Urology Flashcards
Management of renal stones
- < 0.5cm
- 0.5 - 2cm
- > 2 cm
<0.5 - increase fluid intake .5-2 = - ESWL (preferred) - Ureteroscopy w/ dorm is basket > 2 cm = - PCNL ( percutaneous nephrolithiotomy)
*** only 1 kidney + stone of any size +/- Anura,fever = Percutaneous nephrostomy
Stent to drain urine first
Stones + fever + hydronephrosis
What does it indicate?
Treatment?
Obstructive Uropathy
Tx - percutaneous nephrostomy
Percutaneous nephrostomy vs percutaneous nephrolithiotomy
Nephrostomy = stoma catheter to pelvicalyceal system for decompression
I.e draining obstructed fluid
Nephrolithiotomy = removal of stone percutaneously via scope
Imaging for suspected renal stone
Non- enhancing CT KUB
Unilateral loin/flank pain + positive hCG =
Suspected ectopic pregnancy
Features of inguinal hernia
Inguinoscrotal swelling - can’t get above it
+ cough impulse
May be reducible
Features of testicular tumours
Investigations required
Discrete testicular nodule / may have associated hydro electric
Symptoms of metastatic disease
- US Scrotum , serum AFP, Beta HCG
Features of acute epididymo-orchitis
Treatment
Dysuria, painful micturition Pain and urethral discharge \+- fever Tender, red scrotal skin \+ve phren’s sign
Tx - antibiotics
Most cases of acute epididymis-or hit is are due to
Chlamydia ( sexually active male)
What is Prehn’s sign ?
Relief of scrotal pain by elevating testicle
Features of epididymis cysts
Diagnostic test
Develop slowly
Can be single or multiple
May contain clear or opalescent fluid
M >40 yrs
- painless, non tender
- lies above and behind testis (upper pole, post part of testes)
= US - diagnostic
Features of hydrocele
Non painful , fluctuate
Clear fluid
Transilluminates
May be presenting feature of testicular ca in young men
Features of testicular torsion
Treatment
Severe, sudden onset of testicular pain
Adolescents and young males
Tender + phren’s sign -ve
Tx - urgent exploratory surgery + fixation *always fix the contra lateral testis
Features of varicocele
Varicosities of pan-pinniform plexus Bag of worms Typically on the left side Dull ache/dragging pain - worse after excercise or at end of the day May show cough impulse
Why does varicocele typically occur on the left side?
Left testicular vein drains into renal vein directly at right angle - high pressure
What can varicocele’s be a presenting feature of ?
Renal cell carcinoma
Renal pain + hematuria + varicocele
Investigation for varicocele
Management
Scrotal Doppler
US is diagnostic
M- reassurance unless in severe pain or infertility
= surgery
Management of testicular malignancy
Orchidectomy via inguinal approach
Treatment of epididymal cyst
Excision via scrotal approach
Management of hydrocele
Children - inguinal approach
- underlying pathology is patent processus vaginalis = processus is fixed.
Adults - scrotal approach
= hydrocele excised or plicated
Major complications of untreated chlamydia/ N. Gonorrhoea in males and females
Males - epididymitis , epididymo-orchitis
Females - salpingitis
Important association of mumps that is not always seen
Or hit is
4-5 days post -parotitis
Local severe pain + tenderness, impalpable testes, swollen scrotum
When do we suspect interstitial cystitis ?
What’s the next step?
Urinary urgency + frequency + suprapubic pain
+ negative culture
- it is a dx of exclusion
Next step - cystoscopy to R/O bladder ca
What is seen on cystoscopy of 10% of patients with interstitial cystitis?
Hunner’s ulcers
1st and 2nd line treatment of interstitial cystitis
1 - bladder training (pelvic floor relaxation) + avoid triggers coffee, NSAIDS for pain
2- amitriptyline, Gabapentin
What is a vesicovaginal fistula?
Common causes
Tract between bladder and vagina
Cause - gynaecological/urinary surgeries esp hysterectomy
- pelvic radiotherapy
Diagnostic test for vesicovaginal fistula?
3 swab test / vaginal gauze test
3 sponges placed in vagina 1 above the other
Bladder - filled with methylene blue via catheter
Swabs removed after 10 mins
RESULTS
Top swab wet but not discoloured - ureterovaginal fistula
Top or middle swab blue - vesicovaginal fistula
Top and middle swab dry, last swab discoloured - urethrovaginal fistula
Cause of stress incontinence
Treatment
Weak bladder outlet
Weak pelvic floor muscles
Tx - pelvic floor excercise (8 contractions/ 3x per day) *of choice
- If fails - surgical retro public mid-urethral tape = free-tension vaginal tape
- If surgery not possible - Duloxetine
Cause of urge incontinence
Treatment
Detrusor over-activity
Tx :
- bladder drill (retraining)
= gradually increase periods between voiding for 6 weeks
- meds - antimuscarininc (immediate release oxybutynin)
Breakdown of LUTS in BPH
Voiding (obstructive) - weak flow, straining, hesitancy dribbling, incomplete emptying
Storage symptoms (irritative)- urgency, frequency, incontinence, nocturis
Post -micturition - dribbling
Complications of BPH
UTI, retention, obstructive uropathy
DRE findings BPH
Firm enlarged smooth
Not nodular
BPH management
Watchful wait
Meds -
-1st line = alpha 1 blockers - tamsulosin, doxazocin, alfuzocin
= side effects - postural hypotension, drowsiness, dyspnea, cough
- 5 alpha reductive inhibitors - finasteride
Surgery - TURP
Tamsulosin vs Finasteride in BPH
Tamsulosin tried FIRST
Finasteride is drug of choice if :
LUTS + prostate enlargement + **RAISED PSA >1.4
Urinary flow obstruction, relieved with catheter
What should be tried before jumping to surgery?
Tamsulosin + refer for trial without catheter (TWOC)
TWOC for 1-2 days after giving Alpha 1 blockers - they relax the smooth muscle of prostate and bladder
The trial is to see if voiding will happen or if further management needed
What is TURP syndrome?
During TURP - excessive irrigation is done to allow good visualisation
Fluid can leak = Dilutional hypOnatremia
= presents as confusion and agitation
What is the most common cancer in adult males in the UK?
Prostate ca
Risk factors of prostate ca
Afro Caribbean
Increasing age
Obesity
Family history 5-10%
Features of prostate ca
Early localised prostate ca - asymptomatic
Other possible features
- BOO - hesitancy, retention
-Hematuria, hematospermia
- pain - back, suprapubic, perineal or testicular
Weight loss
Prostate ca on DRE
What is the appropriate/initial investigation?
Asymmetrical, irregular, hard, nodular enlargement
Loss of median sulcus
I-
1st line = Multiparametric MRI
Serum PSA - most appropriate F/U investigation
When should you suspect prostate ca based on PSA?
40-49 yrs - PSA >_ 2.0 ng/ml
50-69 yrs >= 3
>70 - >= 5
Most common tumours causing bone mets
Prostate
Breast
Lung
Most common sites of bone mets
Spine- = cauda equine syndrome - saddle paresthesia, unable to initiate voiding, back pain —— Urgent MRI spine Pelvis Ribs Skull Long bones
Features of bone mets
Pathological fractures
Hypercalcemia*****
Raised ALP
Increased thirst