are mostly voiding or storage (FUUND / WISE)
o Associated symptoms - visible hematuria, suprapubic discomfort, or colicky pain, and their medication history (anticholinergics, antihistamines and bronchodilators)
o Previous urologic or pelvic surgery
o Family history of prostate cancer
Does the size of gland (prostate) correlate with degree of symptoms (LUTS)?
No
Pharmacological management options for a patient with LUTS?
- Anticholinergics (e.g. oxybutynin, tolterodine) for overactive bladder, helping to relax bladder muscle by opposing parasympathetic cholinergic control of contraction
- Alpha blockers (e.g. alfuzosin, tamsulosin) and / or 5alpha-reductase inhibitors (e.g. finasteride) for BPH can help in reducing prostate size by relaxing prostatic muscle
- Loop diuretics (e.g. furosemide, bumetanide), may be taken mid-afternoon to prevent nocturia
BPH treatment done on smaller prostates and when the primary obstruction occurs at the bladder neck
TUIP
What is the neurophysiology of micturition?
Stretch receptors in the bladder wall relay information to PMC and activate micturition reflex (normally inhibited by cortical input)
Micturition (voiding):
• Stimulation of parasympathetic neurons (bladder contraction)
• Inhibition of sympathetic and somatic neurons (internal and external sphincter relaxation, respectively)
• Voluntary relaxation of the pelvic floor and striated urethral sphincter
What is the definition of cystitis?
Symptoms suggestive of UTI + evidence of pyuria and bacteriuria on U/A or urine C&S
What is asymptomatic bacteriuria?
If asymptomatic + 100,000 CFU/mL
When does asymptomatic bacteriuria need treatment?
Pregnancy, immunosuppressed, prior to urologic surgery
What is uncomplicated cystitis?
Uncomplicated: lower UTI in a setting of functionally and structurally normal urinary tract
What is complicated cystitis?
Complicated: structural and/or functional abnormality, male patients, immunocompromised, diabetic, iatrogenic complication, pregnancy, pyelonephritis, catheter-associated
What is the definition of recurrent cystitis?
Recurrent: >3UTIs/yr
Risk factors of cystitis?
Risk factors: stasis/obstruction, foreign body (catheter), immunosuppression/metabolic, anatomic, menopause.
Painless gross hematuria is _____ until proven otherwise
Bladder cancer
Clinical features of cystitis
Cystitis - Suprapubic pain, irritative (freq, urg, dysuria, nocturia), maybe hematuria, rarely febrile!
Main source of bacteria causing cystitis is from the ____
GI tract
What are common organisms of cystitis?
KEEPS: E coli + gram –ves (90%), S saphrophyticus or fecalis, Klebsiella, Enterococci, Proteus/Pseudomonas
What are the two most common organisms of cystitis?
E. coli and S.saprophyticus 2 most common
Investigations for cystitis?
U/A, urine C&S
• U/A: leukocytes ± nitrites ± hematuria
• C&S: midstream, catheterized, or suprapubic aspirate
What are 1st line treatment options for cystitis in the absence of culture?
- Trimethoprim/sulfamethoxazole
- Nitrofurantoin
- Fosfomycin
What is the duration of antibiotics for males and females for cystitis?
Female: 3d
Males: 7d
Do males or females need pre/post treatment cultures for cystitis?
Male: pretreatment cultures recommended, posttreatment cultures only if symptoms persist.
Female: No need for pre/post treatment culture.
Treatment options for recurrent cystitis for females?
If related to coitus – TMP/SMX post-coital, pee after sex. If not, daily low dose TMP-SMX for 6mnths or self-start treatment based on symptoms.
Treatment option for post-menopausal women for recurrent cystitis?
Vaginal estrogen therapy
Treatment for complicated cystitis
Ciprofloxacin 10-14d OR ampicillin + gentamicin OR ceftriaxone
Pretreatment culture recommended, post only if symptoms
Treatment for cystitis in pregnancy
Pre AND Post-treatment cultures needed. Cefixime for 7d. Do not use quinolones, TMPSMX in last 6 weeks, or nitrofurantoin after 36wks!
