Urology Flashcards
What are the causes of obstructive uropathy?
Upper: Tumour: renal, ureteric, bladder or external compression e.g. colon cancer Ureteric stricture or clot Kidney/ ureteric stone Retroperitoneal fibrosis
Lower: Neuromuscular retention Blood clot in urethra Enlarged prostate: BPH / Ca Urethral stricture Ca bladder
What are the symptoms of obstructive uropathy?
Reduced urine output
Suprapubic pain/tenderness
Upper: renal colic, palpable mass, haematuria, deranged U&Es, vomiting in some
Lower: haematuria, hesitancy/poor urine flow, deranged U&Es
How would you investigate obstructive uropathy?
A-E examination + full history Bloods: FBC, U&E, CRP, PSA, bone profile (calcium) Urine dip + send for MC&S Ultrasound scan + bladder scan CT KUB- non contrast Urodynamics Cystoscopy
How would you bypass upper and lower urinary obstruction?
Upper: nephrostomy
Lower: urethral/ suprapubic catheter
How would you manage hydronephrosis?
Treat underlying cause
Nephrostomy to relieve immediate pressure
If idiopathic due to narrowing of the renal pelvis -> pyeloplasty
What are the indications for catheterisation?
Surgery/anaesthesia
Paralysis/neurogenic bladder
Monitor urine output
Immobile patients who can’t go to the toilet
Bladder irrigation
Intravesical medication e.g. bladder cancer
Severe, resistant incontinence
How should you manage asymptomatic bacteruria in a catheterised patient?
No management
How would you manage symptomatic bacteruria in a catheterised patient?
7 days antibiotics
Change catheter ASAP
What are the symptoms of BPH?
LUTS:
Frequency, urgency, hesitancy, intermittency, poor stream, incomplete emptying, straining, nocturia, terminal dribbling, incontinence (urge)
What score is used to grade the severity of prostate symptoms?
IPSS
International prostate symptom score
How is BPH investigated/diagnosed?
- Abdominal exam + DRE
Palpable bladder, enlarged prostate - Urine dip - rule out UTI
- Bloods: PSA - not directly after DRE, may be slightly raised or normal
- MRI prostate
How is BPH managed?
- If symptoms aren’t too bothersome, don’t need to treat
- Lifestyle to manage symptoms: double voiding, reducing fluid intake in the evening, reduce caffeine consumption
- a-blocker: tamsulosin
- 5a-reductase inhibitor: finasteride
- Surgical options:
TURP- resection
TUVP- electrovaporisation
HOLEP- laser enucleation
Prostatectomy
What are the complications of TURP?
Bleeding Infection Pain Erectile dysfunction Incontinence Retrograde ejaculation Failure to resolve symptoms Urethral stricture
What are the causes of raised PSA?
BPH/Ca prostate Recent manipulation- DRE, anal sex Recent ejactulation Strenuous exercise Prostatitis UTI
What is the most common causative organism in acute bacterial prostatitis?
E-Coli
STI- chlamydia
What are the symptoms of prostatitis?
Pelvic pain: rectal, penile, testicular, abdominal, groin, sacral, suprapubic
LUTS
Pain on defaecation
Sexual dysfunction
In acute/bacterial: fever, N&V, systemic symptoms
Prostate tender and enlarged on DRE
How would you investigate prostatitis?
DRE- tender, enlarged prostate
Urine dip, MC&S
STI screen
Bloods: FBC, CRP, U&E, PSA, cultures if systemic symptoms
How is acute prostatitis managed?
Admit if unstable
2-4 weeks antibiotics- ciprofloxacin usually
Paracetamol/NSAID analgesia
Laxatives to relieve pain on defecation
How is chronic prostatitis managed?
a-blocker e.g. tamsulosin Paracetamol/NSAID analgesia Laxatives Antibiotics if acute symptoms or <6m CBT in chronic, refractory disease (pelvic pain syndrome)
Where does prostate cancer most commonly metastasise?
Lymph nodes
Bone- pelvis/lower spine often
What are the symptoms of prostate cancer?
May be asymptomatic
LUTS + haematuria
Sexual dysfunction
Urinary obstruction
B-symptoms: weight loss, fever, night sweats, fatigue
In advanced disease: bone pain, cord compression
How is prostate cancer investigated?
- Abdominal exam + DRE- hard, craggy, enlarged prostate
- Urine dip, MC + S
- Bloods: PSA
- Multi-parametric MRI scan
- Prostate biopsy (transrectal or transperineal)
What is the scoring/severity system for prostate cancer?
Gleason score: most common pathology score + second-most common
6= low risk 7= moderate risk 8+= high risk
TNM also used
How is prostate cancer managed?
- MDT discussion
- Active surveillance in low-grade/elderly patients
- External beam therapy +/- brachytherapy
- Hormone treatments: androgen receptor blockers, goserelin (GnRH antagonist), orchidectomy
- Radical prostatectomy
What are the differentials for testicular lumps?
Hydrocele Varicocele Epididymal cyst Testicular cancer Hernia Testicular torsion
What are the differentials for testicular pain?
Epididymo-orchitis Testicular torsion Strangulated hernia Trauma Scrotal oedema Tumour/hydrocele/varicocele
What are the common causative organisms of epididymo-orchitis?
E-coli
Chlamydia
Gonorrhoea
What are the symptoms of epididymo-orchitis?
Testicular pain, swelling
Urethral discharge
Dragging/heavy sensation in scrotum
Systemic features e.g. fever
How would you investigate epididymo-orchitis?
