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urology Flashcards

1
Q

Nerves involved in micturtion (urination)?

A

0 Pelvic nerve - realeases ACH which binds to muscarinc receptors on detrusor muscle (causes contraction & urination) - PARASYMPATHETIC CONTROL

0 Pudendal nerve - releases ACH which binds to nicotinic receptor on external sphincter (causes contraction - holds urine in when we are trying to not go to the toilet) - SOMATIC CONTROL (we control it )
(both come from the sacrum nerve region)

Hypogastric nerve - comes from lumbar region ( splits in to , one to B3 adrenorecptor (causes relaxation detrusor muscle ) and the other to A1 adrenoreceptor ( causes contraction of internal sphincter - allows storage of urine ) - releases noraadrenaline

Overall - SYMPATHETIC (hypogastric nerve ) (RESPONSIBLE TO URINE RENTION
PARASYMPATHETIC (pelvic nerve) - VOIDING / PEEING)

  • also afferent pelvic nerve (which is stimulated when the bladder is stretch - initiates the micturition reflex.
    PONS contains micturition centre
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2
Q

Differences between female and male urinary tract?

A

Female - no prostate , shorter urinary tract , and no internal sphincter .

(Men have both internal and external sphincters - )
* internal is to prevent reflux of seminal fluids into the male bladder during ejaculation.

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3
Q

What are lower urinary tract symptoms ?

A 
Storage 
- Increased frequency
- Increased urgency 
- staining 
- incontinence
( Bed wetting -sign of chronic rention)
- Nocturia

Voiding

  • Poor flow
  • Interrupted stream
  • Urinary rention
  • hesitanncy
  • terminal dribble (prolonged final part of micturition)

Post voiding

  1. Incomplete evacuation
  2. Post Micturition dribble (dribble after you have left the toilet -so finished urination)
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4
Q

Exams & Investigations for men with LUTS ?

A

EXAMS

0 Exam of abdomen - for distended bladder , abdominal distention , supra pubic/ hypo gastric (below umbilicus region dullness on percussion )
May signify - distended bladder

0 Digital rectal exam - assess prostate & any possible masses
( Prostate cancer )

0 examination of extenal genitalia
(checking for meatal stenosis (opening of the penis - meatal scarring from penis injury can cause narrowing ) , Phimosis (inability to retract foreskin - it is too tight , cause voiding dysfunction ) , Penile cancer .

0 Examination of perineum, lower limbs to assess motor and sensory function
(neurogenic bladder - MS , Diabetes , Parkinson’s disease etc )

INVESTIGATIONS

Urine dipstick

serum creatinine - EGFR
PSA

International prostate symptoms score

Bothersome LUTS - should be advice to to do urinary frequency - volume chart.

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5
Q

Causes of LUTS in men ?

A 
Structural abnormalities in prostate , bladder , bladder neck , urethral sphincter & urethra 
0 BPH 
0 Cnacer of prostate , bladder , rectum 
0 Urethral stricture 
0 Phimosis 
0 Detrusor muscle weakness
o Primary bladder neck obstruction ( bladder neck does not open enough during during voiding )
(Cause voiding symptoms )

0 Drugs with antimuscarnic action ( muscranic receptors contract bladder allowing urination ) e.g. Tricyclic antidepressants , antimuscarnic drugs for urinary incontinence ( oxybutynin , tolterodine , darifenacin), disopyramide(prevention of supraventricular and ventricular arrythmias )

( Voiding symptoms & stress incontinence )

Abnormal peripheral or central nervous system which control bladder& spincter

  • Diabetic autonomic neuropathy
  • Neurogenic bladder
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6
Q

What is Overactive bladder syndrome ?

A

Set of storage symptoms - urgency , incontinence , frequent urge to urinate after just going etc.

CAUSES

0 BPH & enlargement
0 Neurogenic bladder - stroke , MS , diabetic neuropathy , Parkinsons, dementia )

0 Lower urinary tract infection

0 Bladder stones
0 Cancer of bladder , prostate.

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7
Q

What is stress urinary incontinence ?