Prevention of UTIs
Maintain good hydration
Void regularly (do not hold urine for prolonged periods of time)
Wipe from front to back to avoid contamination of the urethra with feces from the rectum
Avoid feminine hygiene sprays and scented douches
Empty bladder immediately before and after intercourse
Definition of pyelonephritis
Definition: Clinical diagnosis of flank pain, fever and elevated WBC
Clinical features of pyelonephritis
Clinical Features: CVA tenderness, flank pain, fever, N/V, chills, LUTS. R/O stone, obstruction – this can be lethal!
Investigations for pyelonephritis
U/A, urine C&S
CBCd: leukocytosis, left shift
Imaging if complicated pyelonephritis or symptoms do not improve with 48-72h of treatment (maybe stone): abdominal/pelvic U/S, CT
Treatment of uncomplicated pyelonephritis
Uncomplicated: pretreatment culture. Ciprofloxacin (500 mg PO bid) x7d ± ceftriaxone (1 g IV) OR ciprofloxacin (400 mg IV) x1
Treatment of complicated pyelonephritis
Complicated: pre and post treatment cultures, urologic assessment if recurrent or symptoms >72hrs. Treatment would be full 14d! CULTURE – amox/clav not good for Pseudomonas and if enterococcol, use amp + gent until sensitivity determined. Admit if needed.
Classification of prostatitis
Acute Bacterial Prostatitis (Category I)
Chronic Bacterial Prostatitis (Category II)
Chronic Pelvic Pain Syndrome (Category III)
Asymptomatic Prostatitis (Category IV)
Signs and symptoms of prostatitis?
LUTS or obstruction and pain. Pain is typically in the perineum but may be perceived at the tip of the penis, lower back, or testes. Some patients report painful ejaculation.
Signs and symptoms of acute bacterial prostatitis?
Acute bacterial prostatitis often causes such systemic symptoms as fever, chills, malaise, and myalgias. The prostate is exquisitely tender and focally or diffusely swollen, boggy, indurated, or a combination.
Signs and symptoms of chronic prostatitis/chronic pelvic pain syndrome
Chronic prostatitis/chronic pelvic pain syndrome typically has pain as the predominant symptom, often including pain with ejaculation. On examination, the prostate may be tender but usually is not boggy or swollen.
For patients with acute or chronic bacterial prostatitis who do not respond favorably to antibiotics, _____ and sometimes ______ may be necessary to rule out _______ or _______
Transrectal ultrasonography and sometimes cystoscopy may be necessary to rule out prostatic abscess or destruction and inflammation of the seminal vesicles.
Treatment of acute bacterial prostatitis?
Acute bacterial prostatitis: Nontoxic patients can be treated at home with antibiotics (ciprofloxacin (500-750 mg PO bid x2-4wks), bed rest, analgesics, stool softeners, and hydration. If sepsis is suspected, the patient is hospitalized and given broad-spectrum antibiotics IV (eg, ampicillin plus gentamicin)
Treatment of chronic bacterial prostatitis?
Chronic bacterial prostatitis: ciprofloxacin (500 mg PO bid) x6wks
Urethritis can be categorized as two etiologies?
Infectious or inflammatory (e.g. reactive arthritis)
Investigations if you suspect infectious etiology for urethritis?
Gram stain, urine PCR and/or culture from urethral specimen
Gonococcal urethritis symptoms?
Hx of sexual contact, thick, profuse, yellow- grey purulent d/c, LUTS
Which investigations should you do for interstitial cystitis
Cystoscopy
What are benign bladder ulcers called?
Hunners
Symptoms/definition of interstitial cystitis
Definition: bladder pain, chronic urgency, and frequency without other identifiable causation
These symptoms worsen as the bladder fills and diminish when patients void; in some people, symptoms worsen during ovulation, menstruation, seasonal allergies, physical or emotional stress, or sexual intercourse
Treatment of interstitial cystitis?
Lifestyle modification - encouraging awareness and avoidance of potential triggers, such as tobacco, alcohol, foods with high potassium content, and spicy foods.
Bladder training
Drugs (eg, pentosan polysulfate sodium, tricyclic antidepressants, nonsteroidal anti-inflammatory drugs [NSAIDs], dimethyl sulfoxide instillation)
Surgery as a last resort
Most common subtype of bladder cancer?
TCC most common subtype
Risk factors for bladder cancer
Risk factors: Smoking, Excess phenacetin use (analgesic abuse), Long-term cyclophosphamide use, Chronic irritation (eg, in schistosomiasis, by chronic catheterization, or by bladder calculi)
3 types of bladder cancer?
