Urology Flashcards
What are the common causes of upper urinary tract obstruction?
Kidney stones
Tumours pressing on the ureters
Ureter strictures
Retroperitoneal fibrosis
Bladder cancer (blocking the ureteral openings to the bladder)
Ureterocele (ballooning of the most distal portion of the ureter- this is usually congenital)
What are the causes of lower urinary tract obstruction?
BPH Prostate cancer Bladder cancer Urethral strictures Neurogenic bladder
What are the causes of neurogenic bladder?
Multiple sclerosis Diabetes Stroke Parkinsons Brain or spinal cord injury Spina bifida
What does neurogenic bladder result in?
Urge incontinence
Increased bladder pressure
Obstructive uropathy
What is the management of obstructive uropathy?
Nephrostomy- used to bypass an obstruction in the upper urinarh tract
Urethral or suprapubic catheter may be used to bypass an obstruction in the lower urinary tract
What are the typical presenting features of hydronepnrosis?
Vague renal angle pain
Mass in the kidney area
Can be seen on an US, CT scan or IV urogram
How can you relieve pressure from hydronephrosis?
Percutaneous nephrostomy
Antegrade ureteric stent
What is BPH?
Hyperplasia of the stromal and epithelial cells of the prostate. Usually presents with LUTS
What are the LUTS which occur in BPH?
Hesitancy Weak flow Urgency Frequency Intermittency Terminal dribbing Nocturia Straining Terminal dribbling
How can you assess the severity of lower urinary tract symptoms?
International prostate symptom score IPSS
What is the initial assessment of men presenting with LUTS?
Digital rectum exam Abdo exam Urinary frequency volume chart Urine dipstick Prostate specific antigen
What are the common causes of raised PSA
Prostate cancer BPH Exercise UTIs Prostatitis Recent ejeculation or prostate simulation
What would the prostate feel like if it was benign and what about if it was cancerous?
Benign- smooth, symmetrical and slightly soft
Cancerous- firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus
What is the management of BPH?
Alpha blockers- tamsulosin (relax smooth muscle with rapid improvement in symptoms)
5- alpha reductase inhibitors- finasteride (gradually reduces prostate size)
The general rule is that alpha blockers are used for symptoms whereas5 alpha reductase inhibitors are used to reduce the enlargement.
What are the most notable side effects of
A) alpha blockers
B) finasteride
A) postural hypotension- if an old man is presenting with lightheadedness on standing or falls check if they are on tamsulosin
B) sexual dysfunction
Give an example of surgeries used for BPH?
TURP- transurethral resection of the prostate
Major complications= bleeding, infection, urinary incontinence, erectile dysfunction, retrograde ejaculation, urethral strictures
What is prostatitis?
Inflammation of the prostate, it can be classed as:
1) acute bacterial prostatitis- infection w/ more rapid onset of symptoms
2) chronic prostatitis- symptoms lasting for at least 3 months
What is the presentation of chronic prostatitis?
Chronic prostatitis presents with at least 3 months of..
- pelvic pain
- lower urinary tract symptoms
- sexual dysfunction
- pain with bowel movements
- tender and enlarged prostate on examination
What does acute bacterial prostatitis present like?
Similar symptoms to chronic prostatitis, as long as systemic symptoms of infection…
- fever
- myalgia
- nausea
- fatigue
- sepsis
What Ix would you do for prostatitis?
Urine dipstick testing
Urine microscopy, culture and sensitivities (MC and S) to clarify organisms and antibiotic sensitivities
Chlamydia and gonorrhoea NAAT testing on a first pass urine
What is the management of acute bacterial prostatitis?
Hospital admission for systemically unwell or septic pts (for bloods, blood cultures, Iv abx)
Abx 2-4 weeks
Analgesia
Laxatives if pain during bowel movements
What is the management of chronic prostatitis?
Alpha blockers (tamsulosin) relax smooth muscle, with rapid improvement in sx
Analgesia
Psychological treatment where indicated- CBT, antidepressants
Abx - if less than 6 months of sx or history of infection- doxycycline or trimethoprim for 4-6 weeks
Laxatives for pain during bowel movements
Where is prostate cancer most likely to spread to?
