Urology Flashcards
Differential Diagnosis: Renal Mass
Splenomegaly Hepatomegaly Adrenal Pathology Retroperitoneal Mass Colon Mass
Reasons Serum Creatinine is a better indicator of renal function than Serum Urea
Less influenced by diet
More specific for renal function
Production rate relatively constant
State of hydration has little effect unless GFR affected
Advantages: Ultrasonography
Real-time Accurate anatomical information Non-invasive Available Safe Mobile First choice: children, babies Distinguish solid vs cystic
Disadvantages: Ultrasonography
Certain structures not visualised Operator dependent No renal function information Equipment quality dependent Limited in obesity No scout image
Components: Cystoscope
Light source
Fibre-optic cable
Red lens system/ fibre-optic system
Sheath for irrigation fluid
Difference between rigid and flexible cystoscope
Rigid: Red Lens System
Flexible: Fibre Optic System
Procedures that can be done by cystoscopy
Biopsy for histology
Stone removal
Resection of tumours (prostate, bladder)
Complications of cystoscopy
Perforation
Infection
Irritation by contrast media
Types of catheter material
Latex
Silicone (silastic)
Time of indwelling for different catheters
Latex: 1 week max
Silicone: 3 months max
Advantages of different catheters
Latex: cheap
Silicone: little urethral damage
Disadvantages of different catheters
Latex: irritable to urethra, forms encrustations
Silicone: expensive
Indications for suprapubic cystostomy
Suspected traumatic urethral injury
Urinary retention (only if unable to pass TUC)
Necrotising Fasciitis of the Perineum
Temporary urinary diversion required (e.g. after surgery)
Neuropathic bladder (only if unable to pass TUC)
Transurethral catheter in situ with development of acute epididymitis
Define Enuresis
Persistence of inappropriate voiding beyond the age of anticipated control
Medical management of enuresis
Tricyclic Antidepressants e.g. Imipramine
Desmopressin e.g. DDAVP
Anticholinergics e.g. Oxybutinin (Ditropan - only with presence of daytime symptoms)
Imipramine mechanisms in enuresis
Lighten level of sleep
Anticholinergic effect on bladder (less detrusor contraction)
Alpha-adrenergic effect on bladder neck (contraction)
Imipramine side effects
Anxiety Behavioural/personality changes CIT symptoms Alopecia Cardiac dysrythmia
Desmopressin mechanisms in enuresis
Corrects abnormal nocturnal ADH surge
Decreases nocturnal urine production
Increases water resorption in collecting ducts
Desmopressin side effects
Headaches
Facial flushing
Nausea
Hypnatraemia
Locations of ectopic testes
Pre-pubic Femoral canal Contralateral scrotum Perineum Superficial inguinal pouch
Complications of undescended testes
Psychological problems Infertility Malignancy Inguinal hernia Trauma Torsion
Potential findings in infants with UTI
Hyrdonephrosis Stones Vesico-Ureteric Reflux Posterior Urethral Valves Ureterocoele Baldder Diverticuli Acute Pyelonephric Ischaemia Pelvic-Ureteric Junction obstruction Neuropathic bladder
Medical indications for circumcision
True phimosis Paraphimosis Genital warts affecting foreskin Recurrent balanitis/phosthitis Superficial penile carcinoma involving foreskin only Foreskin trauma Inadequate previous circumcision
Surgical principles of all circumcision
Asepsis
Haemostasis
Protection of glans
Adequate excision but not excessive
Methods of circumcision
Clamps
Shields
Surgical excision
Contraindications to Circumcision
Prematurity Current illness Blood dyscrasia Hypospadias Chordee Buried penis Webbed penis
Complications of Circumcision
Haemorrhage Infection Meatal ulcer Skin complications (phimosis, concealed penis, chordee, skin bridge) Glanular injury Necrosis Urethrocutaneous fistula
Causes of Necrosis in circumcision
Use of diathermy with clamp
Use of local anaesthetic with adrenaline
Use of tourniquet
Tight dressings
Special investigations in a man with LUTS
Urine MCS Urine Dipsticks PSA Ultrasound AXR Prostate Biopsy
Innervation of bladder function