- Transitional cell carcinomas (urothelial carcinoma), which account for > 90% of bladder cancers. Most are papillary carcinomas, which tend to be superficial and well differentiated and to grow outward; sessile tumors are more insidious, tending to invade early and metastasize
- Squamous cell carcinomas
- Adenocarcinomas
Squamous cell carcinomas, which are less common and usually occur in patients with _____
Squamous cell carcinomas, which are less common and usually occur in patients with parasitic bladder infestation
Bladder adenocarcinoma, you should r/o?
Metastasis particularly from intestinal carcinoma.
Presentation of bladder cancer
Presentation: hematuria (gross or microscopic). Irritative voiding symptoms could also present (suggesting carcinoma in situ) - uncommon
Diagnosis of bladder cancer?
- Urine cytology
- Cystoscopy + biopsy
- TURBT (transurethral resection of bladder tumour) is DIAGNOSTIC AND THERAPEUTIC.
For low stage (stage T1 or more superficial) bladder tumors _____ is sufficient for staging.
Cystoscopy with biopsy is sufficient for staging.
If a bladder tumor is found to invade muscle (≥ stage T2), what should be ordered?
Abdominal and pelvic CT and chest x-ray are done to determine tumor extent and evaluate for metastases
TNM definitions for bladder cancer?
Ta - Noninvasive papillary (within the urothelium)
TIS - Flat tumors (carcinoma in situ)
T1 - Invades subepithelial connective tissue
T2 - Invades muscle
T3 - Invades perivesical tissue
T4 - Invades adjacent organs
Treatment for low grade Ta bladder cancer?
Low grade Ta: TURBT alone is CURATIVE, but 70% recurrence so can add intravesical chemotherapy to reduce recurrence.
Treatment for high grade Ta/1, CIS bladder cancer?
TURBT + adjuvant intravesical therapy, but here BCG (bacillus calmette-guerin) is the most effective intravesical agent – given 4 weeks after the TURBT. May do partial cystectomy
Treatment for T2+ bladder cancer?
Need aggressive multimodal treatment (radical cystectomy + chemo). Alternative – maximal TUR + radiation + chemo, used for poor operative candidates or patients who refuse to lose bladder
What is a radical cystectomy?
Radical cystectomy – removal of bladder and surrounding perivesical fat, prostate, seminal vesicles, pelvic lymph nodes
Options after radical cystectomy?
Need to do a urinary diversion (ileal conduit - take some ileum out of GI tract, with its mesentary, take one end and attach to ureter and take other end and make stoma into the skin (gold standard), neobladder – making a new bladder out of bowel, Continent - essentially making a reservoir but hook it up to the skin and not the urethra - When they want it to drain, they pass the foley catheter into the reservoir
Treatment for metastatic bladder cancer?
Metastatic UC: poor prognosis, <1yr survival. Chemo is gold standard here, do not do cystectomy (does not prolong life).
Follow up for bladder cancer?
Follow Up: Yearly cystoscopy for at least 5 years. MRI if indicated
Signs and symptoms of bladder stones?
Urinary obstruction – upstream distention - pain
Severe waxing and waning pain radiating from flank to groin, testis, or tip of penis from distended collecting system or ureter (ureteral colic)
Colic nature of the pain - Rapid onset, writhing
Associated nausea/emesis
Hematuria (90% microscopic), diaphoresis, tachycardia, tachypnea
Irritative LUTS (frequency, urgency)
BEWARE OF FEVER – r/o concurrent pyelonephritis and/or obstruction
Key points in bladder stone Hx
Diet (especially FLUID INTAKE) Predisposing medical conditions Predisposing medications Previous episodes/investigations/treatments Family Hx (1st degree relative)
4 common places stones get stuck
Ureteropelvic junction, near the gonadal vessel, pelvic brim (where common iliac splits, ureterovesicular junction.
Labs for bladder stones
Labs: CBC + urinalysis + urine culture + pH (blood/WBC), consider HCG, crea (to make sure we can give NSAIDS), serum Ca, PTH
• pH: acidic means uric acid/cystine whereas basic means struvite stones
What is the gold standard imaging for renal colic?
Non-contrast Low-Dose CT abdopelvis (NCCT)
Which stones do Non-contrast Low-Dose CT miss?