A

involuntary leakage of urine cause by excretion ( sneezing , coughing , exercise , laughing , intercourse )

CAUSES

Malfunction in urethral sphincter by :

injury to urethral area
0 Prostatecromy or other surgery to pelvic area.

or

Drugs

0 that increase urine production e.g. caffeine , alcohol , diuretics

0 Alpha blockers - relax bladder & urethra - prevents contraction of internal sphincter of bladder.

That cause overflow incontinence due to urinary rention
1. with antimuscarnic action ( muscranic receptors contract bladder allowing urination ) e.g. Tricyclic antidepressants , antimuscarnic drugs for urinary incontinence ( oxybutynin , tolterodine , darifenacin), disopyramide(prevention of supraventricular and ventricular arrythmias ), sedative antihistamines

  1. Opiod analgesics
  2. sympathomimetics e.g. pseudoephedrine
  3. reduce awareness and need to urinate
    ( zopiclone , zolipidem )
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8
Q

Indications of zoplicone , pseudoephedrine ?

A

Zoplicone - sleeping pill for insomnia

Pseudoephedrine - decongestant - for nasal congestion.

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9
Q

What causes acute urinary rention?

A

0 Chronic outflow obstruction

  • BPH ( common)
  • Prostate cancer - uncommon

0 Stones or blood clots in urethra

0 Urethral stricture

0 severe constipation

0 Pelvic tumour

0 Perineal pain

Drugs such as
those with :

antimuscarnic action ( muscranic receptors contract bladder allowing urination ) e.g. Tricyclic antidepressants , antimuscarnic drugs for urinary incontinence ( oxybutynin , tolterodine , darifenacin), disopyramide(prevention of supraventricular and ventricular arrythmias ), sedative antihistamines

  1. Opiod analgesics
  2. Anaesthetics
  3. sympathomimetics e.g. pseudoephedrine
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10
Q

Contraindications of alpha blockers ?

A

Alpha blockers - relax muscles e.g smooth muscle in BV (treat hypertension ) & internal spincter , urethra ( LUTS - voiding)

Alpha blocker - block the alpha 1 adrenorecptor
(located on internal spincter & urethra - which contracts to prevent micturition)

Indications - improve voiding symptoms

CONTRAINDICATIONS

Hx of
0 Postural hypertension
0 Micturition syncope (9 fainting during or immediately after urinartion due to severe drop in BP).

Prescribe in caution to people with raynaud’s pehneomemon.

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11
Q

Causes of Scrotal pain

A

Acute torsion
( acute testicular torsion in children and young adults is testicular torsion until prove otherwise)

Fournier’s gangrene

Testicular mass - hyrodceles , testicular cancer , epiymimal cyst.

Infections of epididymis /orchitis

Rule out referred pain :

  • Ureteric stones
  • Hernias
  • Myofascial pain
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12
Q

What is testicular torsion ?

A

Spontaneous condition - Twisting of testicle on spermatic cord.

UROLOGICAL EMERGENCY - TIME SENSITIVE ( want to prefect infarction & infertility & necrosis ) - within 6 hrs (good), within 12hrs - 50 % of resolve , after 24hrs -NOT GOOD.

Just after birth , young adults .

SIGNS & SYMPTOMS

0 Sudden severe testicular/ scrotal pain (- may exist on its own - most common)

(may experience abdominal pain)

  • Hx of intermittent acute on & off pain may indicate periods of torsion & spontaneous detorsion

0 High riding testicle ( due to shortened testicle ) vs unaffected side

0 Horizontal lie (tesicle may lie horizontal)

0 Absent cremasteric reflex ( inner thigh stroked , testicle pulled upwards (retraction ) towards inguinal canal )
( cremaster muscle located in the testes - contracts pulling testiscle towards inguinal canal )

0 Nausea & vomiting (especially in paedriatrics)

With time :

0 Scrotal swelling - becomes worse as time goes on.

0 Scrotal erythema

RISK FACTORS

  • Age under 25
    (12 -18 most affected)
  • Neonates
  • Bell clapper deformity (tunica vaginalis is highly attached to the cremaster muscle so testes is free in the scotum moving around like a bell - predisposes to intra - vaginal distorsion)
  • undescended testes

-

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13
Q

Neurovasculature of the testicle?