Sympathetic: Contract proximal sphincter
Parasympathetic: Contract detrusor muscle
Somatic: Voluntary contraction of external sphincter
Medical therapy of incontinence
Alpha-agonists: increase internal sphincter tone
Oestrogens: increase bladder neck tone
Anti-cholinergics: relax detrusor muscle, increase bladder capacity
Haematological causes of haematuria
Anticoagulants
Leukaemia
Haemophilia
Causes of vesico-colic fistula
Crohn’s disease
Diverticulitis
Sigmoid colon carcinoma
UTI commoner in women because:
Shorter urinary tract
Proximity to faecal reservoir
Diabetes predisposes to UTI because:
Glucose in urine = culture medium
Impaired WBC function
Autonomic neuropathy
Antibiotic treatment of acute pyelonephritis
Co-amoxyclav
Cephalosporins
Gentamycin
Quinolones
Causes of penile pain during erection
Peyronie’s disease
Priapism
Medical conditions associated with Erectile Dysfunction
Ischaemic Heart Disease Diabetes Mellitus Hypertension Dyslipidaemia Depression
Aetiological factors of ED
Vasculogenic Neurogenic Chronic Systemic Disease Hormonal Drugs Penile Problems Diabetes Mellitus
Side effects of PDE5 inhibitors
Headaches
Flushing
Rhinitis
Dyspepsia
Oral medication in Peyronie’s disease
Vitamin E
PABA
Colchicine
Intralesional Agents for Peyronie’s disease
Verapamil
Interferon
Cortisone
Treatment options for condylomata accuminata of foreskin
Salicylic Acid Podophylin Interferon Imiquimal 5-fluoro-uracil ointment Tri-chloro-acetic acid Circumcision Laser Cryotherapy Cauterisation
Possible causes of varicocoele
Congenital absence of valves in spermatic veins
Compression of left renal vein between aorta and superior mesenteric artery
Neoplastic obstruction of renal vein and IVC
Right-angled T-junction of left testicular vein to left renal vein
Complications of Varicocoele
Infertility
Testicular atrophy
Pain/discomfort
Special investigations when diagnosing urogenital TB
Semen analysis Pus swab from scrotal sinus Early morning urine culture (Louwenstein-Jensen) Histology Cystoscopy CXR IVP
Pre-testicular factors causing male infertility
Calcium Channel blockers Smoking Chemotherapy Anabolic steroids Alcohol
Triad of abnormalities in prune belly syndrome
Cryptorchidism
Urogenital tract abnormalities
Congenital absence of abdominal wall musculature
Causes of death in prune belly syndrome
Non-functioning renal tissue
Pulmonary hypoplasia
Cause of female pseudohermaphroditism
Congenital adrenal hyperplasia
Enzymatic deficiency in glucocorticoid metabolic pathways
Characteristics: female pseudohermaphriditism
Salt and water wasting
Hypertension
Hyperpigmentation
Factors affecting gender assignment
Fertility
Phallus size
Family wishes
Surgical management of posterior urethral valves
Endoscopic disruption
Vesicostomy
Upper tract diversion
Indications for transurethral catheterisation in chronic urinary retention
Renal failure
UTI
Incontinence
Complications of TUC in chronic urinary retention
Post-obstructive diuresis
Haematuria
Underlying systemic conditions predisposing to necrotising fasciitis
Diabetes Mellitus AIDS Malnutrition Chronic alcoholism Chemotherapy Transplant patient Steroid therapy
Antibiotics in necrotising fasciitis
Penicillin
Metronidazole
Cephalosporin/Aminoglycosides
Surgical management of Priapism
Aspiration and Irrigation
Embolisation of internal pudendal artery
Glans puncture technique
Corpospongiosal shunt
Indications for Surgery in bladder injury
ALL intraperitoneal ruptures Severe bleeding Large urine leak Penetrating bone fragment Laceration of vagina/rectum Penetrating injuries Surgery for other organs
Complications of bladder injury
Peritonitis
Abscess
Urinary fistulae
Osteitis
Signs of urine in peritoneal cavity
Abdominal distension
Ileus
Urinary ascites
Increased urea and creatinine
Complications of urethral injuries
Stricture Impotence Urine leakage Para-urethral abscess Necrotising fasciitis Cystitis/Epididymitis
Causes of penile injury
Iatrogenic Blunt Penetrating Avulsion Strangulation
DM causes ED why?