Sees all stones EXCEPT THOSE RELATED TO ANTIVIRALS (INDIVIR) – drug that crystallizes and forms stones.
First line imaging for renal colic in pregnancy?
Ultrasound - first line in pregnancy
What percentage of bladder stones are visible on KUB Xray?
90% of stones visible – doesn’t see uric acid stones
Why should you also get a KUB Xray for renal colic
KUB Xray helps us follow the stone so get this too!
Initial management of renal colic?
Pain control – Narcotics, NSAIDS (renal function) (Avoid if planning SWL), Acetaminophen
Anti-emetics
IV hydration prn
IF FEVER - prompt cultures and CONSULT UROLOGY - DISCUSS ANTIBIOTICS
Alpha-blockers as medical expulsive therapy (MET) - Tamsulosin (Explain that these are off-label and associated with dizziness and retrograde ejaculation)
Initial management of a <5mm renal or ureteral stone?
- Discharge home with instructions to drink >2L of water/day
- Tamsulosin for ureteral stones
- 90% will pass spontaneously
- Should follow-up with urology within 1-2 weeks
Initial management of a >5mm renal or ureteral stone or signs of obstruction?
- Consult urology
* +/- tamsulosin – indication for stone 6-10mm in the distal ureter
When should you use extracorporeal shock wave lithotripsy (SWL)?
Ureteral stones <1cm or renal stones <2cm
What are contraindications of extracorporeal shock wave lithotripsy (SWL)?
Contraindications: pregnancy, bleeding/coagulopathy, febrile UTI, distal obstruction to stone being treated. Follow up with KUB and give tamsulosin.
Complications of extracorporeal shock wave lithotripsy (SWL)?
Complications - hematuria (normal), ureteral obstruction, hematochezia, sepsis and hematoma are rare
When should you use ureteroscopic laser lithotripsy (URS)
Ureteral stones or SWL failures. Very good for distal stones, immediate as opposed to SWL
Success of shock wave lithotripsy (SWL) depends on what?
Success depends on stone size (<1cm is best), location (renal pelvis is best), composition (good for Ca oxalate dihydrate (not mono), uric acid, or struvite stones), patient habitus (distance from skin to stone), anatomy.
When should you not used SWL?
Do not use SWL if stone is >2cm, stone is cystine made, patient needs to be stone free fast, patient habitus excludes SWL, or if SWL has failed 2x.
When should you use percutaneous nephrolithotomy (PCNL)?
Large >2cm renal stones. Good for LARGE or MULTPLE stones (better than SWL) and can remove right away.
What can be done to prevent bladder stones?
Hydration, diet, urinary alkalization.
- Increase hydration to 2-3Lurine/d – reduces risk by 50%! Can add Vit C since citrate reduces stone formation.
- Diet: maintain normal Ca (weird, why? this binds oxalate in gut so it doesn’t bind Ca in kidney!), minimize foods high in oxalate (e.g. spinach, almonds, choc, pop), DASH diet, Reducing Na intake - Sodium drags calcium into the urine so more likely to form a stone
- Consider urinary alkalization – with uric acid and cysteine stones. Potassium citrate (preferred) or sodium citrate (alternative).
Most common cancer in men 20-40, can be bilateral but mostly metachronous
Testicular Cancer
Types of testicular cancer?
- Seminoma - classic, anaplastic, spermatocytic
- Non-seminoma (embryonal, yolk sac, teratoma, choriocarcinoma)
Most common solid mass in testicle in older men?
Lymphoma
Risk factors for testicular cancer?
Cryptorchidism (decreased if orchidopexy performed before puberty), FHx, personal history of testicular cancer (contralateral testis), germ cell neoplasia in situ
Presentation for testicular cancer?
Presentation: painless testicular mass (CANCER until proven otherwise), 30% with distant mets:
- Neck mass (Left supraclavicular lymphadenopathy)
- Cough / SOB (lung mets)
- Back pain (retroperitoneal lymphadenopathy)
Evaluation for testicular cancer?
- History and Physical (firm testicular mass)
- Serum Tumor Markers
- Scrotal U/S
What are the serum tutor markers for testicular cancer?
AFP, LDH, HCG
AFP is from trophoblasts in fetal yolk sac, if high it is a _____?
NSGCT
____ can be elevated in both seminoma and NSGCT
HCG
Metastatic evaluation for testicular cancer?