A

Arterial : testicular arteries ( arise directly from the abdominal aorta )

Venous supply - Pampiniform plexus into testicular veins.

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14
Q

Intra vaginal vs extra vagina distorsion?

A

INtra - inside tunica vaginalis
( young children and adults )

Extra - outside tunica vaginalis.
( happens during fetus development when testes descend - so usually found in neonates - at bith)

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15
Q

Treatment of testicular detorsion?

A

Non - neonate

1ST LINE

  • Discussion of immediate emergency scrotal exploration
    (DO SURGERY )
  • Pain relief
    (in extreme pain)
  • May need antiemetics (for nausea & vomiting )

2ND LINE

Manual de-torsion followed by scrotal exploration
(if surgery not available within 6 hrs)

NEONATE

1ST LINE

if torsion at birth
(stabilisation & urologica consultation on surgery )

If normal testes at birth but developed torsion - immediate urological consultation for emergency scrotal surgery .

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16
Q

Treatment of testicular detorsion?

A

Non - neonate

1ST LINE

  • Discussion of immediate emergency scrotal exploration
    (DO SURGERY )
  • Pain relief
    (in extreme pain) - morphine
  • May need antiemetics (for nausea & vomiting )- Ondansetron

2ND LINE

Manual de-torsion followed by scrotal exploration
(if surgery not available within 6 hrs)

NEONATE

1ST LINE

if torsion at birth
(stabilisation & urologica consultation on surgery )

If normal testes at birth but developed torsion - immediate urological consultation for emergency scrotal surgery .

17
Q

What is hydrocele ?

A

Collected of fluid btw parietal and visceral layer of tunica vaginalis .

TYPES

0 Communicating (patent process vaginalis - so peritoneum connected with tunica vaginalis - peritoneal fluid flows freely btw them. 
(LARGE PATENT PROCESS VAGINALIS - IS A RISK FACTOR FOR INGUINAL HERNIAS.)

0 Non -communicating (simple ) - Tunica valginalis - producing more fluid than it can absorb)

SIGNS & SYMPTOMS

0 Scrotal mass
( may be soft if large , tense if small .) , may restricted to scrotum or extend to canal )

  • may enlarge following activity ( if communicating ) - increased intra - abdominal pressure e.g crying , straining , raising arms - increaes peritoneal flow to scrotum.
    (also means is smaller in the morning after lying down (reduce intra- abdominal pressure ) than evening / afternoon)
0 Transilimination 
( fluid so most  are easily transilluminted)

RISK FACTORS

  • Male
  • Prematurity & low birth weight
  • infants :
    < 6 months
    Late descended testes
  • Increased intra - abdominal pressure e.g. ascites , peritoneal dialysis , shunts if patent process vaginalis .

0 Infection , minor trauma , torsion , epididymitis ( can cause inflammation - causing non - communicating hydroceles )

0 Testicular cancer

0 Connective tissue disorders (communicating )

0 Varicocelectomy - most common complications of this .

  • Note hyrocele can happen in females not as common , - Happen along canal of Nuck
    (abnormal patent pouch of parietal peritoneum extending from round ligament of uterus anteriorly to labia majora via inginal ring into canal. ( female equivalent of patent process vaginalis in males)
    ( OVERALL CONNECTION BTW PERITONEAL CAVITY , INGUINAL CANAL , LABIA MAJORA)
18
Q

Investigations & Diagnosis - hydrocele?

A

Clinical diagnosis

Consider

Ultrasound
( if unable to palpate testis , fever , gastro symptoms ( N & V , constipation, shadow on transillumination) - may signify another differetial

In females 
(Inguina ultasound done )
19
Q

Treatment of hydrocele ?

A

Below two / infants and toddlers

1ST LINE
(observation and reassurance )
- will usually resolve by 2 years of age .

2ND LINE
Surgery

  • underlying pathology
  • If not resolved by age 2 , or not decreasing in size
  • Palpable abdominal mass as wells as scrotal hydrocele -(suggest abdominal - scrotal hydrocele)
  • Co -concomitant inguinal hernia suspected.
  • Hydrocele localised to spermatic cord.