Autonomic neuropathy
Microvascular disease
Atherosclerosis
Signs of Psychogenic Erectile Dysfunction
Sudden onset Morning erections Situation-specific Premature ejaculation Psychiatric history
Signs of Organic ED
Gradual onset
Gradual worsening
No morning erections
Erections not rigid enough
Treatment of ED
Psychotherapy Vitamin E PDE5-inhibitors Testosterone ICI Intra-urethral capsules Vacuum device Penile prosthesis Arterial surgery Venous ligation
Causes of Priapism
Idiopathic ICI Pharmaceuticals Haematological disease Malignancy Spinal injury Perineal injury
Causes of Urinary Retention
Underlying bladder outflow obstruction
Underlying detrusor weakening
Precipitating events
Precipitating events for urinary retention
Cystitis/prostatitis Pharmaceuticals Alcohol Post-operatively Cardiac failure Constipation
Contraindications to SPC
Empty/Fibrotic/Small bladder
Macroscopic haematuria
Previous lower abdominal surgery
Skin infection on lower abdominal wall
Complications of SPC
Bowel injury Haematuria Migration Bleeding Infection
Causes of sterile pyuria
Urogenital TB Treated gram negative UTI Urolithiasis Papillary necrosis Bladder carcinoma Radiotherapy of bladders Schistosomiasis
Causes of papillary necrosis
Urogenital TB Diabetes Mellitus Analgesic abuse Recurrent UTIs with VUR Sickle cell disease
Bladder complications of schistosomiasis
UTI Bladder wall calcification Reduced capacity bladder Bladder calculi Squamous metaplasia SCC
IVP findings in schistosomiasis
Calcified bladder wall Calcified ureters Granulomata of bladder wall Filling defect of bladder Irregular bladder wall Small bladder capacity Hydro-ureteronephrosis
Surgical treatment of schistosomiasis
Enterocystoplasty
Ureteric reimplantation
Radical cystectomy and urinary diversion
Ureteric complications of schistosomiasis
Atony
VUR
Ureteric stricture
Renal failure
Common sites of genitourinary TB
Bladder Kidney Ureter Epididymis Seminal vesicles Prostate
Cystoscopy findings in GUTB
Erythema
Bleeding
Granulations
Golf hole ureteric openins
IVP findings in GUTB
Moth-eaten calyces Papillary necrosis Cavities in medulla Infundibular stenosis Blunted calyces Straight ureters PUJ obstruction Hydro-ureteronephrosis Small bladder
Criteria for renal donors
no renal disease no malignancy no diabetes no active infection negative serology ABO compatibility negative lymphocytotoxic cross-match
Benign renal tumours
Oncocytoma
Adenoma
Angiomyolipoma
Aetiology: TCC of the bladder
Smoking
Industrial carcinogens
Drugs
Pelvic irradiation
Drugs causing Transitional Cell Carcinoma
Analgesics
Cyclophosphamide
Industries implicated in TCC
Rubber Printing Dye Petroleum Leather
Aetiology: Squamous Cell Carcinoma of the bladder
Bladder calculi
Recurrent UTI
Indwelling catheter
Schistosomiasis
Aetiology: Renal Cell Carcinoma
Smoking
Obesity
Acquired cystic disease
Von Hippel-Lindau disease
Radical nephrectomy removes what?
