Urology Flashcards
What is epididymo-orchitis
Clinical syndrome consisting of pain, swelling and inflammation of epididymis, with or without inflammation of the testes
What is orchitis
Infection limited to the testis
Most common cause of epididymo-orchitis in men under 35 yrs old
Sexually transmitted pathogen such as chalmydia trachomatis and neisseria gonorrhoeae
Most common cause of epididymo-orchitis in men over 35 years old
Non-sexually transmitted gram neg enteric organism such as escherichia coli, pseudomonas spp etc
Risk factors include recent instrumentation or catheterisation
Aetiology of acute orchitis
Viral: Mumps, coxsackie A, varicella
Bactieral: E. coli
Granulomatous: Syphilis, TB
Presentation of epididymo-orchitis
Unilateral scrotal pain and swelling(acute)
Symptoms of urethritis or urethral discharge
Symptoms of underlying cause(mumps, TB)
IX for epididymo-orchitis
Gram-stained urethral smear
MSU
HIV testing
General advice for epididymo-orchitis
Rest, analgesia and scrotal support
NSAIDs
Avoidance of sexual partner until completion of treatment
Medical management of epididymo-orchitis
If epididymo-orchitis is thought to be due any sexually transmitted organism, including gonorrhoea:
Treat without waiting for test results with ceftriaxone 1g intramuscular (IM) injection plus doxycycline
If epididymo-orchitis is thought to be due to chlamydia or other non-gonococcal organism:
Treat orally with doxycycline or ofloxacin
If epididymitis is thought to be due to sexually transmitted chlamydia and gonorrhoea and/or enteric organisms:
Consider treating with 1g ceftriaxone IM plus ofloxacin 200 mg orally twice daily for 10 days.
If epididymo-orchitis is thought to be due to an enteric organism (for example, Escherichia coli):
Treat without waiting for test results with ofloxacin levofloxacin
Complications of epididymo-orchitis
Reactive hydrocele
Abscess formation and infarction of the testicle
Infertility
Testicular atrophy in mumps
Causes of AUR in men
BPH
Meatal stenosis
Paraphimosis and phimosis
Prostate cancer
Infections such as balanitis and prostatic abscess
Causes of AUR in women
Prolapse(cystocele, rectocele)
Pelvic mass(malignancy, fibroid, ovarian cyst)
Acute vulvovaginitis
Drug-related causes of AUR
Anticholinergics(antipsychotics, antidepressants)
Opioids
Alpha agonists
Benzodiazepines
NSAIDs
Which precipitants should be considered in AUR
Alcohol consumption
Recent surgery
UTI
Constipation
Large fluid intake
Cold exposure or prolonged travel
PMH
Meds
Appropriate imaging ix for AUR
Ultrasound - can provide a measure of post-void residual urine
CT scan
Initial management of AUR
Immediate and complete bladder decompression(immediate catheterisation for men)
Alpha-blocker should be offered before removal of catheter
Pharmacological treatment for post-op retention
Cholinergics
Intravesicle prostaglandin
Secondary management of AUR
Prostatic surgery
Trial without catheter(TWOC) for men with BPH and AUR
Alpha-blocker is prescribed before commencing TWOC
Complications of AUR
UTIs
AKI
Post-obstructive diuresis
Post-retention haematuria
Prevention of AUR in men with BPH
Long-term medical treatment(5-reductase inhibitors alone or in combination with alpha-blockers)
What does chronic urinary retention refer to
Painless inability to pass urine
Significant bladder distension due to long standing retention resulting in bladder desensitisation
Most common cause of chronic urinary retention in men
Benign prostate hyperplasia (BPH)
Most common cause of chronic urinary retention in women
Pelvic prolapse or pelvic masses
Clinical features of chronic urinary retention
Painless urinary retention
Associated voiding LUTS(weak stream and hesitancy)
Reduced functional capacity(ability of bladder to store urine)
Overflow incontinence may also be present
Nocturnal enuresis
IX for chronic urinary retention
Post-void bedside bladder scan
What is high-pressure urinary retention
Refers to urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and backs up into upper renal tract
what does high-pressure urinary retention lead to
Hydroureter and hydronephrosis
What is low pressure urinary retention
Occurs in patients with retention with the upper renal tract unaffected due to competent urethral valves or reduced detrusor muscle contractility/complete detrusor failure
What is post-obstructive diuresis
Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate
Over-diuresis can lead to worsening AKI
Mx of chronic urinary retention
Patients with high post-void volumes or high pressure should be catheterised long-term
Should not undergo a TWOC due to concerns of repeat renal injury
What is an option for chronic urinary retention if patients do not wish for a long term cath
Intermittent self catheterisation
Complications of chronic urinary retention
UTIs
Bladder calculi
Chronic kidney disease
What is vesicoureteral reflux(VUR)
Refers to urine refluxing from the bladder back into the ureters
Presentation of upper urinary tract obstruction
Loin to groin or flank pain on the affected side (due to stretching and irritation of ureter and kidney)
Reduced or no urine output
Non-specific systemic symptoms, such as vomiting
Impaired renal function on blood tests (i.e. raised creatinine)
Presentation of lower urinary tract obstruction
Difficulty or inability to pass urine (e.g., poor flow, difficulty initiating urination or terminal dribbling)
Urinary retention, with an increasingly full bladder
Impaired renal function on blood tests (i.e. raised creatinine)
Common causes of upper urinary tract obstruction
Kidney stones
Tumours pressing on the ureters
Ureter strictures
Retroperitoneal fibrosis
Bladder cancer
Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)
Common causes of lower urinary tract obstruction
Benign prostatic hyperplasia (benign enlarged prostate)
Prostate cancer
Bladder cancer (blocking the neck of the bladder)
Urethral strictures (due to scar tissue)
Neurogenic bladder
what does neurogenic bladder refer to
Refers to abnormal function of the nerves innervating the bladder and urethra. It can result in overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra.