ADULTS

Idiopathic & no discomfort

( Consider observation & reassurance )

Underlying causes - torsion , infection , orchitis , epididymisis , testicular cancer , trauma , varicocele operation )

  • if 20 - 40 with no palpable testis -arrange scrotal ultrasound .

Discomfort or infection

1ST LINE

Surgery or aspiration and sclerotherapy
( sclerotherpay - injection of irritant into vein causing it to scar , forcing blood to re - route to healthier veins - used to treat varicose veins & spider veins. )

20
Q

What is Acute Epididymitis ?

A

Inflammation of the epididymis
( CAN BE ACUTE OR CHRONIC )

SIGNS & SYMPTOMS

0 Scrotal pain

0 Swelling (less than 6 weeks (Acute ) , more (Chronic)

(* these are usually unilateral and gradual in onset vs torsion (sudden severe pain)

  • if there is Hot , erythematous swollen hemiscrotum - e.g. diffuse enlargement of testes - Epidiymo-orchitis.

0 Tender epididymis ( tender tubular structure posterior testes. )

0 Fever - if bacterial cause.

If caused by :

STI - purulent utheral discharge

UTI - frequent urination & painful micturition (associated with Lower urinary tract infection)

Reactive hydrocele or abscess formation (if fluctuant swelling or induration (hardening of soft tissue ,becomes firm but softer than bone) of scrotal tissue )

CAUSES

0 STI
(risk factor unprotected sex)
0 UTI
( RF : Bladder outflow obstruction e.g. BPH )

RF :

  • Unprotected sex
  • Bladder outflow obstruction
    ( incomplete bladder emptying and high volume voiding pressures - cause reflux of infected urine into ductal system)
  • Instrumentaion of urinary tract
    ( Catherisation . Cystoscopic procedures

Weak

-Immunosuppression
(due to HIV , Diabetes , transplant etc)
* Candida albicans , haemophilus influenza , Myobacterium TB , cytomegalovirus
(most seen in HIV patients)

  • Candida spp. (another form of candida ) , Norcardiosis
    (most seen in diabetes )
  • Vasculitis
  • mumps
  • Exposure to TB
  • Amiodarone ( treat cardiac dysrhythmias )
    (drug induced amiodarone ) - at certain high serum conc of the drug , Body produces antibodies that attack the epididyimis)
21
Q

Diagnosis and investigation of epididymitis ?

A
  • Gram stain of urethral secretions - in mean with purulent discharge , dysuria (symptoms of urethritis)
  • urine dipstick test (WBC)
  • urine culture (isolate causative organism)
  • urine microscopy (WBC)
  • urethral secretions culture & NAAT (nucleic acid amplification test )
    (NAAT is preffered for N gonorrhoeae , C tracgomatis , M genitalium )

Consider :

  • Colour duplex ultrasound - if abscess or torsion / infarction)
  • HIV test
  • Syphillis test

( done for p at risk of STI)

22
Q

Causes of epididymitis/

A

Bacterial causes e.g. TB etc

( retrograde ascent of bacterial pathogen from bladder and urethra to epididymis via vans deferens & ejaculatory ducts)

Non - bacterial epididymitis

Amidarone induced

Vasculitic.

23
Q

Most common cause of Acute scrotal pain?

What questions would you ask?

A

Epididymitis.

Ask about :

Sexual history e.g STI

LUTS - Urinary tract infections

Recent instrumentation.

24
Q

Differentials of Epididymtitis ?

A

Testicular torsion
( Sharp severe pain vs gradual pain build up of epididymitis)
* Negative Prehn’ s sign
( if testicular torsion - when affected hemiscrotum is elevated - relief of pain ( if not - negative)

0 infected hydrocele
( hx of pre - existing hydrocele

0 Acute idiopathic scrotal oedema - usually pediatric pop but can be adults
- redness , oedema (usually painless )
bilateral or unilateral)

0 Strangulated inguinal hernia

0 Testicular tumour - painless swelling , gradual onset - but can mimic epididymitis

  • Ultrasound used differientiate them all
25
Q

What is Cystitis ?

A

Inflammation of the bladder .