Kidney
Adrenal Gland
Perinephric fat
Indications for heminephretomy in RCC
<4cm incidentaloma
bilateral tumours
poor total renal function
unilateral tumour with solitary kidney
RCC treatment option
Radical nephrectomy
Heminephrectomy
Immunotherapy
Renal artery embolisation
DDX: painless scrotal mass
Hydrocele Varicocele Epididymal cyst Chronic epididymitis Tumour Inguinal hernia
DDX: painful scrotal mass
Strangulated inguinal hernia
Acute epididymitis
Tumour - haemorrhaging
Scrotal trauma
Risk factors for testicular tumours
Undescended testis Infertility Atrophy of testis Orchitis Carcinoma in situ Intersex
Tumour markers in testicular tumours
B-HCG
AFP
LDH
Treatment of testicular tumours
Radical orchiectomy
Chemotherapy
Radiotherapy
Aminoacids in Cystineuria
Cystine
Ornithine
Lysine
Arginine
Complications of renal stones
UTI
Obstruction
Chronic irritation
Neuropathic Bladder complications
Renal failure Calculi Recurrent UTI Vesicoureteric reflux Urethral diverticulum/fistula SCC bladder Autonomic dysreflexia
Aetiology of BPH
Male sex Age Hormones Geographical Race/Diet Fat Genetics Stromal epithelial interaction
Causes of LUTS
BPH Prostate carcinoma Urethral stricture Bladder neck contracture Neurogenic bladder dysfunction Diabetes mellitus
Medical Management of BPH
A-Adrenergic blockers
5-A-reductase inhibitors
Surgical indications in BPH
Renal failure Recurrent haematuria Recurrent UTI Hydronephrosis Contraindicated medical treatment Failed medical treatment Previous prostatic surgery
Complications of TURP
TURP-syndrome Secondary haemorrhage Septicaemia Retrograde ejaculation Incontinence Urethral stricture
Aetiology: Prostate carcinoma
Age Genetics Race Geography/Environment Hormones
Pathology of Prostate ca
Adenocarcinoma
TCC
Sarcoma
SCC
Causes of raised PSA
BPH Prostate Ca Prostatitis Urinary retention Prostatic procedures Age
Medical treatment in prostate ca
Luteinising-Hormone Releasing Hormone
Oestrogens
Anti-androgens (flutamide)
Orchiectomy complications
bleeding wound sepsis psychological trauma hot flushes ED osteoporosis
Signs of spinal cord compression
motor dysfunction
sensory loss
urinary retention
Treatment: spinal cord compression
high dose steroids
urgent castration
radiotherapy to spinal cord
Complications: Renal Injury
Haemorrhage Secondary Haemorrhage Urinary extravasation Infection Ileus Renal infarction Hypertension Death
Indications for surgery in renal injury
Haemodynamic instability Renal artery thrombosis Suspected visceral damage Suspected renal pelvis injury Non-functioning of major part of kidney
Causes of secondary haemorrhage in renal injury
Pseudoaneurysm
AVF
Commonly isolated bacteria in necrotising fasciitis
Enterobacteria Bacteroides Streptococci Staphylococci Peptostreptococci Clostridia
Early signs of necrotising fasciitis
Pain
Erythema
Swelling of scrotum
Pyrexia
Late signs of necrotising fasciitis
Cyanosis/blistering of skin Crepitus Cutaneous necrosis Extension to abdomen and thighs Septicaemia Death
DDX of necrotising fasciitis
Scrotal cellulitis Scrotal abscess Strangulated inguinal hernia Penile gangrene Scrotal gangren Pyoderma gangrenosa
Indications for intervention in renal colic
Renal failure UTI Failure of stone progression Large stone Anuria Repeated colic Convenience
Semen analysis pattern in varicocele
Oligospermia
Teratospermia
Asthenospermia
Renal injury Grade 1
Contusion/Haematoma
Renal Injury Grade 2
Laceration <1cm parenchymal without urinary extravasation
Renal injury Grade 3
Laceration >1cm without collecting system rupture or urinary extravasation
Renal injury Grade 4
Laceration extending through cortex, medulla and collecting system
Main renal artery injury with contained haemorrhage
Renal injury Grade 5
Shattered kidney
Avulsion of hilum with devascularised kidney
Causes of Vesico-Ureteric Reflux
Congenitally short submucosal tunnel Bladder outflow obstruction Iatrogenic Duplex ureters Ureterocele
Complications of VUR
Chronic Pyelonephritis
Hypertension
Chronic Renal Failure
Indications for Surgery in VUR
Failure to prevent UTIs Poor medical compliance Very severe reflux Associated pathology Persistent VUR in female adolescents
Surgery for VUR
Subureteric Teflon Injection
Reimplantation of ureter
