Urology Flashcards
What is non-visible Haematuria?
5% risk of malignancy, 20% for visible
Anything more than a ‘trace’ of blood on dipstick
List 3 false positives for haematuria
Exercise
Periods
Myoglobin
List 2 false negatives for haematuria
Vit c intake
Heavy proteinuria
Compare Nitrites and Leucocyte use in diagnosing UTI
Nitrites: More specific for UTI (Less false +ves)
Leukocytes: More sensitive for UTI (Less false -ves)
What things are looked at on a urine dipstick
Blood Nitrites, Leukocytes Glucose pH (Stones) Urine specific gravity
Protein
Ketones
Bilirubin urobilinogen
What exams would you do in someone with haematuria
Abdomen
External genitalia if male
DRE if male
What would you ask about in history to someone with haematuria
Duration/ where in stream/ clots?
Past investigations/ treatment?
Cancer RFs (Smoking, Occupation, Fhx)
Anticoagulants?
List 3 radiological investigations for Haematuria
USS KUB
CT Urogram (Upper urinary tract)
Flexible Cystoscopy (Lower Urinary Tract)
What can USS detect?
Renal masses
Hydro
Bladder masses (if bladder full) or bladder enlargement
Which malignancy is USS less accurate at detecting?
Upper tract TCC
Rare, 0.75% of pts with visible haematuria
When is CT urogram used?
As a 2nd line test in recurrent visible haematuria where USS and Cystoscopy are negative
Compared to USS, what is a CT Urogram better at detecting?
What else can it show?
Upper tract TCC
Renal masses (RCC) Filling defects in bladder (Tumour/ stones)
What is Pseudohaematuria?
List some causes
Red/ brown urine that is not due to presence of haemoglobin.
Medication (Rifampicin/ Methyldopa)
Hyperbilirubinuria
Myoglobinuria
Foods (Beetroot/ Rhubarb)
Compare CT urogram to non-contrast CT KUB
CT U: More definitive for UT-TCC. More radiation, requires IV contrast
nc CT KUB: Faster, used more for Stones,
Outline use of Cystoscopy
Done with Local Anaesthetic
Small biopsies can be taken for diagnosis, as well as looking
Not useful during active bleeding (poor views, needs a GA Cystoscopy and washout)
List haematuria causes
UTI/ Parasitic (Schistosomiasis)
Stones
Maligancy (Urinary tract or Prostate)
BPH
Trauma
Radiation cystitis
Nephrological causes (e.g IgA Nephropathy)
Where are Renal Cell Carcinomas (RCC)?
What’s the commonest type of RCC, and what is this associated with?
Kidney parenchyma
Clear Cell RCC, associated with Von-Hippel Lindau syndrome (Inherited disorder, causes tumours/ cysts to grow in multiple body parts- Inner eyes, Brain, Spinal cord, Pancreas, Adrenal glands, Kidney etc)
RCC is an Adenocarcinoma, more common in Males, derived from PCT epithelium.
What are some RFs
Smoking, Obesity, HTN, FHx, Dialysis
Anatomical abnormalities (Horseshoe pr Polycystic Kidney) Industrial carcinogen exposure (Cadmium, Lead etc)
What is the presentation triad of RCC? (15% of cases)
Haematuria, Loin pain, Palpable mass
Possible Varicocoele, via Renal Vein obstruction
How soon does RCC metastasise
What substance may it secrete?
Early, before local symptoms usually
PTH-rP
List some Paraneoplastic syndromes associated with RCC
Stauffer’s Syndrome (abnormal LFTs)
Hypercalcaemia (PTH-rP)
HyperT (Renin)
Polycythaemia (EPO)/ Anaemia
Amenorrhoea/ Baldness/ Cushing’s
Pyrexia
Outline diagnosis and staging investigations for RCC
USS picks most up
Contrast CT needed to confirm and stage
Outline surgical RCC treatment
Smaller tumours (T1): Partial nephrectomy
Larger tumours (T2): Radical nephrectomy (Kidney, Perinephric fat, Para-aortic lymph nodes. Spare adrenal glands if possible)
How can RCC be managed non-surgically?
Percutaneous Radiofrequency Ablation
Laparoscopic/ Percutaneous Cryotherapy
Renal artery embolisation may be needed if haemorrhaging
Outline treatment of Metastases of RCC
Chemo+ Radio- therapy considered ineffective
Immunotherapy (IL-2 or IFN-Alpha agents)
Biological agent (TK-Inhibitors: Sunitinib, Pazopanib)
Metastasectomy
How does UT-TCC present?