Lymph nodes and bomes
Its almost always androgen dependent- meaning they rely on testosterone to grow
Where are most of prostate cancers found?
Peripheral zone of the pro#tate
What are the key risk factors for prostate cancer?
Increasing age Family history Black african/ caribbean origin Tall stature Anabolic steroids
What is the presentation of prostate cancer?
Can be asymptomatic, may present with LUTS
Haematuria, erectile dysfunction, symptoms of advanced disease or mets (weight loss, bone pain, cauda equina)
What is the first line Ix for prostate cancer?
Multiparametic MRI
Prostate biopsy is the next step in establishing prostate cancer diagnosis after multiparametic MRI, what are the options for prostate biopsy?
TRUS- transrectal US guided biopsy
Transperineal biopsy
What are the main risks of prostate biopsy?
Pain Bleeding Infection Urinary retention due to short term swelling of the prostate Erectile dysfunction
How do you diagnose bone mets?
An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.
A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.
What is the gleason grading system?
The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy
What is the treatment of prostate cancer?
Depending on the grade and stage of prostate cancer, treatment can involve:
Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery
How does hormone therapy work for prostate cancer?
Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:
Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)
What are the side effects of hormone therapy?
Side effects of hormone therapy include:
Hot flushes Sexual dysfunction Gynaecomastia Fatigue Osteoporosis
What are the risks of radical prostatectomy?
Radical prostatectomy involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.
Last updated May 2021
What is urge incontinence?
When you have a strong, sudden need to urinate that is difficult to delay
What is epididymo orchitis?
Epididymitis is inflammation of the epididymis. Orchitis is inflammation of the testicle. Epididymo-orchitis is usually the result of infection in the epididymis and testicle on one side.
What are the causes of epididymo orchitis?
Escherichia coli (E. coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
What is the presentation of epididymo orchitis?
Usually gradual, over minutes to hours, and will present with the following…
- testicular pain
- dragging or heavy sensation
- swelling of the testicle and epididymis
- tenderness on palpation, particularly over the epidydymis
- urethral discharge (should also make you think of chlamydia or gonorrhoea)
- systemic symptoms such as fever and potentially sepsis
What is the key differential for epididymo orchitis?
The key differential diagnosis for epididymo-orchitis is testicular torsion. Testicular torsion is a urological emergency that requires rapid treatment to avoid the testicle dying. Both present similarly, with acute onset of pain in one testicle. If there is any doubt, treat it as testicular torsion until proven otherwise.
How do you diagnose epididymo orchitis?
With epididymo orchitis you need to establish whether the cause is likely to be an enteric organism (E.coli) or a sexually transmitted organism (chlamydia or gonorrhoea), the features that make a sexually transmitted organism more likely…
Age under 35
Increased no. of sexual partners in the last 12 months
Discharge from urethra
Investigations to help establish the diagnosis…
1) urine microscopy, culture and sensitivity
2) chlamydia and gonorrhoea NAAT testing on a first pass urine
3) charcoal swab of purulent urethra, discharge for gonorrhoea culture and sensitivities
4) saliva swap foe PCR testing for mumps id suspected
5) serum antibodies foe mumps if suspected (IgM acute and IgG precious infection or vaccination)
6) Ultrasound may be used to assess for torsion or tumours
What is the management of epididymo orchitis?
Acutely very unwell or septic patients are admitted to hospital for treatment (IV antibiotics).
Patients with a high risk of sexually transmitted infection should be referred urgently to genitourinary medicine (GUM) for assessment and treatment.
Local guidelines guide the choice of antibiotic.
For patients that are at a low risk of STIs, a typical choice is:
Ofloxacin (usually first-line) for 14 days
What warnings do you need to give pts when giving quinolone abx (ofloxacin, levofloxacin, ciprofloxacin)?
Tendon damage and tendon rupture (notably in achilles tendon)
Lower seizure threshold (caution in pts with epilepsy)
What is testicular torsion?
Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.
What does testicular torsion present with?
Acute rapid onset of unilateral testicular pain
May be associated with abdominal pain and vomiting
Sometimes abdominal pain is the only symptom in boys (always do testicular exam and ask about testicular sx in boys presenting with abdominal pain)
What would you see on examination of someone with testicular torsion?
A firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation so that epididymis is not in the normal posterior position
What is bell clapper deformity?
Testicle normally is fixed posteriorly to the tunica vaginalis.
A bell clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent
The testicle will hang in a horizontal positin (like bell clapper) instead of the typical more vertical position
It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.
What is the management of testicular torsion?
Urological emergency
And there is an urgent requirement for treatment, any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.
Management involves
NBM in prep for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
Orchiopexy (correcting the position of the testes and fixing them in place)
Orchiedctomy (removing the testicle) if the surgery is delayed or there is necrosis
Hat confirms the diagnosis of testicular torsion?
A scrotal ultrasound can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.
What are the key causes of scrotal or testicular lumps?
Hydrocele Varicocele Epididymal cyst Testicular cancer Epididymo-orchitis Inguinal hernia Testicular torsion
What is a hydrocele?
Collection of fluid within the tunica vaginalis that surrounds the testes
They are usually painless and present with soft scrotal swelling.
What is a hydrocele?
What are the examination findings?
Collection of fluid within the tunica vaginalis that surrounds the testes
They are usually painless and present with a scrotal swelling
The testicle is palpable within the hydrocele
Soft, fluctuant and may be large
Irreducible and has no bowel sounds (distinguishing it from a hernia)
Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
What is the management of hydrocele?
Management involves excluding serious causes (e.g., cancer). Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.
What is a varicocele?
A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men. They can cause impaired fertility, probably due to disrupting the temperature in the affected testicle. They may result in testicular atrophy, reducing the size and function of the testicle.
Why do most varicoceles occur in the left testicle?
Varicoceles are the result of increased resistance in the testicular vein, incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampniform plexus.
The right testicular vein drains directly into the inferior vena cava. The left testicular vein drains into the left renal vein. Most varicoceles (90%) occur on the left due to increased resistance in the left testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.
What may varicoceles present with?
Throbbing/dull pain or discomfort, worse on standing
Dragging sensation
Sub-fertility or infertility
What would the examination findings of varicoceles be?
A scrotal mass that feels like a “bag of worms”
More prominent on standing
Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
What do varicoceles that do not disappear when lying down, raise concerns about?
Retroperitoneal tumours obstructing the drainage of the renal vein, these warrant an urgent referral to urology for further investigation.
What are the Ix you would consider for a varicocele?
Ultrasound with doppler imaging can be used to confirm the diagnosis
Semen analysis if concerns about fertility
Hormonal tests- FSH and testosterone if there are concerns about function
What are epididymal cysts?
Very common in adults
Most cases are asymptomatic
Patient may present having felt a lump, or they may be found incidentally on ultrasound
Examination findings…
- soft, round lump
- typically at the top of the testicle
- associated with the epididymis
- separate from the testicle
- may be able to transilluminate large cysts (appearing separate from the testicle)
What are the types of testicular cancer?
Testicular cancer arises from the germ cells in the testes
Germ cells are cells that produce gametes (sperm in males)
There are other, rare tumours in the testes such as: non germ cell tumours and secondary mets
Testicular can be divided into two types: seminomas, non seminomas
What are the risk factors for testicular cancer?
Undescended testes
Male infertility
Family history
Increased height
What is the presentation of testicular cancer?
Painless lump on the testicle, occasionally it can present with testicular pain
The lump will be… Non tender (or even reduced sensation) Arising from the testicle Hard Irregular Not fluctuant No transillumination
Can rarely get gynaecomastia
What are the investigations for scrotal lump you are suspecting is testicular cancer?
Alpha fetoprotein- may be raised in teratomas (not in pure seminomas)
Beta- hCG- may be raised in both teratimas and seminomas
Lactate dehydrogenase (LDH)= a very non specific tumour marker
Staging CT scan can be used to look for areas of spread and to stage the cancer
What is the staging system used for testicular cancer?
Its called the royal marsden staging system
Stage 1= isolated to testicle
Stage 2= spread to retroperitoneal lymph nodes
Stage 3= spread to lymph nodes above the diaphragm
Stage 4= metastasised to other organs
What are the common places for testicular cancer to metastasise?
Lymphatics
Lungs
Liver
Brain
What is the management of testicular cancer?