Urine MC+S
STI screen
Penile swab
USS to rule out torsion/tumour
How is epididymo-orchitis managed?
Supportive:
analgesia, supportive underwear, reduced activity, abstain from sex
Antibiotics- depending on cause
if not STI, usually 14 days ofloxacin
If STI- refer to GUM
What are the potential complications of chronic untreated epididymo-orchitis?
Chronic pain
Testicular atrophy
Infertility
Scrotal abscess
What deformity predisposes men to testicular torsion?
Bell-clapper deformity
- Absence of fixation between testicle and tunica vaginalis
- Testicle hangs in more horizontal position
What are the signs of testicular torsion on examination?
Swelling and redness of the scrotum, firm
Exquisitely tender testicles
Absence of cremasteric reflex
Abnormal lie of the testicle
What is the name of the sign seen on USS in testicular torsion?
Whirlpool sign
How is testicular torsion managed?
Orchidopexy - surgical fixation of the testicle
This is usually done bilaterally, providing prophylactic fixation of the contralateral testicle.
Orchidectomy if necrosis has already occurred
What is a hydrocele like on examination?
Soft, round, fluctuant mass
Irreducible
Transilluminates
Why should hydroceles be investigated?
Because they can be associated with testicular cancer, torsion, infection
What causes varicoceles?
Increased resistance in the testicular vein leading to engorgement of the pampiniform plexus.
90% occur on the left hand side, as the L testicular vein drains into the L renal vein- can therefore be associated with renal cell carcinoma.
What is a varicocele like on examination?
“Bag of worms”
More prominent on standing and disappears when lying down
Asymmetry in testicular size
What are the complications of varicoceles?
Testicular atrophy
Subfertility
What does an epididymal cyst feel like on examination?
Soft, round, fluctuant mass
Separate to the testicle, more associated with the epididymis
May transilluminate if large
What are the two most common histological types of testicular cancer?
Seminoma
Teratoma
What are the symptoms of testicular cancer?
Painless testicular lump - may be associated with pain in some cases
- > hard, irregular, irreducible, immobile, will not transilluminate
- > arising from the testicle
B symptoms
Symptoms of metastasis
What are the most common site of metastasis of testicular tumours?
Lung, liver, brain
What are the blood markers for testicular cancer?
LDH- very non-specific
AFP- teratomas
B-hcg- teratomas and seminomas
What are the most common causative organisms in UTI?
E-Coli
Klebsiella
Enterococci
Pseudomonas
What are risk factors for UTI?
Female gender Old age, incontinence, poor hygiene Sexual activity, anatomical complexities Catheter use Immunosuppression
What are the symptoms of UTI?
Dysuria, frequency, haematuria Suprapubic pain Nocturia, incontinence Fever + systemic symptoms Cloudy/strong smelling urine Confusion/delirium
How is UTI diagnosed?
Urine dip - nitrite + leucocyte +/- blood positive
Bloods: raised inflammatory markers
MSU: MC&S
Bloods + cultures if septic
Catheter culture / sample from bag
How long should you treat a UTI for?
3 days- simple UTI
5-10 days- anatomical, recurrent, immunosuppressed
7 days- men, pregnant women, catheter-related
When should nitrofurantoin be avoided in pregnancy and why?
Trimester 3
Due to foetal haemolysis
When should trimethoprim be avoided in pregnancy and why?
Trimester 1
Due to folate antagonism
What are the symptoms of pyelonephritis?
UTI symptoms + renal angle tenderness/back pain
More likely to have systemic symptoms
How is pyelonephritis diagnosed?
Urine dip + MSU to confirm infection
Bloods: raised inflammatory markers, U&E deranged, cultures
USS kidney
CT KUB
How is pyelonephritis managed?
7-10 days antibiotics-
usually cephalexin, co-amoxiclav/trimethoprim, ciprofloxacin
If septic- admit, IV abx and sepsis 6 protocol
Supportive: paracetamol, fluids
What is the red flag symptom of bladder cancer?
Painless haematuria
What are the risk factors of bladder cancer?
Age
Occupational exposure to chemicals involved in the dye and rubber manufacturing industry
Smoking
What is the most common histology of bladder cancer?
Transitional cell carcinoma
How is bladder cancer diagnosed?
Flexible cystoscopy with biopsy = gold std
Urine dip, MC + S, USS
Staging CT
How is bladder cancer treated?
Trans-urethral resection of the tumour if non-muscle invasive
Intra-vesical chemotherapy - cisplatin, 5-FU
Intra-vesical BCG
Radical cystectomy + urostomy / diversion
Chemo/radiotherapy
What is the most common type of kidney stone?
Calcium oxalate
RF= Hypercalcaemia + reduced UO
Which type of kidney stone is not visible on x-ray?
Uric acid
Which type of kidney stone is associated with infection?
Struvite stones
Which type of kidney stone is most associated with forming staghorn calculi?
Struvite
What are the symptoms of ureteric stones?
May be asymptomatic
Renal colic- loin-groin pain, writhing around
Haematuria
Nausea and vomiting, oliguria, may have fever if infective
How do you diagnose ureteric stones?
Urine dip- haematuria
Bloods: U+E, calcium +/- uric acid level
AXR may show some calcium stones
non-contrast CTKUB = gold standard
How are ureteric stones managed?
NSAIDs e.g. IM diclofenac
Buscopan can help in some cases
Anti-emetics + antibiotics if needed
Plentiful fluid
If < 5mm: watchful waiting
Tamsulosin can encourage passage
Surgical: external lithotripsy, laser lithotripsy, percutaneous nephrolithotomy, open surgery