Visible haematuria, Possible signs of obstruction
Outline diagnosis of UT-TCC
CT Urogram is test of choice
May need Ureteroscopy +/- Biopsy to confirm
Outline UT-TCC treatment
Small low grade tumours: Laser ablation sometimes
Otherwise: Nephro-ureterectomy (if possible, laparoscopically)
Outline rarity of Bladder cancers: TCC, SCC, Adenocarcinoma
Sarcomas very rare
TCC: 80%
SCC: 20%
Adenocarcinoma: 1%
List RFs of Bladder TCC
SCC: Long term catheters, recurrent UTI, Stones, Schistosomiasis
Smoking, Age, Exposure to aromatic amines (Dyes, Rubber, Plastic manufacture)
Schistosomiasis, Previous radiation to pelvis
Outline the 3 classes of bladder cancer
Superficial/ Non-muscle-invasive: Doesn’t penetrate into deeper layers of bladder wall
(T2) Muscle-invasive: Penetrates deeper layers of bladder wall
Locally advanced/ Metastatic: Spreads beyond bladder and distally
After detection of bladder cancer (Cystoscopy) outline the purpose of TURBT
Allows assessment of;
Histological type (TCC or SCC)
Grade (1,2,3)
Stage (Tis, Ta, T1, T2)
How is a non-muscle invasive bladder cancer treated?
Single dose of Intravesical Mitomycin
What are the 3 classes of a Superficial TCC
Low risk (Grade 1 or 2, Ta)
Intermediate risk
High risk (Grade 3, Ta or T1)
Outline process of TUBRT
Resection of bladder tissue by Diathermy, during Rigid Cystoscopy
Typically done under R/G Anaesthesia
How are Low, Intermediate and High risk Superficial TCCs treated?
Low: Cystoscopic surveillance
Intermediate: Consider x1/wk Mitomycin for 6wks
High: BCG regimen, Cystectomy if very high
Superficial TCCs have a high recurrence rate, and are likely to be more invasive.
What is BCG?
Bacillus Calmette Guerin
Live attentutated mycobacterium bovis
Used for TB inoculation, if given intravesically it stimulates type IV hypersensitivity activating cells to tumour antigens
How are Muscle-invasive TCC, SCC and Adenocarcinoma in Bladder treated?
Neoadjuvant Chemo + Radical Cystectomy (Urinary Diversion needed afterwards)
Outline Radical Cystectomy in Males and Females
Both get Pelvic Lymph node dissection
Males (Cystoprostatectomy) Removal of Bladder + Prostate +/- Urethra
Females (Anterior Exenteration): Remove Bladder, Uterus, Tubes, Ovaries, Anterior vaginal wall
Name 3 methods of Urinary Diversion after Radical Cystectomy
Ileal Conduit
Neobladder
Continent Cutaneous Diversion/ Indiana Pouch
Describe an Ileal Conduit
Ureters connected to part of SI, brought out as a stoma
Urine drains into Stoma bag
Describe a Neobladder
Ureters connected to new ‘bladder’ made of SI, connected to Urethra.
(Routine check of Bloods, B12 Folate as Ileum partially involved)
Describe Continent Cutaneous Diversion/ Indiana Pouch
Pouch fashioned from part of bowel (E.g Right Hemicolon)
Catheterisable Stoma- Pt passes catheter to empty pouch intermittently
When is Neobladder contra-I?
If tumour extends to Prostatic urethra
Urethrectomy needed
When is Continent Cutaneous Diversion/ Indiana Pouch contra-I?
(Issues: Metabolic acidosis, Stones, Incontinence, Mucus, Perforation)
Renal impairment
Hepatic impairment
Inadequate small bowel (Crohn’s)
Unable to catheterise
List Prostate Cancer RFs
Vasectomy doesn’t increase risk
Age, Fhx, Genetics (BRCA, HPC1), Black
Obesity, DMII, Smoking
Most Prostate cancers are Adenocarcinomas and Multi-focal.
Which prostate zones are affected?