Key causes of neurogenic bladder
Multiple sclerosis
Diabetes
Stroke
Parkinson’s disease
Brain or spinal cord injury
Spina bifida
Consequences of neurogenic bladder
Urge incontinence
Increased bladder pressure
Obstructive uropathy
Management of obstructive uropathy
Nephrostomy
Urethral or Suprapubic catheter
What is a nephrostomy
A nephrostomy may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone).
A nephrostomy involves surgically inserting a thin tube through the skin at the back, through the kidney and into the ureter. This tube allows urine to drain out of the body, into a bag.
Complications of obstructive uropathy
Pain
AKI(post-renal)
CKD
Infection
Hydronephrosis
Urinary retention
Overflow incontinence of urine
What is idiopathic hydronephrosis as a result of
Result of a narrowing at the pelviureteric junction (PUJ) – the site where the renal pelvis becomes the ureter. This narrowing may be congenital or develop later.
Mx of idiopathic hydronephrosis
It can be treated with an operation to correct the narrowing and restructure the renal pelvis (pyeloplasty).
Typical features of hydronephrosis
Vague renal angle pain and a mass in the kidney area
Imaging ix for hydronephrosis
Ultrasound
CT KUB or iV urogram
Treatment of hydronephrosis
Treat underlying cause
Percutaneous nephrostomy
Antegrade ureteric stent
Where do cancers in the bladder arise from
Cancer in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.
Risk factors for bladder cancer
Smoking
Age
Aromatic amines(dye and rubber industries)
Schistosomiasis(SCC of bladder)
What type of bladder cancer do factory workers in industries such as dye and rubber tend to get
Transitional cell carcinoma of the bladder
Types of bladder cancer
Transitional cell carcinoma (90%)
Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma
Presentation of bladder cancer
Painless macroscopic haematuria
When do NICE recommend two week wait referral for suspected bladder cancer
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
Diagnosis of bladder cancer
Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.
Staging of bladder cancer
TNM
There is a clear distinction between:
Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
Muscle-invasive bladder cancer (invading the muscle and beyond)
Mx of bladder cancer
Transurethral resection of bladder tumour(TURBT)
Intravesical chemotherapy
Intravesical BCG vaccine
Radical cystectomy
Radiotherapy may also be used
What is TURBT
Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.
When is intravesical chemotherapy used
Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.
Use of BCG in bladder cancer treatment
Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.
Options for drainage of urine following a radical cystectomy
Urostomy with an ileal conduit (most common)
Continent urinary diversion
Neobladder reconstruction
Ureterosigmoidostomy
What type of cancers are most prostate cancers
Adenocarcinomas that grow in the peripheral zone of the prostate
Key risk factors for prostate cancer
Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids
Presentation of prostate cancer
Asymptomatic
LUTS(similar to BPH)
Hesitancy, frequency, weak flow, terminal dribbling and nocturia
Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)
Above what age can men request PSA
Men over 50
Common causes of raised PSA
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
How might a cancerous prostate feel on palpation
A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation.
In primary care, these findings require a two week wait urgent cancer referral to urology.
1st line ix for prostate cancer
Multiparametric MRI of prostate
2nd line ix for prostate cancer
Prostate biopsy - Transrectal ultrasound-guided biopsy(TRUS), transperineal biopsy
Main risks of prostate biopsy
Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction (rare)
Grading prostate cancer
Gleason grading system based on histology from prostate biopsies
Mx of prostate cancer
Depending on the grade and stage of prostate cancer, treatment can involve:
Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery
what is a key complication of external beam radiotherapy
A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum.
Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.
What is brachytherapy
Involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis).
Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.
Purpose of hormone therapy in prostate cancer mx
Aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:
Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)
Side effects of hormone therapy in prostate cancer mx
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
Key complications of radical prostatectomy
erectile dysfunction urinary incontinence
Which type of rta causes nephrolithiasis
Type 1 RTA