Depending on the grade and stage of testicular cancer, treatment can involve…
Surgery to remove the affected testicle (radical orchidectomy), a prosthesis can be inserted
Chemotherapy
Radiotherapy
Sperm banking- to save sperm for future use as treatment may cause infertility
What are the side effects of treatment for testicular cancer?
Infertility Hypogonadism (testosterone replacement may be required) Peripheral neuropathy Hearing loss Lasting kidney, liver or heart damage Increased risk of cancer in the future
Prognosis for testicular cancer?
Goood, greater than 90% cure rate
Met disease is also often curable
Seminomas have a slightly better prognosis than non seminomas
Pts will require follow up to monitor for reoccurence
This usually involves tumour markers, CT scans, CXRs
What is LUT infection?
Infection of the bladder causing cystitis, which can spread to the kidney causing pyelonephritis
Urinary tract infections are far more common in woman as the urethra is shorter
Commonly caused by E.coli,
Bacteria can be spread through sexual activity, incontinence, poor hygiene, urinary catheters
What is the presentation of a Lower UTI?
Dysuria (pain, stinging or burning when passing urine) Suprapubic pain or discomfort Frequency Urgency Incontinence Haematuria Cloudy or foul smelling urine Confusion is commonly the only symptom in older and frail patients
When should you suspect pyelonephritis?
Fever
Loin/back pain
Nausea/vomiting
Renal angle tenderness on examination
What would suggest infection on a urine dipstick?
Nitrites (gram neg bacteria break down nitrates into nitrites)
Leukocytes (leukocyte esterase)
Red blood cells- microscopic Haematuria, this is where blood is identified on a urine dipstick but not seen when looking at the sample or macroscopic haematuria, this is a common sign of infection but can also be present with other causes like bladder cancer or neohritis.
Nitrites are a better indication of a UTI than leukocytes
NICE summaries suggest that the presence of nitrites or leukocytes plus red blood cells indicates that the patient is likely to have a UTI.
If both are present the pt requires treatment for UTI
If only nitrites are present then its worth treating as a UTI
If only leukocytes are present, the pt should not be treated as a UTI unless there is clinical evidence they have one
When is a midstream urine sample sent for microscopy, culture and sensitivity done?
This is not done in all patients with an uncomplicated UTI, however it is important in..,
Pregnant pts
Patients with recurrent UTIs
When sx do not improve with antibiotics
Other than gram neg, aerobic rod shaped bacteria E coli causing UTIS, what other organisms can cause UTIs?
Klebsiella pneumoniae (gram-negative anaerobic rod) Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)
What are the antibiotic choices and duration of antibiotics for UTIs?
Follow local guidelines. An appropriate initial antibiotic in the community would be:
Trimethoprim (often associated with high rates of bacterial resistance)
Nitrofurantoin (avoided in patients with an eGFR <45)
3 days for simple UTIs in women
5-10 days for immunosuppressed women, abnormal anatomy or impaired kidney
7 day of abx for men, pregnant women or catheter related UTIs
Change catheter when someone is diagnosed with a catheter related urinary tract infection.
What do urinary tract infections in pregnancy increase the risk of
Pyelonephritis
PROM
Pre term labour
What is the management of UTIs in pregnancy?
Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).
Trimethoprim needs to be avoided in the first trimester as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.
What are the risk factors for pyelonephritis?
Female sex
Vesico-ureteric reflux (usually in children)
Diabetes
What is the triad of symptoms for pyelonephritis?
Fever
Loin or back pain (bilateral or unilateral)
Nausea/vomiting
Pts may also have; Systemic illness Loss of appetite Haematuria Renal angle tenderness on examination
What are the investigations for pyelonephritis?
Urine dipstick will show signs of infection including nitrites, leukocytes and blood
Midstream urine (MSU) for microscopy, culture and sensitivity testing is essential to establish the causative organism, the sample should ideally be collected before starting antibiotics.
Blood tests will show raised white blood cells raised markers ie: CRP.
How do you treat asymptomatic bacteriuria?
You don’t!
What is the presentation of RCC?
Triad of; haematuria, loin pain, abdo mass
What is the management of RCC?
Partial or total nephrectomy if confined disease
What should you do if someone has signs of urinary calculi alongside infection?
Urgent IV abx and renal decompression