Peripheral (>75%)
Transitional (20%)
Central (5%)
List causes of raised PSA
PSA is a serine protease, acting as a seminal anticoagulant
Urinary retention UTI BPH, Prostatitis etc Vigorous exercise Ejaculation
(Not affected by DRE)
List possible Prostate cancer symptoms in more advanced local disease
(Other than LUTS, Bone pain, Weight loss)
Haematuria, Haematospermia
Suprapubic pain, Loin pain
Tenesmus
Outline Prostate Cancer screening
No population based screening programme- BUT men can request, after counselling
ERSPC showed;
- Screening probably reduces mortality (11yrs)
- Significant overdiagnosis and overtreatment
PSA simply gives indication of risk of Cancer on biopsy
List 2 side effects of Aggressive treatment
Incontinence and impotence
List investigations fo prostate cancer
PSA, DRE
mpMRI + Bone scan (for staging)
TRUS Biopsy
Transperineal/ Template Biopsy preferred (Better for viewing anterior prostate)
Describe the TRUS (TransRectal UltraSound-guided) Biopsy
What is there a risk of?
Done transrectally, usually under Local Anaesthetic
12 cores taken bilaterally in equal distribution from Base to Apex.
1-2% risk of Sepsis
Describe a Template/ Transperineal Biopsy
Compare to TRUS
Done transperineally, as a day case under GA
- Better access to anterior prostate
- Lower risk of infection
Outline Gleason grading and the scores for Low, Intermediate and High grades
Overall Score: Sum of Most Common + 2nd Most Common growth patterns
Low grade: 3+3=6 (lowest score, as 1+2 not used anymore)
Intermediate Grade: 3+4=7
High Grade: 4+3=7 OR 8/9/10
2 types of Surveillance of Prostate Cancer are Active Surveillance and Watchful Waiting
Describe Watchful Waiting
Symptom guided approach where;
- Definitive therapy is deferred
- Hormone therapy is initiated at time of symptomatic disease
Who is Watchful Waiting for?
Older pts with lower life expectancy, but can be offered at any stage of Prostate Cancer
(Aim: Palliative treatment for Symptoms/ Metastases)
Describe Active Surveillance (Continual investigations to monitor disease with aim of curative treatment)
Monitoring;
- PSA every 3mths
- DRE every 6-12mths
- Biospy every 1-3yrs
Outline Prostate Cancer treatment in;
- Low risk
- Intermediate and High risk
- Metastatic disease
- Castrate-resistant disease
(Risk takes into account Gleason Score, PSA and Staging)
Low risk: Active surveillance
Intermediate and High: Radical treatment
Metastatic: Chemo + anti-hormonal agents
Castrate-resistant: Further chemo (Docetaxel), CSs, Anti-androgen, Androgen deprivation therapy
List 3 Radical treatment options for Locally advanced Prostate Cancer
Radical Prostatectomy
External beam Radiotherapy + Hormones
Brachytherapy
Outline Radical Prostatectomy
Can be done Laparoscopically, Open approach, Robotically- most common
Removal of Prostate gland, Resection of Seminal vesicles and surrounding tissue +/- Pelvic L Node dissection
List most common ADRs of Radical Prostatectomy
ED
Stress Incontinence
Bladder neck stenosis
Cancer re-occurrence
Compare External Beam Radiotherapy to Brachytherapy
External Beam Radiotherapy: Focused radiation
Brachytherapy: Transperineal implantation of Radioactive seeds directly into Prostate
List 2 Chemo drugs used in treating Prostate Cancer Metastases
Docetaxel, Cabazitazaxel
List the MoA of these drugs;
Goserelin
Bicalutamide
Enzalutamide
Abiraterone
Goserelin: GnRH Receptor agonist
(Androgen levels rise at first, but then lower by -ve feedback)
Bicalutamide: Testosterone receptor antagonist
Enzalutamide: Lowers serum Testosterone
Abiraterone: Lowers serum Testosterone
Penile cancer is a SCC and is very rare (1/100,000)
How is it treated
Excision (Circumcision, Glansectomy, Partial/ Total Penectomy)
Consider Inguinal and/or Pelvic L Node dissection
Superficial disease only: Topical Chemo (5-FU)
List RFs of Penile cancer
Does Circumcision affect risk?
HPV (main one), Smoking, Phimosis, Lichen Sclerosis, untreated HIV
Yes, virtually unknown in pts circumcised as child
Signs of Penile cancer
Palpable/ ulcerating penis lesion
Painless usually
Discharge/ prone to bleeding
Outline Ureteric Colic history
Exam: May be TachyC, may have Flank/ IF Tenderness
Unilateral Sudden Colicky pain, radiating to Iliac Fossa/ Testicles/ Penis/ Labia
N+V
List investigations for Ureteric Colic
Bloods: FBC, CRP, U&Es
Urine: Dipstick, MSSU for MC&S
Radiology: CT KUB
How is Ureteric Colic managed?