CT chest/abd/pelvis. Needed for staging
Before staging of testicular cancer what surgery should be performed and how?
Radical Orchiectomy – very effective if tumor confined to testis, should not be delayed more than 1-2 w. Groin incision, don’t go through scrotal because it alters lymphatic drainage and increases risk of local recurrence. Orchiectomy through inguinal ligament for all stages
Define Stage 1 testicular cancer
Stage 1 - confined to testicle, CT scanning negative
Define Stage 1S testicular cancer
Stage 1S - take out testicle, CT scan normal, but tumour markers don’t normalize so you must repeat tumour markers - Implies that there is microscopic disease somewhere
Define Stage 2 testicular cancer
Stage 2 - enlarged lymph nodes in retroperitoneum below the diaphragm
Define Stage 3 testicular cancer
Stage 3 - Lymphatic metastases above diaphragm
Treatment of seminoma Stage 1?
Stage 1: Surveillance
Treatment of seminoma Stage 2/3?
Stage 2/3: Radiation + chemo
Treatment of non-seminoma Stage 1S, 2 and 3?
Stages 1S, 2 and 3 treated with chemo (BEP x 3 cycles)
Treatment of non-seminoma Stage 1?
Stage 1: Surveillance
Treatment post-chemotherapy NSGCT:
- STM normal and retroperitoneum LN <1cm – surveillance
- STM normal and retroperitoneum LN >1cm (risk of teratoma) – surgery
- STM high – chemo
What is a hydrocele
Collection of fluid between the visceral and parietal layers of the tunica vaginalis.
Childhood hydroceles can be due a ______
Patent processus vaginalis
Childhood hydroceles usually resolve by when?
It usually resolves by age one.
Clinical presentation of a hydrocele
<1yo or >40, chronic, not pain, TRANSILLUMINATES, urinalysis normal. Get a U/S if you cannot find the testicle and rule out any neoplasm.
Treatment of a hydrocele?
Treatment: aspiration (temporary) and surgical excision if large/bothersome, embarrassing, or painful!
What is a spermatocele?
Are sperm containing cysts within the epididymis caused by ductal obstruction.
Clinical presentation of a spermatocele?
Lesion is usually discrete non-tender, cystic mass, >40, chronic, TRANSILLUMINATES, urine normal.
Treatment of spermatocele?
Treat: excise if large/bothersome or leave alone.
What is a varicocele?
Dilation of veins of pampiniform plexus in spermatic cord
What percentage of varicocele are left sided, why?
> 90% on the left-side since the gonadal vein drains into renal vein @ right angle there
Clinical presentation of varicocele
“Bag of worms”, often painless, pulsates with valsalva
If right sided varicocele then order what?
CT abdo to r/o retroperitoneal CA
Treatment of varicocele
Can treat with varicocelectomy that ligates the incompetent vessels if showing any symptoms of infertility (impaired sperm quality or quantity, loss of testic volume, or pain).
What is an inguinal hernia?
Protrusion of abdominal contents through the inguinal canal into the scrotum
What is an indirect inguinal hernia?
Indirect - through internal ring, often into scrotum: congenital
What is a direct inguinal hernia?
Direct - through external ring, rarely into scrotum: abdominal muscle weakness
Clinical presentation of inguinal hernia?
o A small bulge in the groin that may increase in size with Valsalva and disappear when lying down
o Can present as a swollen or enlarged scrotum
o Discomfort or sharp pain - especially when straining, lifting, or exercising
What is a hematocele?
Trauma with bleed into tunica vaginalis
Why get a US when suspect a hematocele?
U/S helpful to exclude fracture of testis which requires surgical repair
Treatment of hematocele?
Treatment: icepacks, analgesics, surgical repair
Treatment for radiation induced hematuria
Hyperbaric O2
Treatment of chronic pelvic pain syndrome?
PT pelvic floor exercises
What are the two types of renal trauma and which is more common?
- 90% (BLUNT TRAUMA – MVA, falls, may cause contusion/laceration/avulsion)
- 10% (PENETRATING TRAUMA - stab wounds and gunshots)
Renal trauma treatment: microscopic hematuria + isolated well-staged minor injuries
No hospitalization
Renal trauma treatment: Gross hematuria + contusion/minor lacerations
Hospitalize, bed rest, repeat CT if bleeding persists
Staging for renal trauma
I – contusion or subcapsular hematoma.