TYPES

UNCOMPLICATED - no complicating factors

  • Uncomplicated acute cystitis should be differentiated from asymptomatic bacteria

COMPLICATED - associated with complicating factors preventing it from resolving with short course of antibiotics :

  • Male
  • Pregnancy
  • Indwelling urinary catheter
  • recent instrumentation
  • recurrent UTI
  • failed treatment for uncomplicated .
  • Immunosupression
  • abnormally functioning bladder.
26
Q

What is Cystitis ?

A

Inflammation of the bladder .

TYPES

UNCOMPLICATED - no complicating factors

  • Uncomplicated acute cystitis should be differentiated from asymptomatic bacteriauria (ABU)
COMPLICATED - associated with complicating factors preventing it from resolving with short course of antibiotics :
- Male
- Pregnancy 
- Indwelling urinary catheter 
- recent instrumentation
- recurrent UTI
-  failed treatment for uncomplicated . 
- Immunosupression
- abnormally functioning bladder. 
- Diabetes 
( requires longer , more agressive antibiotics. )
27
Q

What is ABU ?

A

asymptomatic bacteruria - 2 consecutive mid - stream samples in women & 1 in men with absence of urinary tract symptoms.

Not infection but commensal colonisation.
( commensal bacteria - supply host with nutrients and defend body against opportunistic infections )

SIGNS & SYMPTOMS

  • dysuria
  • Urgency
  • Frequency
  • suprapubic pain ( might be seen ) - Prior history of UTIs and treatment history .

Compliactions

Pyelonenephitis (inflammation of the kidney - upper UTI infection cann start in bladder , urethra and work its way up to kidney) - present with :

Flank pain
Abdominal pain
Fever

May have vaginitis at the same time :

  • Vaginal discharge
  • Vaginal pruritus .

RF :
0 Frequent sexual intercourse

0 Hx of UTI
0 Urinary catheter
0 Spinal cord injuries
0 Pregnancy ( cystitis & ABU quickly progress to pyelonephritis - which has potential for fetal loss)

0 Immunodeficiency
0 Older age 
0  Diabetes 
0 ABU 
0 Congenital urological abnormality
28
Q

Investigation of cystitis ?

A

0 Urinalysis
- positive to leukocyte esterase (suggest WBC present) , nirities (bacteria change nitrates to nitrites) , Haemoglobin)

0 Urine microscopy

0 urine culture with sensitivity

29
Q

UTI - treatment , not pregnant

A

NOT PREGNANT OR CAHETERIZSED, NO HAEMATURIA

Simple analgesia + antibiotics (if indicated - treat empirically or based on recent culture sensitivities . )

  • Nitrofurantoin 100mg ( treats UTI )
  • Trimethoprim 20mg
  • Pivmecillinam 400 mg intial , then 200 for 3 days
    ( only suitable in uncomplicated UTIs or blocked catheter )
  • fosfomycin 3g sachet

RECURRENT UTI

0 Referral to specialist + behavioral & personal hygiene measures (wiping front to back , hydration , avoid occlusive underwear) + ANTIBIOTIC PROPHYLAXIS :
( if nothing else working ):
- Trimeth
- Nitrofuran
- Amoxicillin
- Cefalexacin
( only start this was acute UTI has been treated - patient should be aware that if breakthrough Acute UTI come back in)

  • IF HAEMATURIA - retest after completion of course of antibiotics to see if blood still present ——————–> if so , urgent referral for urological , gynaecological cancers.
    ( if pregnant refer to obstetrics )

IF INDWELLING CATHETER - check blockage - change , send sample of urine (mid - stream ) , the antibiotics )

  • Nitrofuran 100mg - 7 days
  • Trimethprim 200mg - 7 days
  • Amoxicillin 500mg - 7 days

2nd

Pivmecillinam , 400mg intiak then 200mg - 7 days
( only suitable in uncomplicated UTIs or blocked catheter )

30
Q

Treatment of ABU ?

A

Choose from these based on sensitivities from recent culture.

Nitrofuran 1?00mg
- Amoxcillin 500mg (only after results from C & S)
- Cefalexin 500mg
( all 7 days)

  • if risk of complicated UTI - specialist referral

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