Analgesia, Antiemetics +/- fluids
Stones will pass on own if ≤5mm, otherwise:
- Uteroscopy + lasertrispy
- ECSWL +/- JJ Stent
- JJ Stent
Infection associated with a Ureteric stone is an emergency. Why?
May be septic, May have Pyonephrosis (Can cause death)
Outline Acute Pyelonephritis history
May have gradual onset pain, not usually colicky. Radiation to IF/ Supraubic region. Uni- or bi- lateral
‘Chills, Fever, Loin pain”
Outline Acute Pyelonephritis on Examination
Fever, may have raised RR/ HR, may have low BP
Tender flank +/- Suprapubically
Outline Investigations for Acute Pyelonephritis
Urine dip: Blood, WCCs, Nitrites
MSU for MC&S +/- blood culture
Consider Renal USS to rule out Pyonephrosis
Baseline bloods
Outline Acute Pyelonephritis Management
Abx + Fluids (Oral or IV for both)
Analgesic, Antiemetic
DVT Prophylaxis
What is a JJ Stent?
What is a Nephrostomy
JJ: Tube inserted into ureter to prevent/ treat obstruction of urine flow
Nephrostomy: When urine is drained from the kidney via a percutaneous tube and collected in an external bag
Primary ddx for old men with nocturnal enuresis?
Chronic urinary retention with overflow incontinence
How is Acute Urinary Retention treated?
- Long-term Catheter (Urethral/ Suprapubic)
- Record RV, Check if mass has disappeared
- Alpha-blocker +/- 5-Alpha-reductase inhibitor
- TWOC for 2-7days. If fails, TURP
Compare High and Low pressure Chronic Urinary retention?
High pressure: Associated with renal impairment
Low pressure: Doesn’t affect renal function
Outline Chronic Urinary retention management
Long-term Indwelling catheter
CISC, TURP
Suggest a complication of catherisation in chronic urinary retention
Post-obstructive diuresis
List some causes of testicular pain
Torsion
Tumour
Trauma
Epididymitis/ Orchitis/ Epididymo-orchitis (UTI, STI, Mumps)
Ureteric Calculi (Rare)
Where can testicular torsion pain radiate to
Groin, Iliac fossa, Flank
How is testicular torsion managed?
Scrotal exploration
+/- Orchidectomy
+/- Bilateral Orchidopexy
Outline Epididymo-orchitis history
Gradual onset, Usually unilateral pain
Often history of;
- UTI
- Unprotected sex
- Catheter/ urethral instrumentation
May have Storage LUTS, Dysuria, Discharge
- Mumps (Bilateral pain)
State the usual cause of Epididymo-orchitis in men 20-40 and 40+
20-40: STI (Especially Chlamydia)
40+: UTI (Especially E. coli)
Outline Epididymo-orchitis examination
May have fever/ Hydrocoele
Red scrotum, tender enlarged Testes/ Epididymis
Name and describe an emergency that is rarely associated with Epididymo-orchitis
(Mortality rate approx 20%, pts rapidly deteriorate wit sepsis and shock)
List some RFs
Fournier’s Gangrene- Necrotising fasciitis that affects the Perineum
DM Alcohol excess Poor nutrition Steroid use Haematological malignancies Recent trauma
How is Fournier’s gangrene treated?
Broad spectrum Abx + Surgical debridement
Outline Epididymo-orchitis management
Check local guidelines
Ciprofloxacin
Doxycycline
Analgesia/ supportive treatment
Reduction of non-essential activity
Consider STI clinic
What can cause Iatrogenic Hypospasdias
Long term catheter use
How can strictures present?
Weak stream
Diagnosed by Flow studies
How is Paraphimosis managed
Mechanical compression,
Dextrose soaked gauze
Dundee technique
Dorsal slit: Leads to circumcision
Bladder Outflow Obstruction, BOO is mainly in men.
List 2 causes
BPH
Urethral strictures
Nocturia is just nocturnal Polyuria. It is due to the loss of Circadian Urine output rhythm with age.
How is it managed?