II – non-expanding perirenal hematoma, <1cm cortical laceration
III - >1cm cortical laceration, no collecting system injury
IV - >1cm laceration or multiple extending into medulla/collecting system. A/V injury or controlled hemorrhage.
V – major vascular injury
Clinical features of renal trauma
- Mechanism of injury – suspicious
- Upper abdominal tenderness, flank tenderness, flank contusions, lower rib/vertebral transverse process fracture
Investigations for renal trauma
U/A - hematuria: requires workup but degree does not correlate with the severity of injury
Imaging - CT abdo (contrast, triphasic) - Penetrating trauma: ALWAYS DO CT. - Blunt trauma: • Adults – do CT if gross hematuria, microscopic hematuria + hypotension, or rapid deceleration injury. • Peds – ALWAYS DO CT.
Absolute indications for surgical intervention/minimally invasive angiography and embolization for renal trauma?
Absolute indications: hemorrhage and hemodynamic instability
Early and late complications of renal trauma?
Early – delayed bleeding, urinoma, abscess
Late – HTN, AV fistula, renal failure
Clinical features of bladder trauma?
Abdominal tenderness, distention, peritonitis, and inability to void
Can be hemodynamically unstable secondary to pelvic fracture
Suprapubic pain
80% of bladder injuries have associated _____
Pelvic fracture
Investigations of bladder trauma?
U/A: gross hematuria in 90%
Imaging (including CT cystogram and post-drainage films for extravasation)
Classifications of bladder trauma?
Contusion (30%) – mucosal disruption/no extravasation. Diagnosis of exclusion.
Intraperitoneal rupture (30%) – rapid rise in pressure, ruptures at dome, contrast will be seen in the abdo cavity!
Extraperitoneal rupture (60%) – extravasation in retropubic area, less severe pain, flame shaped collection of contrast at bladder base.
Penetrating trauma
Treatment of penetrating bladder trauma?
Penetrating trauma – surgical exploration
Surgical indications for extraperitoneal bladder perforations?
Surgery if: infected urine, rectal/vaginal perforation, bony spike into bladder, laparotomy for concurrent injury, bladder neck involvement, persistent urine leak and failed conservative management
Treatment for extraperitoneal bladder perforations?
Extraperitoneal bladder perforations – typically non-operative with foley insertion, and follow with cystograms. Possible surgery
Treatment for intraperitoneal bladder rupture?
Intraperitoneal rupture usually requires surgical repair and suprapubic catheterization
Least commonly injured as part of GU tract; injury can be external or iatrogenic (more common)
Ureteral Trauma
Treatment of ureteral trauma if immediate discovery?
Immediate discovery: definitive open repair or stent.
Treatment of ureteral trauma if delayed discovery?
<5days consider open repair; >5 days do percutaneous tube drainage with delayed repair.
Complications of ureteral trauma?
Urethral stricture, urine leak/urinoma, pyelonephritis.
Etiology of urethral trauma?
Posterior urethra: common site of injury is junction of membranous and prostatic urethra due to blunt trauma, MVCs, pelvic fracture. Shearing force on fixed membranous and mobile prostatic urethra
Anterior urethra: straddle injury can crush bulbar urethra against pubic rami. Confined to Buck’s fascia – “sleeve of penis” or Colle’s fascia if anterior.
Other causes: iatrogenic (instrumentation, prosthesis insertion), penile fracture, masturbation with urethral manipulation
Clinical features of urethral trauma?
Blood at urethral meatus High-riding prostate on DRE Swelling and butterfly perineal hematoma Penile and/or scrotal hematoma Sensation of voiding without U/O Distended bladder
Investigations of urethral trauma?
Must perform RUG or cystoscopy prior to catheterization
Treatment of partial urethral disruption?
- very gentle attempt at catheterization by urologist
- with no resistance to catheterization - Foley x 2-3 wk
- with resistance to catheterization - suprapubic cystostomy or urethral catheter alignment
Periodic flow rates/urethrograms to evaluate for stricture formation
Treatment of simple urethral contusion?
No treatment
Treatment of complete urethral disruption?
Immediate repair if patient stable, delayed repair if unstable (suprapubic tube in interim)
Periodic flow rates/urethrograms to evaluate for stricture formation