Advice;
- Reduce night-time fluids
- Try low dose loop diuretic 4-6hrs before bed
- Demsopressin as last resort
Flow rate interpretation needs at least 150ms voided
What Qmax values suggest obstruction chance;
10–30%
60%
90%
10-30: >15ml/s
60: 10-15ml/s
90: <10ml/s
Outline the phases of a Urodynamic study
Filling Phase;
- Should be slow gentle pressure rise
- Phasic contractions could= OAB (Detrusor)
- Pt asked to cough (stress incontinence?)
Voiding Phase;
- High pressure, low flow= Obstruction
- Low pressure, low flow= Detrusor failure
Outline the Medical Treatment for BOO
Alpha blockers
5-alpha-reductase inhibitors
Anticholinergics (if OAB symptoms)
Outline the Surgical Treatment for BOO
TURP/ Various forms of laser prostate surgery
Open Retropubic (Millin’s) prostatectomy
Outline Alpha-blocker use in the treatment of BOO
List 2 ADRs
Relax prostatic/ bladder neck smooth muscle
Tamsulosin, Alfuzosin are “Uro-selective”
Doxazosin if BP control needed
ADRs: Retrograde ejaculation, Postural HypoT
List 3 ADRs of 5-alpha-reductase inhibitor use in the treatment of BOO
ED, Rash, Reduced libido
When would you operate on BOO
Complications: Chronic retention, Bladder stones, Benign Prostatic Haematuria
LUTS not controlled on medication
Acute retention- Failed TWOC on Alpha-blockers
With regards to TURP;
- Why is Glycine used?
- List 4 side effects/ complications
- For irrigation, acts as an electrical insulator to prevent current dispersing
Confusion, Fits, Visual symptoms, BradyC, Vomit all due to Hyponatraemia caused by absorption of irrigation fluid
Define OAB:
Urgency, w/ or w/o incontinence, often accompanied by Frequency and Nocturia
List Conservative OAB treatment
- Weight loss, stop smoking, avoid caffeine
- Pelvic floor exercises
- Bladder training
List Medical OAB treatment
Anticholinergics (Oxybutinin, Tolterodine)
Topical oestrogens (if post-menopausal)
B3 Agonist (Mirabegron)
Stress incontinence is treated Conservatively with W loss and Pelvic floor exercises.
Medically, Duloxetine no longer used.
Outline surgical treatment
TVT (Tension-free vaginal tape) or TOT (Transobturator tape)
Autologous slings w/ Rectus Fascia
Colposuspension, Urinary diversion, Artificial Sphincter (rare in women)
List neurological conditions that can affect Bladder/ Sphincter function
Spina Bifida Spinal Cord injury Diabetes MS Parkinson’s
What percentage of urinary tract stones are made of calcium?
List the 3 types
80%
Calcium Oxalate (35%)
Mixed Oxalate and Phosphate (35%)
Calcium phosphate (10%)
List types of Non-calcium stones
Struvite stones (Mg ammonium phosphate)
Urate stones (Only radiolucent stones)
Cystine stones (Associated with familial disorders)
Describe Struvite stones
Often large
Most common cause of Staghorn Calculi (stone fills renal pelvis)
Often due to infection
Outline pathophysiology of Urate stones
High levels of Purine in blood either from Diet or Haematological disorders
(Red meat, Myeloproliferative disorder)
Outline pathophysiology of Cystine stones
Associated with Homocystinuria
(HCS Affects absorption and transport of cystine in bowel and kidneys
Outline non-imaging investigations for Ureteric stones
Urine dip
FBC, CRP, U&Es
Urate and Calcium levels
Analysis of stone if possible
Best imaging investigation for Renal tract stones?
Non-contrast CT KUB
List 4 criteria for Inpatient admission in a pt with renal tones
Post-obstructive AKI
Uncontrollable pain
Evidence of infection
Large stones (>5mm)
Suggest 2 initial urgent managements for a pt with renal stones who has signs of SIRS
Stent insertion
Nephrostomy
Outline Retrograde Stent Insertion
JJ Stent
Stent within ureter, approaching from distal to proximal via Cystoscopy
Keeps ureter patent to temporarily relieve obstruction
List 3 definitive managements for renal tract Calculi
ESWL, Extracorporeal Shock Wave Lithotripsy
PCNL, Percutaneous Nephrolithotomy
Flexible Uretero-renoscopy, URS
Outline ESWL
List 2 contra-Is
Sonic waves to break up the stone.
Typically reserved for small stones (<2cm) via USS/X-ray
Contra-indications include pregnancy or stone positioned over a bony landmark (e.g. pelvis).
Outline PCNL
For renal stones only, being the preferred method for large renal stones (E.g staghorn calculi).
Percutaneous access to kidney w/ a nephroscope passed into the renal pelvis. Stones then fragmented by lithotripsy.
Outline Flexible URS
Passing a scope retrograde up into the ureter
Stones fragmented by laser lithotripsy and removed.
Recurrent renal stones can cause scarring and loss of kidney function
How are these pts managed? (Depends on stone type)
Oxalate formers: Avoid high Purine (Red meat, Shellfish) + Oxalate foods (Nuts, rhubarb, sesame)
Ca formers: Check PTH levels to exclude primary Hyperparathyroidism. Avoid excess salt.
Urate formers: Avoid high Purine foods. Consider urate-lowering meds (Allopurinol)
Cystine formers: Consider genetic testing
What commonly causes Bladder stones
Caused by Urine stasis in bladder
Chronic urinary retention
May occur due to infections (Schistosomiasis)
How are bladder stones managed definitely
Cystoscopy, allowing stones to drain or fragmenting via lithotripsy
A UTI is defined by Symptoms + Bacteriuria
Outline management of Asymptomatic Bacteriuria
DO NOT TREAT unless;
- Pregnant woman
- Prior to urological surgery
(Treatment is actively harmful as low virulence organisms replaced with worse ones)
List common Abx used in UTI treatment
Trimethoprim, Nitrofurantoin
Cefalexin, Augmentin, Ciprofloxacin
(IV options: Augmentin, Tazocin, Gentamicin, Meropenem)
Compare use of trimethoprim and Nitrofurantoin
Tri;
- Upto 30% community resistance
- Don’t use in 1st trimester
Nitro;
- Only active in urine (Useless for Pyelonephritis)
- Not effective in renal failure
- Don’t use in 3rd Trimester
How are UTIs due to MGNOs (Multi-drug Resistant Gram Negative Organisms) treated?
In community: Some treated with Trimethoprim/ Nitrofurantoin if sensitive. Can also use Oral Fosfomycin
In hospital: IV Meropenem
How are recurrent UTIs in women managed in terms of advice and investigations
Excuse structural cause with USS +/- Cystoscopy
Avoid synthetic pants, Expensive/ perfumed soaps. Showers > baths
How are recurrent UTIs in women managed in terms of Abx and Non-Abx
Non-Abx;
- Topical Oestrogen if post-menopause
- Cranberry capsules (weak evidence)
- D-Mannose (Expensive, non-prescription)
- Methenamine Hippurate (Weak evidence)
Abx;
- Poist-coitus: Single Abx dose
- Self-start at 1st sign of symptoms
- Low dose continuous prophylaxis
When should Pyelonephritis be considered in men
NEVER
Consider Stones, Pyonephrosis etc
(Pyonephrosis- Pus in renal pelvis)
Compare Acute and Chronic prostatitis
Chronic Pancreatitis AKA Chronic Pelvic Pain Syndrome
Acute: Rare, pts unwell and usually in hospital on IV ABx
Chronic;
- Pelvic/ perineal pain
- Men may have urinary/ sexual dysfunction
How is Orchitis investigated + managed
Stay swollen for 4-6wks
Investigations;
- 1st void urine for Chlamydial PCR
- MSU, USS
Management;
- Oral Ciprofloxacin (+ Doxazosin in young men)
- IV ABx if unwell
10-14 days of Abx
How are Unilateral Undescended testes at birth managed?
Review at 6-8wks old. If unresolved, review again at 3mths.
If undescended at 3mths, refer to surgeons
By age 1, 2/3rds of pts with undescended testes will have spontaneously resolved.
After what age are testes unlikely to descend? When is surgical correction recommended
6mths
Between 6-18mths
How are Biilateral Undescended testes at birth managed?
Senior paediatrician referral in <24hours;
- Endocrine or Genetic testing
Once excluded, and testes undescended by 3mths, refer to surgery by 6mths
Outline Acute Prostatitis treatment
1st line: Oral Ciprofloxacin
2nd line: Oral Trimethoprim
(E.coli is resistant to Trimethoprim, but is a common cause of Prostatitis)
Klinefelter’s Syndrome results from an extra X Chromosome in boys (47XXY)
How does it present
Tall
Hypogonadism
Gynaecomastia
Delayed puberty
How long do Tamsulosin and Finasteride take to work
T: 24hrs
F: Upto 6 mths
Outline surgical treatment for Overactive Bladder if medical doesn’t work
Botox injections:
- ADR: Urinary retention (1 in 5), teach pt to self Catherine
Sacral nerve stimulation (S3)
Clam Ileocystoplasty
Urinary diversion (Ileal conduit)
Compare Physiological to Pathological/ Scarred Phimosis
Physiological: Foreskin non-retracted before age 2
Pathological/ Scarred: Episodes of 4skin infection lead to scarring, leading to more infections
Compare presentation of Physiological and Pathological Phimosis
Physiological;
- Parents may bring in child, may notice adhesions
- Recurrent 4skin infection and UTIs
Pathological;
- Painful erection
- Preputial pain (Pain of skin of Glans)
- Haematuria, Weak stream
- Recurrent UTIs
What is Peyronie’s Disease
Fibrous plaque formation in Corpus Cavernosum’s Tunica Albuginea
Leads to Penile Angulation or hourglass-like deformity with distal flaccidity
How can Peyronie’s Disease present?
Thought to be due to vascular trauma-> Leakage/ immune reaction in TA. Some aspect of genetic susceptibility
Usually only affects erect penis
- Curved penis
- Painful intercourse
List RFs for Testicular Cancer
Most common cancer in Males 20-40
Caucasian/ North European descent
Cryptorchidism
Fx, Previous testicular mlignancy
Kleinifelter’s Syndrome
Outline the Classification of Primary Testicular Cancers
Are they Malignant or Benign usually?
GCTs (95%);
- Usually Malignant
- Seminomas or NSGCTs (Yolk Sac, Chroriocarcinomas, Embryonal Carcinomas, Teratomas)
NGCTs (5%);
- Usually Benign
- Leydig Cell or Sertoli Cell Tumours
Compare Leydig and Sertoli Cell tumours
Leydig: Secrete Androgens
Sertoli: Secrete Oestrogens
Compare Seminomas and NSGCTs
Seminomas: Remain localised until late, V good prognosis
NSGCTs: Early Mets, Worse prognosis
How may Testicular Cancers present?
Lymphatic drainage to Para-aortic nodes
Unilateral, Painless testicular lump
O/E: Irregular, Firm, Fixed, Doesn’t Transilluminate
Signs of Mets: W Loss, Back pain, Dyspnoea
Outline use of Tumour Markers in Testicular Cancer
Both, Diagnostic + Prognostic means
- AFP: Raised in some NSGCTs, never Pure Seminomas
- LDH: Tumour volume + treatment response
- Beta-HCG: High in 60% of NSGCTs, 10% of Seminomas
Outline non-tumor marker Investigations for Testicular Cancer
Why should a Trans-scrotal Percutaneous Biopsy NOT be done?
Scrotal USS: Initial assessment + tumour markers
CT w/ Contrast: For Staging
Might cause Seeding of the cancer
Outline the Royal Marsden Classification
Used to Stage Testicular Cancer
Stage 1: Confined to Testes
Stage 2: L nodes involved below Diaphgram
Stage 3: L Nodes involved A+B Diaphragm
Stage 4: Extralymphatic Metastases
Outine Management of Testicular Cancer IN GENERAL (non-specific)
Pre-treatment Fertiity Assessment
Semen analysis + Cryptopreservation offered to all pts
Surgery: Radical Orchidectomy (Removal of Teste, Epididymis, Spermatic Fascia+Cord)
- May use Radiotherapy, Chemotherapy
Compare Treatment of Seminomas and NSGCTs
NSGCTs;
- Orchidectomy (Alone if Stage 1)
- Chemo (Adjuvant if no Mets, 1/+ Cycles if Mets)
Seminomas;
- Orchidectomy (Alone if Stage 1)
- Consider Chemo if high recurrence risk
- Radio or Chemo, if Metastatic
Outline Testicular Cancer Prognosis and Complications of Treatment
High rate of complete remission
Radio + Chemo: High risk of 2ndary malignancy (e.g leukaemia)
What is the analgesia of choice for renal colic
IM Diclofenac
What is Hydronephrosis
Dilation of the Renal Pelvis from hydrostatic pressure/ Urinary tract obstruction
